Peter Smulowitz, M.D., M.P.H., is Chair of Emergency Medicine at Beth Israel Deaconess Needham in Needham, Massachusetts. He is a past president of the Massachusetts College of Emergency Physicians and previously served as the site lead for CARe (Communication, Apology, and Resolution) programs at Beth Israel Deaconess Medical Center. As a young physician, Dr. Smulowitz was involved in a missed diagnosis that resulted in the untimely death of a patient. In an essay published in BMJ Quality & Safety, he describes the aftermath of the death of a healthy young man in the Emergency Department 13 years ago and how the experience continues to affect his practice of medicine.
The Betsy Lehman Center: The event you describe happened early in your career. Did anything in particular prompt you to write about it now?
Dr. Smulowitz: There are two major reasons I wanted to write about it now. First, speaking about and writing about this event is a big part of how I continue to heal, even 13 years later. The deliberative thinking that goes into putting something on paper helped me process my feelings over this event, which was so catastrophic early in my career. The second reason is that I’m hopeful that in sharing this story, I can help others who may have had similar experiences. There are many physicians and other members of the health care workforce who suffer in silence in the aftermath of adverse events. And there are even more physicians who just feel overwhelmed by this system that seems to demand perfection. Simply put, there is no reason for others to suffer like I did, and I hope my essay helps.
The Betsy Lehman Center: How have readers and your colleagues responded to your essay?
Dr. Smulowitz: I’m grateful to those who have reached out to thank me for sharing this experience, and especially to the younger physicians who have shared with me their insecurities and how hard they are on themselves. It’s distressing to me how many physicians feel overwhelmed by the erroneous notion that making a mistake in medicine is somehow a mark of inadequacy or haunted by the specter of being sued at some point in their careers.
Interestingly, some have mentioned how hard it must be for me to feel vulnerable by sharing this story. The fact is, what was really difficult was keeping this inside for so many years. Knowing that others feel the same way, that I’m not alone in these struggles, has been a blessing.
The Betsy Lehman Center: You say that experience still informs how you view yourself as a physician. How so?
Dr. Smulowitz: While I’ve repaired much of my confidence in my skills as a physician since this event, as I state in the essay, I still feel fragile to some degree. It takes just another small mistake or an unexpected outcome for those feelings of inadequacy and insecurity to come rushing back, though of course much less so than early in my career. This experience and the years of practice since then have taught me a lot about how to approach my own mistakes and those of others with much more equanimity. It is so easy to assume that a missed diagnosis is somehow a failure on the part of an individual physician, but we often forget that what is so clear in retrospect may have been really challenging in the moment. And this may be for a variety of reasons either related to complexities of the patient, challenges or failures in the system, or maybe a simple bias or blind-spot for the particular physician. But put in that same place, none of us really know whether we would have made that same mistake. So rather than cast blame, we need to better support physicians after adverse events and simultaneously continue to make the systems in which we work safer.
The Betsy Lehman Center: There were other clinicians involved in that adverse event 13 years ago. Did you have an opportunity to talk with them at the time or since?
Dr. Smulowitz: Unfortunately, no. I often wonder how the radiologist involved in this case felt, and if they experienced a similar struggle in the aftermath. Historically our system has not promoted a real healing process for clinicians. I would undoubtedly welcome this connection.
The Betsy Lehman Center: What advice do you have for physicians who worry about the potential for error and wrestle with feelings of uncertainty and imperfection?
Dr. Smulowitz: I want to remind them that no matter how good or experienced we are, we all make mistakes. Furthermore, making a mistake — even a major one — does not define us. I also want to remind every physician that they should not feel alone either with their struggles over their insecurities or in the aftermath of an adverse event, and that they should reach out to a colleague, formal peer support program, or anyone who will understand what they are going through.
But it’s not just the medical profession that I think can benefit. I want my essay to promote a more humanistic discussion between physicians and patients and families about the illusion of perfection in medicine and especially with how we react after bad things happen. The lay public must start to appreciate that we are all striving to build a system that reduces harm, but that because human beings are central to the practice of medicine, perfection is simply unattainable. No matter how hard it is, or how serious the event, we should not place blame on individuals. Mistakes are inevitable in the complex system in which we work. We need to learn how to forgive others — and ourselves — when mistakes happen.
