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Mistake-Based Medicine and the Harm of Self-Critique

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I’m fairly certain my colleagues don’t like me. It’s the sticky notes, I think. That, and my personality. But they’re interconnected, like DNA and the maladies of man. I stick them to everything. The sticky notes, that is. To their desks. To their chairs. Most commonly, to their charts. Little pearls of wisdom that come to my mind about the way they care for patients — I’m like a white-coated Easter Bunny with a basketful of neon 3-inch squares.

I wouldn’t have dropped the thyroid dose. Armour always suppresses TSH.

Septra only? Cellulitis with confluent erythema is often strep. 

Xarelto 15 BID is the loading dose. After 3 weeks, 20 QD.

My gifts are like little chocolates. Saving the world from imperfection. Preventing the cancer that grows from each mistake.

… That’s where my personality comes in, I guess. I hold myself to a pretty high bar. My wife tells me that bar’s not just for me — but who wouldn’t want to learn at every opportunity? What could be more important than the truth? Hurt feelings? Ha! Myers-Briggs has labeled me as an ENTP. The T is for “Thinking.” Feeling is for the Fs. I interact with the world through my head; the Fs, through their hearts. That’s why they don’t like me. At least, that’s my theory. But that doesn’t stop me from loving them. Which is why I leave them all the notes.

In case you’re finding this confusing, there are two things you need to know about my practice. We share our panel. No PCPs, so that each doc can work part time. That’s why there’s so much crossover. Also, no EMR. We’re still on paper. But that’s a story for another time.

It’s been difficult lately. Trying to understand the “why” behind my not being liked. But then something changed. A wrinkle in my universe. An anomaly that hiccupped the arc of time. It happened last Tuesday. I arrived at work like any other day. Searched for my favorite pen. Found my Rx pad. Pulled up the chair. Sat down. That’s when I saw it. Like a still-hot ember from last night’s tired fire. Yellow. Fluorescent. Blinding. Like a sun bludgeoned square, right there, in the center of my desk. I stared at it, not sure what to think. Its lower edge looked like a wave’s lip in the moment before it breaks, quivering in the cool current that blew from the air conditioner mounted upon the wall.

A sticky note. Meant for me. 

D-dimer in a 29 yo?!? Zero risk factors for pulmonary embolism. CTA negative. Well’s criteria? Radiation vs. age?

… And that’s when I got it. The pain of the T in the absence of the F. It’s the same thing with texting. Same with emails. All those great ideas that might sting without the sugar coating of emojis. All the hurt from unadorned words.

She was gone, of course. My colleague. Only her sticky note remained, like a mountain lion’s scat. I could imagine her tracks that led backward from here. Her phone call to my patient after the clinic had closed and her dinner back home was growing cold. The talk of risks and benefits, her youth, so many rads. The call to the hospital, the begging of the CT tech to fit her in. The half sleep that’s bred from worry. The waiting for the phone to vibrate, hoping for good news from the radiologist on the other end.

If she had been there, my colleague, the doctor who’d left the note, I would have told her. I would have told her about the cat lady. But, instead, there was only that sticky note. That steaming pile and all its blame. Its lower edge flapping like the tongue of a child.

I met the cat lady in my third year as chief resident. It was me and Taylor, my intern, who was taller than me by half a foot. We had admitted the cat lady before the fog of night had grown too thick. Her X-ray was pretty clean, except for a haze around the right hilum that a desperate resident can always call. No smoking. No asthma. No COPD. Only 53 years old. But her O2 saturation values were 92%. So we swallowed the pill the ER doc had sold us. Called her pneumonia. Tucked her in. I wrote her for ceftriaxone, azithromycin. Methylprednisolone q 6, some duonebs just in case. She was a bit quirky, too, slippery. Not schizophrenic, per se, but she pitched her tent close to the line. That’s what made it hard, perhaps. My lack of trust. My thinking I might know better than her. “Poor historian,” I wrote. I remember her perseveration with her cats. She had nine in all, kept telling Taylor and I all of their names. I remember being struck by her disregard for her own condition. All that mattered, it seemed, was who would feed the cats. That’s when I came up with my theory for the Cat Index. I remember being excited to share it with the team the next day on morning rounds. My hypothesis was that the number of cats a patient keeps (indoors) is inversely proportional to their sanity. I beta tested it on Taylor. She laughed. The pager beeped. We moved on.

Fast forward to 3 a.m. A half dozen admissions between then and now. The same pager. It was the cat lady’s floor. We ran the stairs. She was coding. We shocked her. We Epi’ed her. I ran the pneumonic in my mind. But we didn’t push the tPA. 

A few weeks later, the autopsy showed that the cat lady had died of a pulmonary embolism. It’s hard to explain that feeling to someone who hasn’t walked a mile in the shoes. I swore to myself that morning I would never miss that diagnosis again. 

Which brings me back to the sticky note, its flickering lip like the twinge of regret. I stared at it. It stared at me. Little. Yellow. Square. Benign. And there, right behind it, the cat lady. And a drowning wave of pain and crushing blame. 

Mistake-based medicine. That’s what I’ll call it. Not to be confused with evidence-based medicine — mistake-based medicine is anecdotal. Its Ns are always 1s. But we carry them with us. Like scars that hide the wounds. And they change the way we practice, in a way that’s hard to shake. The 29-year-old on whom I’d ordered the D-dimer — the subject of my colleague’s sticky note — didn’t have a pulmonary embolism. Not even close. It was probably anxiety, the ailment that’s usually left when the other labels refuse to stick. But there, in the recesses of my past digressions and sins, was that painful memory of the woman Taylor and I lost. Her hungry cats, the blame that befell me. 

And then, as I sat there in its wake, something unfamiliar began to seep from the note’s yellow edges. A little bit of F beneath my T. Some recognition. Acceptance. Forgiveness. 

My mistake with the cat lady had no place here. Not when it was bludgeoning logic. Not when it was bringing harm. Maybe mistake-based medicine shouldn’t hold such a high station inside these walls.

We try our best. But we’re just human. Sometimes, we break the oath. Sometimes, we do some harm. But to bear the burdens of those lessons throughout an entire career, the ones that make us better, that smooth the edges, that hone the art — the weight can become too much. It’s not just the inboxes, the prior authorizations, the endless clicking, the messages that never cease. The burnout happens from within, too.  

So now, I too hate the sticky notes.

I’m learning not to hate myself. And to accept, just a bit, the imperfection. In my colleagues and myself.

The secret is forgiveness. For all the mistakes we made. And a letting go of fear. Of the mistakes we’re yet to make. And perhaps a recognition, too. That my colleagues can hold their own. That their own cat ladies lurk about.  

That’s my theory, at least. That, and the Cat Index.

Do your past mistakes haunt you — maybe even change the way you practice? How do you let go? Share your ghosts in the comments.

Steve Rogoff, MD is a rural family practice, emergency, and functional medicine physician who lives in Hawaii. His interests include surfing, music, and playing with words. His writing can be found at Steve is a 2021–2022 Doximity Op-Med Fellow.

Image by MADUAart / Getty

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