We are constantly talking about all of these people in this country who are dying from medical errors. According to a recent publication, it is the third leading cause of death in the US. But who is doing all this killing, because it's certainly not me, right? I haven't killed anyone because of any mistakes. But statistically, I have to be a part of this number. I made some little something somewhere, that when added up on a balance sheet, pushed someone from the "alive" column" into the "dead" column. But it's hard to know what to do about this, personally. As a system, there are lots of things that organizations do, like tracking and labeling, human factors engineering, checklists, etc. etc. But what can I do?

In medicine, we talk a lot about "n=1" studies. In a research protocol, n is the number of participants in a study. The bigger the n, the more powerful the study to make a conclusion. But in practice, it is those n=1 studies that influence our behavior. I missed a cholangiocarcinoma whose only significant finding was a mildly elevated alkaline phosphatase. That was my only clue, and I dithered. And now, I'm suspicious of every alk phos elevation, constantly wary of missing this diagnosis. But it is a fairly uncommon cancer. I'll see tons of breast and colon and prostate and lung cancers in order to see one more cholangiocarcinoma. Of the 454 cancers found yearly per 100,000 population, cholangiocarcinoma makes up 1-2 total. There will be 452+ other cancers that I am going to see before I see another one. But here I am, fretting about a mildly elevated alk phos, wondering if I should get an MRCP.

A friend of mine described being a doctor as being continuously haunted by ghosts. There is always some ghost of a previous patient hanging over you, reminding you of your mistakes and failings. And it takes a fair bit of bravery to count up those ghosts and look for any patterns.

The right thing

Recently, I had to go to a meeting where we reviewed our HCAPS scores and other quality metrics. If you don't know what these are, then you're lucky. And we've had industry experts come in and talk to us about "Here's how to get your HCAPS better!" or "Shaving down your length of stay" or some other talk, in order to game our numbers and earn ourselves a few extra nickels. Most of the time, I play on my phone the whole time, or zone out completely. I have open disdain for such talks, not because quality of care is important, because it is. Quality of care is extremely important. But average LOS and HCAPS and HEDIS and all these quality metrics are all surrogates. I can make those numbers better, but that doesn't mean that I'm a good doctor.

However, one of these speakers said something that reached me. "The most important thing," he started. "...is that we do what is right for our patients. That's job #1. Then, we should figure out how we can get paid better for it. But even if we can't get paid better, at least we know we did what is right."

I spend a lot of time doing what is right, rather than what is expedient or what gets me more money. And that sounds so estimable and noble, but in reality, that is hard work. That is spending time arguing with an insurance company over a refused prior authorization, or seeing that patient who came in so late to their appointment but with acute problems that can't wait till next week, or spending 5 extra minutes writing a good note that most likely no one will ever read.

I used to be a little bitter that here I was, doing the right thing, and getting no credit for it. As well, there were plenty of others doing a fairly terrible job, and no one was calling them out for it. And it took this line from this industry expert to remind me that the goal wasn't to get credit. The goal was to do the right thing. That's the reward. Getting credit is just a pleasant side effect, should it happen.

When I was in college, I was the proverbial "nice guy" who never got the date with the girl, and I was similarly bitter back then. Here I was, such a nice guy, but ignored by so many women. And I was reminded by a very wise old lady that goodness is its own reward. If you are being nice to women only for the expectation of a reward, then that's not chivalry. That's being a creep.

Too little, too late

Last year, I saw Mr S, a wonderful gentleman in his seventies who was wheelchair bound and required constant supervision. The reason I was seeing him wasn't his paraplegia, but his terrible cholesterol and triglycerides, despite medications. I met with him and his caretaker, and we talked about his diet. In a shining moment of shared decision making and patient centered care, I asked him to tell me about what he eats and where we thought we could make changes. He proceeded to tell me about his diet, but we never got past breakfast. Every morning, he ate sausage, bacon, and 2 donuts.

We discussed what changes he could live with (his caretaker was more than willing to make the changes since her own doctor was fairly critical of her own lab results), and he agreed that he was willing to change his breakfast. He would get rid of the pork products, the donuts, and would change to a hearty bowl of oatmeal and fresh fruit. And his cholesterol and triglycerides improved dramatically. I couldn't wait to see him back in the office for his follow up appointment at 3 months, but the day before the appointment, his family called. He had died.

I can't help but feel that I made this guy's life miserable. He only had a few months left on this earth, and instead of bacon and donuts, he died with a belly full of oatmeal and cantaloupe. If I had known that we were dealing with a few months, what was the point of getting his cholesterol better? In medicine, it's really hard to know when you've been successful. Everyone dies. So what does it mean when one of my patients die? Did they meet their projected life expectancy? Did they get to median survival? The goal posts aren't the same for everyone. Maybe Mrs J who has bad COPD and CAD will be lucky to make it to 75. Maybe Mr O will live to be 100, despite his terrible diabetes.

People tell me that they appreciate the care I deliver, but it is exceptionally hard to know if you are a good doctor. Because the most important metric, are my patients living longer/better, has no control group for comparison.

After Mr S died, I went out to breakfast that weekend, and had pancakes and bacon and sausage. And I poured out some bacon and syrup for him.