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Reflect ions

A TALE OF TWO RESIDENTS

He was crying silently, eyes down with just a few tears and no sobbing or sniffling. 1 had just told him about a mistake he had made. An elderly patient had been sent home. She shouldn’t have been and returned later, unable to be resuscitated.

As one of several of his ED attend- ings 1 didn’t really know him all that well. He was quiet and serious, with an almost military bearing. “A solid resident with an adequate fund of knowledge who did his work and could be trusted,” his evaluation might say. He was not the type you would expect tears from. I wanted to cry too, not for the patient, but for him. Who knows whether his error really had anything to do with this death?

“I’m sorry,” was all he said. “I know,” was all I could say. We

sat across the desk from one another, both of us embarrassed and avoiding eye contact, until the tears stopped.

“I’d better go,” he said. “Thanks.”

“You shouldn’t forget this . . . or make too much of it,” I said lamely, knowing he’d ignore at least half my advice. I also knew that this event

would shape all our future interac- tions. I knew him much better now. We might not be friends, but a bond had been formed.

This mistake need go no further. Despite the outcome, it was not that serious. Mistakes of judgment often aren’t. His evaluation would change. “He could be my doctor,” it would say.

He was angry. Behind his fierce dry eyes I could see a combination of scorn and defiance. I had just told him about a mistake he had made. A pa- tient with pneumonia in three lobes had gone home against medical ad- vice, but no antibiotics had been giv- en. The patient had returned, sicker, but would probably do all right.

I thought I knew him well. He was very smart but easygoing, fun to be around. “A star!” his evaluation might say. I was stunned by his anger. I could feel anger welling up in me too, my face getting red and hot.

“It was his decision to leave! I told him he needed to stay and get antibiot- ics,’’ he said loudly.

“But why not give him oral antibi- otics?” I sputtered.

“I don’t think we should encour- age that kind of behavior,” he an- swered almost calmly.

We sat across the desk from one another. He stared at me unflinching- ly. I confess to feeling at least uneasy, more likely a little afraid.

“You’d better go,” I said. He left without another word. I

knew that this event would shape all our future interactions. I knew him much better now. Any bond between us was fractured, probably irrepara- bly.

I would have to take this mistake to a higher authority. This was serious, less an error of judgment than a judg- mental one. The outcome didn’t mat- ter. His evaluation would change. “I’m unsure he possesses the neces- sary qualities to be a physician,” it would say.

KEITH WRENN, MD Emergency Department 703 Oxford House Vanderbilt University Medical

Nashville, TN 37232-4700 Center