By: Madeline Brockberg, MD

In my eight short weeks as an intern, I have gotten very used to the fact that I will not just be frequently wrong, but I will be spectacularly and imaginatively wrong.  Recently, I met two patients that forced me to think about the ways I want to be wrong.

It was the middle of the day and my shift was passing me by quickly as I tried to keep up with the chaotic pace. I completed one patient’s chart and picked up a new patient who had just arrived. She was a 40-year-old woman who had sprained her wrist while working out. When I walked into the room, I found her relaxing in her bed and laughing with her husband. They were a charming couple and we chatted comfortably before the exam. As I conducted the interview, there were no alarm bells ringing in my head, my gut did not twist in knots and the hairs on the back of my neck stayed firmly in place.  I went through my list of questions and was already deciding my plan as I untied the back of her gown–pain control, X-ray, immobilization.

I pulled apart her gown. Her neck, back and hips looked like an upsetting piece of modern art, with multiple bruises and abrasions all in different stages of healing, creating swirls of purple, green and yellow. As my eyes traversed this hidden landscape, the mood in the room changed quickly. I kicked myself for not asking her husband to step out while I took the history or did an exam.  Why hadn’t I noticed before the lack of eye contact she was making with me? Or the way her husband was answering some questions for her? It didn’t take much more investigating for the social worker that specialized in domestic violence and the police to get involved. I felt like I had over trusted my patient and too easily taken my guard down. And I had been wrong.

Time doesn’t stop in the Emergency Department for anyone, so as many others flocked to help, I signed up for another patient who was waiting to be seen. She was a 33-year-old woman with a long psychiatric history including depression, anxiety, drug abuse, bipolar disorder and panic attacks who was coming in for anxiety and heart palpitations. As I walked over to her room, EMS informed me they thought it was a panic attack. As the nurse walked out of the room, she too wanted to let me know she thought it was a panic attack. I walked in the room and the patient did indeed look panicked. She was crying, anxious and told me all about the chest pain she was having and how terrified she felt. I sympathized with her but I also reasoned with myself why her chest pain was from her anxiety and not the other way around. I convinced myself that if she would take a few deep breaths and some medication, her heart would stop pounding and make its way down from 170 beats per minute to a much more reasonable rate. I spoke with my supervisor who raised an apprehensive eyebrow at me. He was concerned about how high and sustained her heart rate was and we ordered some imaging.  Hours later, the results of a CT scan showed a blood clot in her lungs and she was admitted to the hospital.

I kicked myself again. Had I let her history of mental illness cloud my judgment? Had I let other providers bias me or would I have come to the wrong conclusion all on my own? I had been wrong. But this time I hadn’t trusted my patient enough. I had rationalized away all of her concerns and symptoms, instead of believing her that this episode felt different. This time felt scarier. This time she didn’t think it was anxiety.

I walked out of my shift into the warm summer night. I felt tired, hungry and I really, really had to pee. But these two patients still weighed on my mind as I trekked home. I asked myself about the ways in which I want to be wrong about my patients. Bad outcomes, missed steps, implicit bias and incorrect first impressions are the current realities of my job. But if I know I am going to often be wrong, would I rather trust my patients too much or not enough? How much of the benefit of the doubt am I willing to extend? Especially in the middle of the night or at the end of a difficult shift? What way do I prefer to be burned?

Luckily, with both of these patients, despite my inexperience, the system we have in place worked to catch what I initially missed. I have safety nets under me that include senior residents, attendings, techs, nurses, social services and objective data to help reel my first impression back closer to reality. But I also have to live with where my mind goes during my initial encounter. I have to answer for the judgments and assumptions I make about patients when they come through the door.  And for now, I would prefer to be wrong because I trusted my patients too much rather than be wrong because I couldn’t trust them enough.

 

Resident Author: Madeline Brockberg, MD
Faculty Editor: Elizabeth Mitchell, MD
Photo Credit: Ben Grimmnitz, MD