A Foundation of Failure

At a recent meeting of our medical school’s advisory college our Dean of Student Affairs asked 190 first-year students for their definition of professionalism. The majority of these young people, just months out of college, were perhaps unqualified to answer the question, yet enthusiasm overwhelmed inexperience, eager faces glowed with engagement, and willing hands shot up in response. “It means always doing your best,” one student yelled, as the Dean scribbled the answer on a white board. “Being respectful to everyone at all times,” contributed another. A murmur of approval was heard from the faculty. “Putting patients’ needs first,” declared a third, and the congress roiled for the next fifteen minutes, bubbling with mostly redundant yet admirably idealist contributions. For most physicians, “professionalism,” an admittedly nebulous term, represents not simply the opposite of “amateurism” but rather the very best practice of medicine. And the students, though overlooking “beneficence” and “sustained commitment to learning” in their description, were right in insisting that it is predicated on proper behavior, hard work, and a stringent commitment to one’s patients. Yet several years into practice, it is increasingly clear to me that professionalism is rooted in an intimacy with and a struggle against failure which inevitably makes demands of and weighs on physicians. It is a difficult and costly proposition, and none of us is spared its toll. As the new student-doctors happily spun their list, optimistically anticipating that good intentions foretell a smooth career, cheerfully unaware of the difficulties awaiting them, my mind turned to two patients I had recently treated and how my role in their care had enhanced and supplied nuance to my own understanding of professionalism. John, a thoroughly enjoyable bus driver, came to see me after an emergency room visit for pharyngitis. He had been evaluated the night before at a local hospital where his rapid strep test had been negative, and he had been told his problem was “viral.” He had been sent home on prednisone and salt water gargles to help reduce his symptoms and told to follow-up with his primary care physician—for whom I was covering—the next day. I spent very little time with John—much less than I should have—and didn’t closely interrogate his history. I took his temperature which was normal, I quickly palpated his neck and found he had no swelling or lymph node enlargement, and I peered into the back of his throat and saw minimal inflammation without pus. John told me he wasn’t feeling much better than he had the night before, but as his symptoms hadn’t progressed, I endorsed the care he had received and told him to call me if he didn’t start to feel better within a day or two. John’s wife, a medical assistant, called me the next afternoon and told me his throat pain was so severe he couldn’t even swallow a can of Ensure. She brought him back to my office and on second and closer inspection I noted that his voice had changed, he was having difficulties opening his mouth, and his submandibular tissues were tender. I admitted him to the hospital and arranged for immediate intravenous antibiotics, a CT scan of his neck, and a formal otolaryngology consultation, yet despite these interventions John required a neck debridement and placement of a temporary tracheostomy. He went on to a full recovery, but only after a harrowing and perhaps avoidable stay in the intensive care unit. Steve, a 50-year-old nurse for whom I’ve cared for several years, had recently complained to me of an acute cough with low-grade fevers. A chest x-ray was negative but his symptoms persisted for several weeks despite trials of cough medicine, anti-histamines, oral and nasal steroids, and finally an antibiotic. After Steve had been coughing for six weeks I asked him to be tested for Bordetella, but several days after his blood draw, with results still pending, I received a frantic email from his wife. Two days prior, Steve had suddenly appeared “dusky.” Upon evaluation in a local emergency room his D-Dimer had been elevated and a CT scan had shown a large central pulmonary embolus. Steve had been anti-coagulated and admitted to the intensive care unit, and a leg ultrasound had demonstrated a sizeable deep vein thrombosis. Even though Steve had never complained of shortness of breath or chest pain and had never been tachypneic or hypoxic, the intensivist believed that the chronic cough had been caused by a cascade of small emboli. Professionalism certainly hinges on propriety, and in this way the students’ intuition was sharp. Yet despite the innumerable pleasures we encounter in our work, it is only through an unrelenting, emotionally costly, and solitary struggle against error and failure that we are challenged to become as thorough, conscientious, and empathetic as possible. This grim truth, often invisible to young trainees, emerges only with experience and sustained introspection yet lies at the very core of our practice. How else but through missing Ludwig’s angina does a young physician re-learn the importance of digging into patients’ histories, interrogating and respecting their physical findings, and attending as rapidly as possible to their needs? What better way than by losing sleep over a patient in whom you believe you’ve missed chronic pulmonary emboli to become vigilant against error? And what could be more humbling and humanizing than being present with patients to whom you’ve admitted errors or oversights, continuing to be active in their care, and working to maintain their trust in you? My father, a superb physician, once characterized medicine as a “lone intellectual struggle against disease,” and the longer I practice the more regard I have for the words “lone” and “struggle.” Physicians who act and practice properly may occasionally be honored by colleagues and adored by patients, and we should allow ourselves to be renewed in those moments. John, it turns out, believes I saved his life and has actually referred family members to my practice, and Steve tried desperately to reassure me—even prior to the state lab calling to report his positive Bordetella test—that I had been appropriately thorough in my evaluation of his cough. Yet medicine remains a difficult and sometimes terrifying pursuit, one in which fear of failure and self-doubt are our close companions and which at times stretches the very best of us to our limits.