Balancing the blame: A resident's perspective

December 21, 2020
Luke Burns, MD

As a doctor tackles the challenges of his senior year of residency, he learns how to balance the blame that can come with heightened responsibilities.

A few months ago, I transitioned into my third year of residency, crossing that invisible line that demarcates the junior residents from the seniors. In my program, this means assuming the role of labor and delivery chief, managing a floor of laboring mothers and antepartum patients.

It was at around 3 am on one of these nights, as I was sitting alone in the board room, that the silence was suddenly shattered by screams. A nurse burst into the room to tell me that the patient in room 11 had her amniotic sac rupture. Shouting from the hallway filled the room.

Room 11 held 1 of our high-risk antepartum patients. But which patient? As I sprang from my seat, I scanned through my mental Rolodex, desperately trying to remember which of the dozen high-risk patients I had assumed care for might now be imminently delivering.

It was only when I reached the hallway and saw the bed rolling past me toward the operating room that I remembered. Room 11 was a patient who was stable, primigravid with breech presentation, admitted several days ago for new cervical insufficiency and funneling. She was the one with daily reassuring nonstress tests (NSTs) and a cervical length that had not changed since admission.

She was also the patient who summoned me every night to her room, convinced she might have felt a contraction, the one I had only just reassured that evening, despite her insistence that this time something was different. Her tocometry was reassuring, her physical exam unchanged, and so we had decided against any intervention. And now she was delivering a 27-week infant in her bed.

The patient was rolled toward me, guided by a swarm of nurses, and as she approached, my eyes found hers. In an instant she recognized me as the young doctor who had ignored her earlier pleas. She pointed a finger directly at me.

“I told you! I told you and you didn’t listen, and now you’ve killed my baby! This is your fault! You killed my baby!”

I froze, speechless. Was she right? What subtle finding on her NST had I overlooked? Had I anchored myself in my own beliefs about her diagnosis? If so, I had missed an opportunity to initiate neuroprotective magnesium, to start ampicillin for her Group B Strep–positive status, to move toward a calm and controlled cesarean delivery.

I grabbed my scrub cap and ran to the operating room.

Sometime later during the gynecology night service, a patient came in to the emergency department (ED) for management of her abnormally trending β-hCG levels. She was a single mother, and sitting beside her was her 4-year-old daughter. She had been waiting several hours and was weary of the mixed messages she had received all week regarding a pregnancy that she had at first been told was a miscarriage and now was told might be ectopic. Now, she said, raising her voice, 1 doctor wants to give her chemotherapy, another wants to cut her open, and the third wants to do some kind of abortion procedure.

I took my time explaining her options. Throughout our conversation, her daughter napped quietly, even as my pager shrieked with incoming messages. Three new consults were waiting for me, including a gynecological oncology patient in the ED with a small bowel obstruction and an apparent non–ST-segment elevation myocardial infarction (NSTEMI).

The patient ultimately decided on a manual vacuum aspiration (MVA), but it would have to be tonight, she said. I leapt into action. My first step was to page the ED attending, asking if he would be willing to permit the procedure under general sedation in the patient’s room. While I waited for his response, I saw the pending consults. The patient with the small bowel obstruction had an outside CT scan that still needed to be read, and I contacted the radiology department to track it down.

Next I rushed upstairs to attend to patients on the floor and received a call from the ED on the way back down. They had decided not to let the patient have her MVA at the bedside, due to a new policy. This patient would need a dedicated operating room, despite the fact that with inadequate insurance she would likely receive a substantially greater bill as a result.

I updated my attending physician at home, then contacted the anesthesia team in the main operating room. The patient’s case fell somewhere between “elective” and “urgent,” but it was close enough to the former that the obstetric anesthesia resident I spoke to did not feel it warranted action tonight. She apologized and hung up.

My last option was to request the procedure be performed in a labor and delivery room. I begged the OB anesthesia resident over the phone, insisting that this patient was dangerously close to falling through the cracks, and she hung up to discuss it with her attending physician. Meanwhile, more gynecology consults had rolled in, and the gynecological oncology patient with the NSTEMI was becoming unstable.

When I returned to the emergency room, it was midnight. The OB anesthesia attending physician had approved the procedure. All of the ducks were in a row, and her MVA was ready to happen. I had pulled a few strings, exhausted all of my options, and now, finally, she was getting the care she needed.

As I approached the room, I heard yelling from within. Something was wrong. Inside, I found an emergency department social worker trying her best to calm the patient down. The patient’s daughter sat wide-eyed in the corner.

“You mean I’ve been waiting here for 6 hours for this procedure, and now nobody is going to take care of my child?”

The social worker explained that a family member or friend would have to care for the patient’s daughter while she had her MVA.

“Who am I going to call at this time? Why didn’t you tell me earlier? I could have found someone then.”

I tried to offer solutions. Maybe we could do something tomorrow? Later this week? She narrowed her eyes at me.

“You have done nothing for me. Absolutely nothing. You have been useless. Worse than useless.”

I stayed silent, not sure what to say.

“I’m going home now, and I’m going to take care of this problem myself. I’m going to end this pregnancy my own way, and you can read about it in the paper tomorrow.”

With that, she gathered up her daughter and left the room. Suddenly, the weight of the entire evening fell upon me, the lengths I had gone to secure this patient proper care, the many other problems I had been juggling, the dead ends I had reached, this accusation, and worst of all, the thought that this woman might hurt herself. In that moment, I lost it. Without knowing what I was doing, I felt my eyes fill with tears.

The social worker laid a hand on my shoulder as I buried my face in my hands. I’ve never cried in public before, certainly not in the hospital, but I could not stop. Even when I had done everything right, somehow things had gone wrong. What would happen to this patient? What was she going to do to herself? After a few minutes, I stepped outside again and the night carried on.

The following week I participated in a straightforward spontaneous birth. As the family thanked me for delivering their child, I did what most doctors do in this situation, refusing the credit and sharing the gratitude among all the nurses and other staff involved in their care.

It was then that I realized if I never accept full credit for a good outcome, why should I accept full responsibility for a bad one? If an upset patient lays blame at my feet, shouldn’t I stop to consider if I am truly at fault before I stoop to pick it up?

Avoiding self-blame is not an easy task. It is impossible for physicians to be entirely hardened against the bad outcomes of our patients. When things go wrong, hindsight forces us to consider every possible choice we did or did not make. But to assume full responsibility for these outcomes is an act of egoism; blaming oneself for the failures of the human body is like taking credit for the miracle of birth. Biology marches on, no matter how closely you follow your ACOG (American College of Obstetricians and Gynecologists) Practice Bulletin.

This is a timely realization for me as I embrace my new role as a senior resident. Now with more responsibility than ever, I need to remember that when things go wrong—and they will—I must learn from these experiences without letting them drag me down.

And perhaps most importantly, I will remember to share them with other trainees. Every 1 of my role models has made a mistake, lost a patient, or cried quietly in the hospital. Attendings and senior trainees should know that it is not their stories of brilliant diagnoses or heroic interventions that most inspire their residents. It is the stories of times when they felt they were knocked down, either by a bad call or a bad outcome, but rose up again, wiser and stronger than before.