There was a night when I was in training that all the decisions, disasters and chaos, which are the practice of medicine, caught up to me.  In those dark hours, I felt practically despondent.  What I had seen left me in tears and overwhelmed by the tasks in front of me.

At that moment a wise attending physician took a moment to sit with me.  Rather than tell me how wonderful a doctor I might someday become or brush away my errors, he validated my feelings.  He said the best doctors cared, worked hard and sacrificed. However, that the basic driving force is fear and guilt.  Fear for the mistakes you might make. Guilt for the mistakes you already had.  How I handled those feelings would determine how good a doctor I became.

I have reflected on those words over the years and tried to use that sage advice to learn and grow.  Focused properly, guilt gives one the incentive to re-evaluate patient care that has not been ideal.  It drives the study and the dissection of past decisions.  Nonetheless, excessive guilt can cause a doctor to avoid completely certain types of cases and refuse even the discussion of those medical issues.

Fear of error drives compulsive and exact care.  It helps doctors study and constantly improve.   Taken too far it can result in over testing, avoidance and over treatment.  The art of medicine requires the practitioner to open his heart to criticism and be strong enough to build from failure.

Some years ago, I saw a patient who had leukemia.  I concluded that the patient’s low blood count was because of this blood cancer.  This was correct.   I missed that in addition to the leukemia she was bleeding from a stomach ulcer.  By the time another doctor spotted the ulcer, the patient was sicker than she might have been, had I made that diagnosis earlier.  To compound that mistake, when I met with the patient and family I rushed and explained the situation too quickly.  They became confused, and angry.  They changed doctors.  The patient recovered and survived, but we were both hurt deeply.

It seems to me that this case shows that there are two basic types of health care error. The first are factual physical medical mistakes.  These are what we all think of most when we think of medical error.   A delay in diagnosis, wrong conclusion, wrong interpretation of tests, the wrong treatment, unnecessary complications, the loss of valuable records or the failure to follow up.  Such mistakes result in the exhaustive study by the doctor of exactly what happened and how to avoid that type of problem in the future.  Good physicians perseverate and constantly replay such events.  These cases become an integral and transformative part of how the doctor practices medicine.

The other type of error is emotionally personal to the patient and doctor.  That is failure in communication between the physician and patient.  It deeply affects a doctor who by being incomplete, distracted or not empathetic undermines the therapeutic relationship.   When patients or families get angry, confused or simply go elsewhere because the doctor has failed to connect with them, doctors are often devastated.  Most physicians work hard to build a healing bond with their patients and when that collapses, it hurts. It requires reflection and insight for a physician to grow from errors in compassion.

I use the case above every day to help me in the practice of medicine.   I know, and I tell my students, mistakes are how we grow.  We owe it to the patients we have seen in the past, to be better doctors tomorrow.  What students and doctors learn from error determines the physicians they become.  Fear and guilt are the marks of excellent doctors.  How they handle those powerful emotions determine their ability to give the finest care.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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