Navigating medical decision-making: Embracing limits and growth

“Ms. Smith is going to the MICU,” the resident on the other end of the line informs me.  My stomach tightens as that visceral sense of guilt and frustration sets in, familiar by now but this time with a newfound intensity.  It is my second week as an attending physician during my chief residency year, and Ms. Smith will now be the first patient transferred to the intensive care unit for whom I am ultimately ostensibly responsible.

Two days prior, flummoxed by her steadily worsening serum creatinine and electrolyte derangements, our general medicine team consulted our nephrology colleagues for assistance with the age-old dilemma for a sick patient with heart failure, renal dysfunction, and difficult-to-determine volume status: to flood with fluids, or aggressively diurese?  With their guidance, we opted for the former option, only to see her fluid status, renal function, and hyponatremia steadily worsen to the point of now needing a higher level of care.

After speaking with the resident, I feel my culpability for Ms. Smith’s clinical decompensation, and the insecurity at my own perceived incompetency, intensify steadily over the next 24 hours.  I frenetically stalk her clinical course while in the MICU, while also fervently reviewing her labs, imaging, and our documentation leading up to her transfer.  I run the case by friends, mentors, people much smarter than me. To my surprise, the responses I receive are unanimous in their prevailing message: what you did was reasonable, take it easy on yourself.

And yet stubbornly, I cling to the pervasive sense of guilt and shame that persists, an emotional albatross that is oppressive, but at least familiar.  In a strange way, to admit that Ms. Smith’s outcome was largely out of my hands, that we had no way to know definitively which course of action was preferable prior to enacting it, and the potential liberation from my self-castigation this might allow, feels scarier than believing the myth I tell myself: that I had control, and was simply mistaken in how to exercise it.

With time, reflection, and the intentional practice of self-forgiveness, I have learned how my interpretation of, and response to, Ms. Smith’s clinical course was clearly mistaken.  Where I reflexively sought to ascribe self-blame for a supposed mistake, what I needed to do instead was step back, acknowledge the limits of my knowledge and power as a physician, and recognize that, with the help and guidance of experts, our team chose a reasonable course of action.

In subsequent conversations with peers in medicine dealing with similar situations, I have come to realize that the sober acknowledgment of our intellectual and clinical finitude as clinicians is one of the most uncomfortable exercises we can undertake in the process of medical decision-making and self-reflection. We would rather cling to a false sense of control, sometimes to our own mental and emotional detriment, than acknowledge the (ironically) liberating reality of the limits of our ingenuity and prowess.

I am not at all suggesting that we as clinicians avoid the difficult but vital work of honest self-reflection and openness to feedback when we make mistakes; I am only suggesting that we are perhaps too eager to mischaracterize certain outcomes as “mistakes” when in fact the decisions that led to such outcomes were in fact reasonable.

To make progress here requires both that we see well, and that we have the courage to describe accurately the nature of our work in challenging medical decision-making and our place in it, because this pernicious tendency toward the façade of control gains power precisely to the degree that it remains tacit and unacknowledged.

Benjamin Wade Frush is an internal-medicine pediatrics resident.

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