Doctored (11 page)

When I found the intern, Zahid Talwar, he was sitting on the side of a gurney, legs dangling, looking bored. He was about thirty years old, a Pakistani man with a long face and a white coat who straightened up respectfully when I arrived. I introduced myself and asked him about the chest pain. It had started after dinner the night before and had lasted about ten minutes. He had slept comfortably, but the pain recurred while he was walking to the bus stop that morning, persisting for almost an hour. It was a dense pressure in the center of his chest. To be on the safe side, he had decided to leave rounds and come to the ER.

His blood tests were normal, as was his first electrocardiogram. He had none of the traditional risk factors for heart disease, such as diabetes, hypertension, or a regular smoking habit. I suspected he was suffering from acute pericarditis, a usually benign inflammation of the membrane around the heart often treated with over-the-counter anti-inflammatory drugs. Characteristic of pericarditis, the pain worsened when he took a deep breath. I told him that if blood tests in six hours were normal, we would send him home. I joked there were easier ways to get out of internship duty.

Later that morning I got a call from an ER physician informing me that my patient's pain had resolved completely after he had taken ibuprofen, further confirming the diagnosis of pericarditis. For a moment I considered sending him home right then, but I decided to wait until the next set of blood tests was complete.

Just before leaving the hospital that evening, I ran into a physician's assistant. He told me that Zahid's subsequent blood tests showed evidence of minor cardiac muscle damage. This took me by surprise. Pericarditis usually does not result in abnormal cardiac enzyme levels. I quickly explained that the problem was probably
myo
pericarditis, in which inflammation of the surrounding membrane can partially involve the heart muscle. He asked me if the young doctor should have a cardiac catheterization to rule out coronary blockages. It was late; I told him that any workup could wait until morning. I assured him that a thirty-year-old with no risk factors did not have coronary artery disease. I instructed him to draw more enzymes and to order an echocardiogram and call me at home if there were problems.

Zahid had chest pains through the night. Doctors who were called to see him attributed them to myopericarditis, the diagnosis I had written in the chart. At 2:00 a.m. he asked for more ibuprofen. “I told them, if it's pericarditis, give me more medication,” he told me later. “Means, do whatever it takes to make the pain go away.”

When I saw him in the morning, the pain had subsided. However, further blood tests showed evidence of continuing heart muscle injury, and an EKG showed nonspecific abnormalities. Though I still doubted that he had coronary disease, I sent him to the cardiac catheterization lab for an angiogram.

I received a call from Rajiv about an hour later, asking me to come over to the lab. When I arrived, the angiogram was playing on a computer screen. It showed a complete blockage of the left anterior descending artery, the so-called widow-maker lesion. The artery looked like a lobster tail, unnaturally terminating after several centimeters. X-rays showed severe dysfunction of the entire anterior portion of the left ventricle. My patient had been having a full-blown heart attack, in which blood flow to the front part of his heart had entirely ceased, damaging the muscle, for more than twenty-four hours.

Nurses were spinning in swivel chairs, impatiently waiting for Rajiv to start the stent procedure. I sat down on a stool, feeling weak. Even the beeping in the control room sounded like an admonition. Rajiv was wearing a lead apron, standing over my patient, who was lying on a narrow operating table behind X-ray-opaque glass. Rajiv stared at me for a few seconds, as if trying to gauge my reaction. “Arm the dye injector, please,” he called out to a nurse.

“Done,” she replied.

“Give me ten cc's of dye for twenty seconds.”

“Coming up.”

“Can I have a three-millimeter stent?”

“You got it.”

And then, before I knew it, he had inflated a balloon and deployed the stent, restoring blood flow down the coronary artery. “All right, I'm done,” he announced.

Afterward, heat rose to my face as colleagues wandered in to inquire about what was going on. I said little, other than that my patient's symptoms had mimicked pericarditis. But what I was thinking was, You bastard, how could you have missed it? I was well aware of the disturbing prevalence of heart disease in South Asians, whose risk is up to four times that of other ethnic groups. I knew that heart attacks in this population frequently occurred in men under forty years of age, who often don't exhibit classic coronary risk factors. I knew all this, but somehow my mind had suffered a block. So much for the expertise I had claimed with Mr. Perkins.

“Don't beat yourself up,” a colleague said sympathetically. “Every doctor I know would have done the same thing.” Another told me that it was his policy to “cath” almost anyone who came to the ER complaining of chest pains. In his opinion, the risks posed by routine coronary angiograms were much less than that of a missed heart attack.

Rajiv came out of the procedure room and took me aside. “It could have happened to anybody,” he said quietly, “but now don't try to justify it.”

I started to blame the on-call fellow, who'd gotten information during the night to diagnose the myocardial infarction, but Rajiv stopped me. “It's not his ass on the line,” he said. “That's the difference now.”

“I'm not sure I did anything wrong,” I replied weakly. “Even Andrew said anyone could have—”

“Andrew thinks you fucked up, all right,” Rajiv snapped. “He's just being nice. Look, it happened. Just admit you fucked up and don't talk about it.”

I looked through the glass at my patient, being wheeled out of the lab.

“People love it when shit happens to somebody,” Rajiv explained. “This morning I had a stent complication. The patient was coding on the table. I was thinking, Fuck, the patient is going to die, I'm going to feel bad, I'll have to talk to the family, lawsuit, paperwork, et cetera, et cetera, but the fellows loved it. It's like NASCAR races: they go round and round in a fucking circle, big deal. But when there's an accident, everyone gets excited.”

What now? I knew I had to explain myself, but how much should I say? I had made errors before, but never one this big—and only a short while on the job, too. Should I just tell my patient the facts? Should I apologize?

Most doctors are afraid to take responsibility for medical errors. We are acutely aware of the potential hazards—legal and professional—of taking ownership of a mistake. In surveys most doctors say medical errors should be reported, but a large number don't report their own, especially minor ones that do not cause disability or death. “Apologies are a means of being polite if you are seven years old,” a doctor wrote on Sermo, the physician online community. “But when you are in medical practice, it has little role in patient care. An apology says, when the smoke clears, ‘I'm too inexperienced to be doing what I did.' And, whether we like it or not, that is precisely what patients, their attorneys, and juries hear.”

Another doctor wrote: “The whole ‘apologize and hope it goes away' thing is such a phony myth perpetuated by ethics types who don't have to worry about career ruin in the lawyer gang-bang that is U.S. health care.” And another wrote: “It's like confessing an extramarital affair to your spouse. What do you expect to accomplish?”

However, studies have shown that physicians' apologies do not necessarily increase malpractice lawsuits. In fact, they might protect against litigation. In surveys patients say they desire acknowledgment of even minor errors. For both moderate and severe mistakes, patients are significantly more likely to sue if a physician does not disclose the error, a fact most doctors are unaware of.

There has been a trend toward such apologies. Twenty-nine states have enacted legislation encouraging them, some even making physicians' expressions of remorse inadmissible in court. It wasn't always this way. Hospital legal departments routinely used to advise doctors never to admit responsibility for errors. During my internship orientation, a lawyer for the hospital said that at some point in our careers every one of us would likely be sued, and that we could even be sued during residency. She offered some advice: document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice.

I couldn't bring myself to talk to my patient in the cath lab, while everyone was watching, so I decided to wait until he got to the recovery room, where it was more private. I found him there lying on a stretcher. The pain in his chest was gone, he happily informed me. However, the groin where the catheter had been inserted now hurt. “They substituted one pain for another,” he said, laughing.

I grasped the side rails of the gurney. “I thought you had pericarditis,” I said carefully. I paused. “I was obviously wrong. I'm sorry.”

He seemed embarrassed. “No, no, please, the past is finished,” he replied. “I am more interested in the future.” He asked me why this had happened; his cholesterol level was normal. I explained that there were many factors besides cholesterol—some we didn't even know about—that were at play. He inquired about his prognosis. I told him that I thought it was good, though because of the significant damage that had occurred to his heart—damage made worse, no doubt (though I didn't tell him this), because of my misdiagnosis—he would have to be on medications for the rest of his life. He nodded, looking disappointed.

A few days later, just before he was to be discharged, I stopped by his room. I asked him with whom he was going to follow up. He told me that he had been given the name of another cardiologist but that he had decided to go with me. “You have been terrific,” he said. “Thank you for everything.”

I nodded silently, feeling empty. “You are much too generous,” I said.

 

FOUR

Good Intentions

In nothing do men more nearly approach the gods than in giving health to men.

—Cicero

The arguments started soon after Mohan was born, and though they were ostensibly about my job and our lack of disposable income, and not so much about the added responsibilities of a new baby, they were really about our future, what sort of lives we wanted to lead, and so, in fact, they really were about Mohan after all.

“I don't think it's asking a lot for you to think about our future,” Sonia said one evening after I had put Mohan to bed. “Your hours are similar to Rajiv's, and yet we are struggling financially. That is why I am bringing up private practice.”

I tried to explain that Rajiv, whose salary was at least double mine, performed invasive procedures, lucratively reimbursed in our current system, but Sonia didn't want to hear about how the American medical payment model should change.

“You think this is about jewelry or a four-car garage? Have I asked for those things?”

She had not, but we couldn't afford them anyway. The glum reality was that we were cash poor. After we paid rent and student loans, there was very little left over. We had enough money to entertain desires—a car for Sonia to drive to New Jersey to visit her parents, for example—but not nearly enough to realize them.

“I told you I don't want to do private practice,” I said firmly. “It has nothing to do with you or how I feel about—”

“But it does, because we are a family. And we are crammed into a tiny one-bedroom apartment!”

A force was bearing down on me, pinning me to the headboard of the bed. I wanted to holler, but I didn't have the energy to deal with the inevitably ugly aftermath. “I can't do it,” I said, though with less conviction than before.

“Of course you can! You considered it during your fellowship. Why don't you talk to my father? He could guide us—”

“I don't want to do private practice!” I shouted. “Those guys are a bunch of crooks. I see it every day in the hospital.”

Sonia's father, a pulmonologist, had made his money in the era after Medicare was introduced. Like most doctors of that generation, he had learned to play the fee-for-service game, amassing a huge personal fortune—millions—the kind of money that wasn't available anymore, no matter how hard you worked. He had told me I was living in a fool's paradise as a salaried physician, where there was little financial incentive to see more patients or order tests. “If you want to get ghee out of a jar, you cannot do it with a straight finger,” he'd said, recounting an old Punjabi proverb. “It has to be bent.” But I didn't want to do private practice. I didn't want to give up my job and the academic life, where I could practice the way I wanted, mostly free from the demands of the marketplace; where there was no pressure to overtreat patients; and where I could take pride in teaching the next generation of doctors. Ironically, it's the people who have money who seem to feel most strongly that you need money to be happy.

“I'm just asking for a plan for a better financial future,” Sonia pressed on. “I know I need to work, but I can't do that right now with the baby. I want nice things for us: a home, safe cars, good schools. They may seem trivial to you, but they are not to me.”

Of course, they weren't trivial, and in fact I felt sorry for my wife, overwhelmed, physically exhausted, and trapped in a shoebox apartment among piles of laundry with no room to move—and all of it under the shackle of financial dependence on me. But I believed that I couldn't allow myself to empathize. I was afraid that if I gave credence to her perceptions, I'd have to compromise what I felt at the time were my principles.