Can physicians forgive themselves? It has been 14 years, and I have not.
Halfway through my internship year, I was on call in the hospital overnight and admitted a patient with cancer. He was dehydrated and possibly infected. After multiple attempts at placing an IV in his arms and feet, I knew we needed to place a central venous catheter. Because I did not have enough experience placing one by myself, I called my supervising resident. She suggested we place the catheter in the patient’s groin, not neck.
A catheter in the neck or upper chest is cleaner, but more difficult to place, with more risks. A groin line can get infected but is less risky.
As we started the procedure, we realized that the patient had significant lymph nodes in both groins. Nevertheless, the resident thought we should proceed. I stuck the needle into the patient’s groin, trying to find the vein, first on one side, then the other. The resident took over but was also unsuccessful. The patient was becoming uncomfortable. We called the third-year resident from the intensive care unit. He placed the line in the patient’s upper chest, and we started intravenous fluids and antibiotics, stabilizing him for the night.
I checked in on my patient frequently that night. On morning rounds, his daughter was at his bedside. She told me she worked at the hospital and asked, “What did you do to my dad last night?” As I explained the situation, she looked at me and said, “He’s having a lot of pain in the groin.” I assured her that pain medications were available and introduced her to the resident on duty that day.
Fast-forward two years. I was the third-year supervising resident in the ICU. I entered a patient’s room where a hospital technologist was performing a procedure. Within moments, the technologist looked at me with piercing eyes and said, “I know you. You took care of my dad. Because of you, he suffered and died in pain.” In a flash, the images of my patient and his daughter came rushing back.
She explained that after that hospitalization, her dad developed a clot in the groin where we had tried to place the line. He had difficulty walking and persistent pain until the day he died, several months later. I started to defend myself, explaining that I’d made sure I had supervision. She said it didn’t matter.
I’d seen hundreds of patients as an intern, so why did this case come back to me so quickly? Because I believed my care had fallen short, even though I had followed the chain of command. When I felt the lymph nodes, I didn’t think it would be possible to place the catheter. But my immediate supervisor did. As trainees, we don’t want to challenge supervisors or seem weak or incapable. This time, my hesitation was well founded, and it will stay with me forever.
But the lessons I learned from this man’s death have stayed with me too. With every patient I see, I think long and hard about recommending a procedure. Is it more likely to do harm than good? I make sure I’ve communicated my reasoning with a patient and family — because, in that case I remember too well, an inability to properly communicate was likely my greatest failure.
Medicine is an imperfect discipline, and doctors are human beings. We have to use our best judgment, and we aren’t always right. But we can always try to do better.
Dr. Manisha Juthani-Mehta is an associate professor and Infectious Diseases Fellowship program director at Yale School of Medicine, and a Public Voices Fellow of the OpEd Project.