Thursday I traversed the frozen surface of the pond for perhaps the last time this season. The ice is thinning quickly. I had on my rubber boots and stayed what I felt to be a safe distance from shore: should I break through, the water would not be over my head. I got some fantastic photos and considered the little adventure a success. However, over dinner that evening when I mentioned that I’d been on the pond earlier, David and Peter were furious. Peter wouldn’t calm down until I promised I wouldn’t go out again.
I have always considered fear the enemy; something to conquer and overcome and I’ve had a lot of practice. Being risk adverse and scrappy has been an asset now that I have lung cancer. As a participant in a phase I clinical trial, there is the potential for unforeseen and possibly life threatening side effects of treatment itself. Before you are given your first dose of an experimental drug, you must read through and sign consent forms which acknowledge this risk. It is something most healthy persons would never do. When you have a terminal illness, it is similar to coming to the edge of a ravine with a tiger on your trail. Between you and safety is a rickety bridge that may or may not support your weight. However, even chancy passage is an easy decision when the alternative is certain death.
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.