Every week, for two hours, I am granted reprieve from the hard sciences and voluminous textbooks traditionally associated with the medical school curriculum. In a unique course called Medical Humanities, we read short works of literature and discuss how it relates to the medical field and our future careers as physicians. Most recently, we’ve read excerpts from a biographical work by Dr. David Hilfiker entitled Healing the Wounds: A Physician Looks at His Work. In this profound self-refection, Dr. Hilfiker divulges what he feels are his most appalling mistakes made as both a resident and physician, courageously acknowledging the reality of imperfection in medical practice. From my perspective as a medical student, his stories were both frightening and enlightening as it brings to light the fallibility of a profession revered for its omniscience. Reading this work encouraged me to reflect on how society views physicians as well as how the medical field has changed since Dr. Hilfiker’s documented experiences.
At one point in Dr. Hilfiker’s stories, he reflects on how the training he received in medical school proved insufficient when confronted with his patient’s emotional response to illness. He states “Why hadn’t I been better prepared for this in medical school? We were so busy trying to figure out what was wrong and what should have been done that there was no time or energy left to understand how an acute medical problem fits into the life of the patient…” It is important to remember that Dr. Hilfiker’s work is based during 1975 and 1982, while he practiced in a small rural town in Minnesota. Based on my experience so far and thorough research while applying, it is evident how medical school curriculums have evolved over the last decades to include training in interpersonal skills and cultural competence. As a first year student, I am granted weekly access to patients, whether it be in clinic with my preceptor (an assigned physician mentor) or with a standardized patient in our Clinical Practice of Medicine course. In both situations, we are taught to assess our patients in the context of their lives. To see a patient is not to see their disease or simply their chief complaint, but to put these aspects of the medical history into the much larger landscape of their lives. We are trained to ask questions about their employment, their family and even how they arrived to the office for a visit – because each puzzle piece provides a little bit more information that can make the larger picture much more clear and accurate.
Another recurring theme in Dr. Hilfiker’s work is the idea that society expects perfection from physicians and how the medical profession has responded to this perception in the past. He states “The medical profession seems to have no place for its mistakes…And if the medical profession has no room for doctors’ mistakes, neither does society.” Although, in many ways, our society still embodies many of the qualities put forth by Dr. Hilfiker, changes have occurred from within the profession. For example, residency programs have recognized that mistakes can occur when residents are over-worked and over-tired. Over the last decade, institutions have implemented the 80-hour work week for residents and 16 hour shifts, capping the time that residents can spend in the hospital. These restrictions were put forth in hopes of reducing the type of mistakes that happen when residents are distracted, or pressured, or exhausted. It is not only to the benefit of the patient that these changes have been undertaken, but also to the betterment of residents. FREIDA, the Fellowship and Residency Electronic Interactive Database Access, now includes information on work schedule including whether a specific program “offers awareness and management of fatigue in residents/fellows.” Additional steps have been taken such as Mortality and Morbidity Conferences, where clinicians can discuss medical errors and adverse events involved in patient care. This is in stark contrast to what Dr. Hilfiker observed when he commented on the stamina of the medical community for embracing its mistakes.
It seems that the medical profession has made some room but will society follow? We have not seen a reduction in the number of malpractice suits filed each year. Instead, doctors have been forced to embrace a cover-all-bases attitude, i.e. – performing additional tests, at additional costs to ensure that a patient has no basis to sue. But is this any better for the patient? For the doctor? For the economy? It seems an unfair expectation for society to lower their standards or expect anything less than perfection when we hold their lives in our hands. However, under the looming ultimatum of perfection or prosecution, one has to question whether society has perpetuated generations of physicians who are terrified to make mistakes and are less likely to admit to when one is made.
My perspective is unique, as I am both a future physician and someone who has witnessed mistakes first hand to the detriment of my family. On one hand, I see my uncle, who was misdiagnosed and more than likely, would not have had the extra months with his family had he just accepted his misdiagnosis. In a previous post, I referred to my uncle as my ‘friend’ and described how he had been misdiagnosed by an oncologist in an especially thoughtless and callous manner. The doctor did not physically meet with my uncle, but instead reviewed the case in his office and sent his diagnosis with his secretary in the form of a post-it note to my family who had sat in his waiting room for nearly three hours. My uncle’s true diagnosis of Stage IV Mantle Cell Lymphoma would have killed him in less than two weeks without prompt medical treatment. Sadly, my uncle passed away last month after fighting valiantly for eight months at MD Anderson in Texas. From the perspective of his niece, this medical mistake was incredibly angering and could have been disastrous had my uncle simply accepted his misdiagnosis and waited to hear about an appointment for a week, as this physician had advised. This case was more than simply a misdiagnosis, it was an affront to proper bedside manner, devoid of humility or compassion on part of the physician.
Putting these facts aside, I do question if fear of making a mistake could change how the oncologist acted in this case? Would he have performed more professionally or reviewed the case more thoroughly had he been fearful of the grave repercussions of a misdiagnosis? On the other hand, I struggle with the extent to which medical students and residents should embrace this fear because I understand the adverse behaviors this type of fear can engender. It is likely more difficult for students to learn techniques if they are scared to perform them. And it’s more difficult to speak your opinion or put forth a differential diagnosis if you are afraid to be wrong. Furthermore, the fear of potentially losing their career may dissuade a student from acknowledging a mistake, which, as Dr. Hilfiker put it, causes a physician to be “thwarted, stunted, we do not grow”. The fear is a double-edged sword. The expectation of perfection can drive a physician to be better but what happens when the expectation isn’t met? Society copes with lawsuits. I am not sure how physicians cope. We learn the tools to diagnose and perform tests and heal, but do we learn what to do when we make a mistake or our training does not prepare us? When do we learn that we can never be perfect and that we must grow from the mistakes that are made?
Dr. Hilfiker’s work exposes the reality of our field. No physician is perfect and should not be expected to be so. As a medical student, I appreciated his honesty on this topic and believe it is important to recognize that mistakes will always be made and that they are important catalysts for growth, no matter the point in our careers.
About Brienne Ryan
Brienne (Hoak) Ryan grew up in Hamburg, NY, the youngest of seven children to a single mother. She completed her undergraduate degree at Syracuse University, followed by a research-oriented Master’s Degree through Roswell Park Cancer Institute in biomedical sciences. After completing the AMSNY post-baccalaureate program, she was accepted to the University at Buffalo School of Medicine and Biomedical Sciences for the class of 2019. Wife, dog-lover, and avid art history buff, Brienne feels great privilege to have realized her childhood dream of becoming a physician.