6. The Mistake
Episode Synopsis
For most clinicians, the idea of harming a patient is a worst nightmare. But in a high-stakes profession, practiced by humans in a dysfunctional system, errors are nearly inevitable. So how do we deal with the shame that follows?
Behind The Scenes
From the very earliest days of this project, we knew we wanted to create an episode about shame and medical error. The first cut of this episode was so emotionally devastating it was almost painful to listen to – which speaks volumes to the challenge and responsibility of working in a high-stakes profession like medicine. In our team conversations, we often referred to the concept of the “second victim,” a term coined by Dr. Albert Wu in 2000, which helps illuminate and address the severe psychological impact of medical error on clinicians. Since Wu’s article was published, the term “second victim” has been criticized by some who argue that it minimizes the fundamentally different impacts that error has on patients and families compared to clinicians. We sought in this episode to both affirm the humanity and emotionality of physicians, and acknowledge that these exist in concert with, not in opposition to, the struggles and pain of patients and their families.
CONTRIBUTORS
Alyssa Burgart, MD, MA
And other healthcare professionals who wish to remain anonymous
PRODUCTION TEAM
Host & Co-creator: Emily Silverman, MD
Co-creators & Research Leads: Luna Dolezal, PhD & Will Bynum, MD
Producer, Editor & Audio Engineer: Sam Osborn
Producer & Assistant Editor: Molly Rose-Williams
Additional Producing: Adelaide Papazoglou
Production Coordinator: Penelope Lusk
Medical Student Producers: Corinne April Iolanda Conn, MPH & Nikhil Rajapuram, MD
Impact Campaign Manager & Assistant Producer: Carly Besser
Executive Producer: Alison Block, MD
Chief Operating Officer: Rebecca Groves
Exeter Team Coordinator: Alice Waterson
Series Illustrator: Beppe Conti
Music: Blue Dot Sessions
SPONSORS
Shame in Medicine: The Lost Forest is made possible in part by the Shame and Medicine project at the University of Exeter, funded by the Wellcome Trust.
The Nocturnists is supported by the California Medical Association, and people like you who have donated through our website and Patreon page.
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Download the discussion guide for Episode 6, "The Mistake" here.
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The below resources are specific to episode 6, “The Mistake.” To learn more about shame in medical culture, you can find recommended resources here.
READ:
Clarkson M D. Haskell H. Hemmelgarn C. Skolnik P J. Abandon the term “second victim.” BMJ. 2019.
Davies O, Dolezal L, Bynum WE IV, Wu C., and Berry H. Needlestick. New England Journal of Medicine. 2022.
Mumby H. The Shame Spiral. The Shame Conversation. 2022.
Ofri D. Ashamed to Admit It: Owning up to Medical Error. Health Affairs. 2010.
Ofri D. My Near Miss. New York Times. 2013.
Ofri D. When We Do Harm: A Doctor Confronts Medical Error. Boston, Beacon Press. 2020.
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000.
Zabari ML. Southern NL. Effects of shame and guilt on error reporting among obstetric clinicians. Journal of Obstetric, Gynecologic, & Neonatal Nursing: Clinical Scholarship for the Care of Women, Childbearing Families, & Newborns. 2018.
WATCH:
Goldman B. Doctors make mistakes. Can we talk about that? TEDxToronto 2010.
Ofri D. Deconstructing Perfection. TEDMED 2015.
GET SUPPORT:
If you are a clinician in need of help, you can call the Physician Support Line — a free, confidential support line where volunteer psychiatrists provide peer support for physicians and medical students — at +1-888-409-0141.
You can also call or text 988 to reach the Suicide & Crisis Lifeline 24/7.
And, as always, please take good care of yourself, whatever that may mean for you.
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The Nocturnists – Shame in Medicine: The Lost Forest
Ep. 6 The Mistake
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
Thanks for listening to The Nocturnists’ Shame in Medicine: The Lost Forest. If this is your first time tuning in, welcome! And I actually recommend you rewind and start at episode one. This is a series that builds on itself over time, so starting at the beginning will definitely lead to the richest listening experience. Enjoy the show!
So, a few months ago, I was texting with a friend of mine who's a surgeon. And we were joking about how when we were kids we were such perfectionists. I mean, we had color-coded notes, A+ on every homework, and we were utterly devastated when we got our SAT scores back and they were only in the 90th percentile. And then my friend asked, “What happens when you take a kid like that, a kid who's a perfectionist, and plop them into medical school and tell them to be perfect or else someone dies?”
We were actually laughing about this over text because, even though it sounds like an exaggeration, it's also kind of true. The stakes in the profession of medicine are so high that it sometimes feels like perfection is the only acceptable way. Of course, we know that nobody's perfect. So how do we embrace that truth and still do our job? How do we even know when we've made a mistake? What's the difference between a mistake, an adverse event, and a bad outcome? When we do make mistakes, how do we navigate the tension between individual responsibility and this broken healthcare system that makes these mistakes so common? How do we even begin to wrap our minds around the devastating consequences of our mistakes on our patients? And how do we take care of ourselves in the aftermath?
In this episode, you'll hear stories from healthcare workers grappling with medical errors. Not all of the stories end in a tragic outcome like a patient death. But all of the stories resulted in profound experiences of shame. You're listening to Shame in Medicine: The Lost Forest. I'm Emily Silverman, and this is “The Mistake.”
Hospital Administrator, RN
So, I'm going to admit that I absolutely love disco music. I love 70s disco. I love early 80s disco. I just love disco music. And one of my favorite songs is called, “There, But For the Grace of God, Go I.” And it is stuck in my head right now. And it makes sense, given the story I'm about to tell you.
Friday afternoon, I'm finishing up shift huddle, you know shift huddle, the one where you're either in a hallway or a back room or some space where someone comes in and announces all the changes and sometimes even gives kudos. And there are nurses and they're waiting around for their assignments. And they're talking, and there's so much excitement and emotion around this conversation. And I want to hear what's going on. And I go over and they're talking about the recent case, this case about the nurse at Vanderbilt, RaDonda Vaught, the one who made a med error, the one who was fired and criminally prosecuted, which is pretty rare.
And one of my favorite nurses, a really good nurse, tells me this story. She tells me about a med error that she made and caused a patient to become over-sedated. And she told me that she reported right away and the response she got from that caused her to feel such deep shame. And she's walked around with this shame for the last twenty some-odd years, she tells me. And she tells me that she always feels less-than. She never feels like a good nurse. And she says, “What if that were me? What if I went to jail?” And then she kind of grins and looks at me and she says, “You know, no one's gonna ever self report again after this case.”
And, you know, immediately I can go into this long story about the studies of how when we don't self-report we cause more harm, and how that's bad for healthcare systems. And it's bad for any system in general. I give her a hug, and it's actually not for her. I hold on a little bit longer because of me, because I'm feeling such immense shame and guilt. I feel so guilty. I'm a hospital administrator. And sometimes my job involves finding bad apples, or looking for blame. So I head back to my office, and I'm sitting in front of my computer, and I'm clicking through email after email, and it's Friday, and I'm, you know, wanting to wrap up, and there's an email. And it's one of those emails that's addressed with PHI in the subject letter, and it says, “Potential harm. Please Investigate. Respond by 5 pm.” And it's three o'clock on a Friday afternoon. So, I feel like, “Okay, well, there goes that.” And the email is asking me if the nurse is to blame. And how do I respond to that? How do I respond when someone breaks a rule, potentially? How do I respond to a nurse that doesn't follow the policy? Which, you know, that's always the answer, right? They just didn't follow the policy.
But my question I want to ask is, how many near-misses does this hospital have? How many near-misses do hospitals across the country, across the world, have every day? And how many are just workarounds, because we need to be more efficient. We need to get the job done, we need to get that order done, we need to treat the patient. And I think about how I respond to this question. Can I respond in a way that doesn't cause some nurse, a nurse that I like, to live the rest of their lives with shame and feeling less-than? What if they go to jail?
I think we've been through enough over these last two-plus years. I think we're all feeling pain and shame and injury, that we were heroes at one moment and just ignored the next. The challenges we're facing right now with people leaving this profession in droves, is that the justice that we seek? And I know that my responsibility as an administrator is to the patient, it's to the patient. And if we blame and punish this nurse, any nurse, the story ends. And we don't prevent harm. Error is not a choice. What is the story?
I think about this RaDonda Vaught case and I think about what if my family member had died? What if that were my family member? And I can tell you that when my mom died, she was pretty young. And I was on a plane and I was begging, begging the doctors and hoping, “Please keep her alive long enough for me to say goodbye. All I want to do is touch her hand. Please, please, you have to do that for me!” And when I got there, she had died. And I didn't get a chance to see her or say goodbye. And in my twenty-something-year-old brain, I was so angry, so angry at this doctor. And I can tell you, I even thought well, how do I get them fired for doing something absolutely impossible? So if my family member were harmed, I know I would be angry. I would never want any family member to go through that, I would never want another patient harmed.
This was a good nurse, the nurse in my email, the nurse that I needed to investigate. And if good nurses break the rule and they get the job done, if rules are broken, and nothing happens, then what? Is it like when the bear goes to the bathroom in the woods? If the workarounds keep happening–in this Vanderbilt case they were overriding meds a lot, they were doing workarounds a lot. Why? On one hand, we want that nurse, all of our nurses, to be efficient–to get the job done, to treat the patient, to make them stop hurting. But what if being efficient meant overriding a medication, breaking the rules? Do I get concerned that one of my very best nurses broke a rule and didn't follow policy? Because if they did, then so many other nurses have. Could I have done that? There, but for the grace of God, go I.
Radiologist
So there's two things that I think listeners need to understand about IR [Interventional Radiology]. The first is that we're accustomed to placing needles near or around the heart. And the one thing you never want to do is hit the heart with a needle. Because it's like crashing the plane. And the second thing to know about IR is that it's normal for us to be the service of last resort. So there's this wonderful seventy-two-year-old grandfather, who is brought in by his family to the emergency department. And a CT is done, which reveals a mass in the head of his pancreas, which is likely a pancreatic cancer. So oncology approaches me, and they ask if I can biopsy this new lesion in his liver. I looked over the CT, and it looked a little sketchy. The lesion was small and it was near his IVC duodenum and, importantly, his heart. And these are always dicey situations. The closer the needle gets to the heart, the pulsatility is transmitted through the needle, and you can feel it. And it is scary. I genuinely feel a little bit of fear anytime you do these procedures, and your hands get a little sweaty, and you can feel the hair stand up on the back of your neck. But if you do enough of them, you just feel more comfortable over time. And so the patient comes to the interventional radiology suite. I place the patient on the CT table and I can see the lesion. So we prep the skin. And I carefully advance the needle through the skin, looks good, I'm lined up. And the whole time I'm just looking at the heart and the lesion, the heart and the lesion, as I advance this needle down to this caudate lobe target.
And I can feel the pulsatility getting stronger, and stronger. And all of a sudden, I notice that the patient's respiration has slightly changed, probably because of the effects of sedation wearing off, and this can affect the position of the heart. So I get a follow-up CT, and I see that there is a new pericardial effusion, which is dense, and it's likely blood. So I presume that the needle has hit the heart and I look up and see that the needle is kind of bouncing around, it's acting like it's touching the ventricle, and then all of a sudden it stops moving.
And, meanwhile, the patient's vital signs are completely stable, but I just call a code. Everything's going through my mind, I've hit the heart with a needle. But I don't have any time to process it because I'm just focused on the patient. The cardiologist rolled in, easily placed a pericardial drain to evacuate the blood, and the patient goes to the ICU. He's okay, but the family is upset. “How was it possible that he was getting a liver biopsy but his heart was hit with a needle? And they're not even in the same part of the body.” So I didn't even speak with risk management. But I just go in there and I tell them straight-up what happened. And it just defused the situation. They were gracious about it. And I'm still shocked that that was the case. I think they were just surprised that someone had told them straight-up exactly what happened. And I didn't try to sugarcoat it or deflect blame.
But, obviously, if you hit the heart with a needle in a hospital, people talk. So I walk out of the ICU and I'm going back to IR to mull this over, and I see a surgery resident straight ahead, and he's in an ICU room with one of his colleagues. I hear the resident say, loud enough for me to hear, “Here he comes.” And he shakes his head, like, “There's the guy that just hit the heart with a needle.” And I looked at him dead-on and he just turns away, kind of looks down to the ground. I don't know why he said that. Maybe he was pissed that somebody made a mistake, or he didn't like me or IR. But the hard part of recovering from something like this is not the act of shame from others. What others think about me just pales in comparison to how seriously I take my own complications and skills. And I think most of my attending colleagues are like that.
I think the challenge is to report back to work the next day and still perform and have a family after seriously harming someone. In medical education this is not taught. We're taught about all the parts of procedures and the care of complex patients. But we don't know how to overcome the incredible guilt that we feel after these kinds of errors. We just develop chronic wounds that take a long time to heal. And the wound is manifested by, in this case, anguish and the constant replay of the procedure in your head, over and over again. And at night, when you try to sleep, you just lay there tossing and turning with this pit of fire in your stomach. And it's hard to concentrate, it's hard to do anything, it's hard to have a conversation, it's hard to talk to your spouse or your loved one or talk to your kid.
And this has been the biggest challenge of my career, is getting over complications and moving on. I don't really talk to my partners about the emotional distress that I feel during these difficult times. And I don't really know how they feel about it. So I work with them all the time, and many of them are my good friends. But I still don't know how other people get over these things. And as time has gone on in my career, I think I've become better able to handle complications and own the struggle. But I think my experience with internal struggles and complications have led me to become a more empathetic physician towards patients and their families, and more honest, because I know the harm that I can cause with my hands. And I think, most importantly, the shame has become fuel to involve myself in medical education, to teach students how to learn to cope with challenging situations like this and live a long career in medicine.
Josh
It was about three in the morning on my overnight shift on labor and delivery, and one of the senior residents called me to come assist with a birth. This mom had been pushing for about three hours and was just flat out exhausted and wanted help. And so we reviewed the options that were available, one being a forcep-assisted delivery, the other being a Caesarean birth. And ultimately the family chose to proceed with a trial of a forcep. The forceps went on to the baby's head relatively easy. And we ultimately found out, through the exam, that the baby's face was pointed upwards, or sunny side up. And those vaginal births are potentially a bit more challenging than if the face were looking down. Overall, the delivery went pretty well. The mom did have a pretty big tear of her perineum that required repair. And the baby seemingly did okay. Leaving that morning after my shift was over, I couldn't help but notice a sinking feeling in my gut that something either didn't go well or was not going to go well.
Shortly after about forty-eight hours, I was actually at a baseball game with my family on Mother's Day and the hospital administrator called me and alerted me, “There is what appears to be a long-term injury to the right eye that was caused by the forcep birth, and the mom got an infection in the laceration we repaired, and it required extensive surgery to fix.” There was no doubt in my mind that I wanted to come and talk to the family. So I went back to the hospital. And before I did it, one of my colleagues, who's a neonatologist, or an ICU doctor, had just finished going over some of the imaging results of the baby, and looked at me and said, “Don't, don't go in there. It is not a safe place for you right now.”
I went home and wept, because I didn't know what else to do. My wife knew something was up, and we decided to go on a walk. And I remember, as I was walking with my family, that I kept looking over my shoulder, thinking that someone was coming after me, retribution. That basically led to multiple sleepless nights. I didn't eat for almost seven to ten days. And I worked the next two weeks in a fog, because I could not go to sleep. My mind was racing with this feeling of, “You have harmed a human for the, potentially, for the rest of his life. And so you get to live with that for the rest of your life.” I got a lot of responses at work that say, “Hey, you do most of the forceps around here, you're bound to have something happen like that.” Or, “It happens to the best of us. You didn't do anything wrong, you did everything right.” All of those might be true. All of them may be right. But it didn't take away the feeling that I had of guilt and shame. I could have harmed a human being for the rest of his life. And that was not something I knew how to deal with. It's been four years. And the week doesn't go by that I don't think about that birth and I don't struggle with the voices in my mind and I don't feel this gut sense of, “You're not good enough.”
Alyssa Burgart
When I was a resident, I had many opportunities to feel shame because we use shame as a terrible teaching tool in many ways. But one time that I remember feeling really deep shame was after a medication error. I was on my OB anesthesia rotation, I'm an anesthesiologist, and had tried to put an epidural into a patient and it had ended up as an intrathecal catheter, which means the medicines go into the cerebral spinal fluid instead of into the epidural space. And the reason that that's really important is that the doses of medications that you use are very, very different. You need much, much lower doses of pain relieving medication when you put them directly into the CSF.
And so I put in this catheter. It was at the end of the day. And I came in the next morning and that same patient was heading into an emergency C-section. The baby was showing signs of distress. It was very chaotic. And as we're rolling this patient back to the operating room, I see that the end of the catheter has, like, been ripped off somehow, which means you can't really give any medications through it, which means it's not particularly useful in an emergency. So I'm, like, scrubbing it and cleaning it and cutting it and trying to sterilly make it possible for me to use this in this emergency situation. I get it attached. You know, it's very high intensity and your heart's racing. You're really trying to get everything set up for this emergency surgery. And my attending hands me some medications, and I give the medications through this catheter that I've fixed. And I'm so pleased that that works out. And then, you know, we get the surgery started and my attending, as they're leaving to go start another case with another trainee, says, “Oh, don't forget to give, you know, the morphine.” And I usually had been giving morphine through an epidural, which is a different dose. And I don't realize it at the time, but I give the patient basically ten times the dose of morphine that I should, in her catheter.
She feels great. We finish her surgery, I take her to the recovery area, you know, and then, six hours later, I get a call from the nurses. You know, “This patient's really not, she's not really awake, she doesn't seem, she won’t breastfeed the baby, she's hardly responsive.” And I start really worrying about what I might be finding. So I go to her postpartum room. And she's, she's got low oxygen saturation and she's just basically obtunded, she's hardly responsive. And I immediately, in my mind, see myself giving this epidural dose of morphine through her intrathecal catheter, and realize that what has happened is an emergency, because now I have created an emergency because I have a patient who is overdosed on an opioid. And it's completely my fault.
The shame that hits you, this spiral of your own shame, is so profound, because, like, as you're figuring it out in the middle of the diagnosis realizing what you've done, your heart rate speeds up, my armpits get kind of sweaty, but you also feel, like, cold, so you’re cold but you're also sweaty. For me, my vision closes down a little bit and I find it harder to hear other people talking to me. And you can imagine how dangerous that is when you need to make some quick decisions. So I kind of pull myself out of that as quickly as I can. And I take care of the patient. And that's the most important thing, of course, is making sure that the patient is safe, especially in a situation where I am the reason the patient is not safe. I get her oxygen. I get her on a naloxone drip. I explain to her husband what has happened and what I'm going to do about it, to move her basically into an ICU to be monitored appropriately. And I have to try to not fall apart because I have royally fucked up. And it's the middle of the day. So there are like six hours left of this day, which you look ahead and you realize all of these patients that lie ahead of you, all the things that you can do to screw up their care. And it's terrifying. It's really hard to talk about, whether it's an error or a bad outcome or you respond to somebody else's bad error or outcome. It can be really overwhelming if you feel that you've had any part in harming another person, because we do not get into this work to harm others. We get into this work to be helpers.
And I think that shame also gets in the way of a lot of restitution. When I had apologized to this woman and her partner, she didn't remember. And so there was a complaint that was very appropriately placed against me later, and when it came to my attention, I called the patient and, you know, and I said, “Hey, you know, I'm, I'm the person that did that to you. And I'm, and I'm sorry.” And, and it's hard to say you're sorry, not because you don't want to, you know, it's the right thing to do. It's hard because it takes you immediately back into all of those shame feelings. And even now, telling the story, you know, ten years later, it is still, I still feel terrible. I still see that, that woman in my mind's eye. And I don't think I'll ever stop feeling bad about it.
And the best thing I can do is, you know, we always try to be better at the work. But when I think about the anesthesiology training that I did receive, you know, I would never start a surgery without doing my checklist of all the safety things that I need to make sure I have if there's an emergency–you know, suction, and we have all of our medications we need, and we have all of our equipment that we need, and the monitors are all working, like, we have an entire list of things that are just completely deeply ingrained into us. And yet what I realized as a young attending physician is that I had absolutely zero emergency plan for myself. So that when I had a serious mistake that I made, I was just completely unprepared to take care of myself. And by “take care of myself,” I mean that I was not prepared for the shame. And I was not prepared to know who to call.
You know, the best way to treat shame is to talk about it. Shame likes to tell us all sorts of stories about how you're a bad person. You're a bad doctor. You never should have gotten into medical school. You shouldn't even be a parent to your own children because look at what a bad job you did today. You're not smart enough to do this. You never should have gotten into this program. You never should get this job. You certainly will be fired because of this. Your brain tells you the most unkind and outrageous things. But the only way that you find out how ridiculous you are treating yourself is when you talk to your colleagues about their own experiences and you realize how universal some of these shame experiences are. But the shame doesn't, we can kind of mitigate it, but I don't think it'll ever really fully go away. But I think it's important to talk about it because it happens to all of us.
Emily Silverman
Thanks for listening to The Nocturnists’ Shame in Medicine: The Lost Forest. To contribute your reactions and reflections to our shame series, and to access additional resources like transcripts, discussion guides, and more, please visit our website at thenocturnists-shame.org.
Shame in Medicine: The Lost Forest was co-created by me, Emily Silverman, as well as Will Bynum and Luna Dolezal. Our producers are Sam Osborn and Molly Rose-Williams, with additional producing by Adelaide Papazoglou. Sam also edited and mixed the series. Thanks to medical student producers Corinne April Iolanda Conn and Nikhil Rajapuram, production coordinator Penelope Lusk, impact campaign manager and assistant producer Carly Besser, and Exeter team coordinator Alice Waterson. The Nocturnists’ executive producer is Ali Block, and our chief operating officer is Rebecca Groves. The series illustrations are by Beppe Conti, and the music comes from Blue Dot Sessions.
Shame in Medicine: The Lost Forest was made possible, in part, by the Shame in Medicine Project at the University of Exeter, funded by the Wellcome Trust. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.
Our show is also made possible with donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoy the show, please follow us on your favorite podcast app so you don't miss an episode. And while you're in there, you can help others find us by leaving us a rating and review. To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com.
I'm your host, Emily Silverman. See you next week.