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When We're All Responsible for a Patient's Death, No One Is

— Doctors increasingly fail to take ownership of their decisions

MedpageToday
A photo of an unoccupied patient room in a hospital.

We stood in front of an empty patient room. It had been cleaned and prepped for the next person. My attending paused, and looked in. For a moment, I felt as if he could see the 40-year-old man who had been there just days before. Perhaps I could see him too: smiling broadly, reading the paper, eager to begin the procedure, surrounded by photos of his children. But this time, the room was empty. The attending turned to face the team. He didn't make eye contact. He looked just over our shoulders. His eyes were wet. "Yeah, I don't know if I should have done it," he muttered, and then softly, "I killed him."

This was years ago when I was still in training. The attending physician had taken his patient for a procedure that pushed the limits of science. It was both seductive and unproven. My attending's comment was a rare instance where I have heard a physician so clearly take responsibility for the consequences of their actions.

At the time, I remember thinking that I understood the procedure. I knew how it ought to work, when it should be considered, and how to deploy it. Now, as I near the age my attending was at the time, I realize that my understanding back then was ill-formed, nebulous, and elusive. I saw it, but only out of focus.

Medicine is a collection of millions of interventions, and viewing any one with clarity -- true clarity -- takes time. First, you read a primer on the topic. Next, you watch how residents, fellows, and faculty speak about and use the procedure. Then, you practice it and gain first-hand experience. At last, when you can, you investigate it deeply.

The attending believed in the intervention. He offered it in good faith. His patient accepted, and at that point, the series of events that led to the man's death were inexorable. Afterwards my attending knew the consequences of his choices: "I killed him," he had said. I was stunned by his admission. It was blunt and pained. My thoughts would return to the patient, his family, and the attending.

In the years since, I have attended dozens of conferences -- known as Morbidity and Mortality (M&M) conferences -- that claim to be about just this moment. A doctor takes an action that leads to a bad outcome, and revisiting that decision -- that choice -- and asking oneself, in front of one's colleagues, if the right call was made. And, yet, none of these conferences seem to take up that task anymore. Almost never does a physician admit their choice led to a bad outcome.

Instead, the focus of these conferences has moved entirely to the "system." We hear stories of patients who get delays in care, the wrong dose of medication, an incorrect therapy, but it was no one's fault. These conferences always end with purported solutions. Next time, every nurse will have to complete a checklist, a pharmacist will have to double review, a doctor will have to click "OK to administer," a hotline will be created, a pathway will be added, a warning will be programmed into the EMR.

All medical interventions are human, but if every choice we make is the system's, is it any wonder we start to believe we are cogs in a machine? If the solution to every misstep is inserting another piece of tired, broken bureaucracy between doctors and patients like a facemask over goggles, is it any wonder burnout arises? The patient is further from your view, foggy, indistinct, and you are further from your own feelings.

Of course, the "system" is profoundly suboptimal. Of course, there are major inefficiencies that can be fixed. Of course, hospital processes can be better. Yet, continually dwelling on these errors without discussing or contemplating the errors of our own choices is a failure of our profession. Rarely these days are we confronted with the eternal question of medicine: should I have acted differently?

Thinking about systems can be a useful tool for improvement, but it risks eschewing the responsibility of being a physician. Increasingly, we come to shield ourselves from pain, discomfort, sadness, regret, and, in our training, grading, ranking, and frank feedback. Our clinical lives become sterile, and removed from our duties.

Ironically, by shifting the burden of our duty to the system, we transfer responsibility for improvement from that which we have complete control -- ourselves -- to that which is ossified and intractable. Worse, we no longer see the primary work of being a physician as improving oneself -- one's knowledge, acumen, and skills -- and instead transform into a factory of outrage towards others who do not yield to our desire.

In a world of systems, responsibility becomes diffuse, and few take ownership of patient decisions. The patient slides around the hospital like the planchette on a Ouija board, every team has a hand on it, but no one decides where it goes. The errors that get made are different errors. There can be no "I killed him." Instead, someone may suffer and die, but there is no one doctor who stands up and says the treatment was not appropriate for the patient.

He knew what he had done, my attending, and he had to tell the patient's wife and children the devastating news. He wondered if he should have done the procedure, and in the years that followed, I knew he would not escape that question. Does he still believe in the intervention? I hope our paths cross, and that one day, I will have the courage to ask him, gently.

"I killed him," he had said. He didn't need a fishbone diagram to map out how he felt, a prolonged conference with three consultants to spread responsibility, a tangential quality improvement project culminating in a poster. He knew there was no system to absolve him. He said it with openness so we might know too, and so, perhaps someday, we might see responsibility in medicine as clearly as we saw his pain.

is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .