How Do I Fail Thee? Let Me Count the Ways

Some days I really envy my friends who work in business, in part, because they get to wear real clothes and cute shoes. It is, after all, hard to feel professional, let alone feminine, in compression socks and polyester, with clunky clogs to finish the look. I try my best to treat my work appearance as importantly as I would if I were venturing into a sales meeting, but it can be a challenge as my scrubs begin to fade or I realize mid-day that there is definitely a smear of poop on my pants. Not my own, I might add.

But beyond envying the fashion of my friends in business, I envy their scope of failure. Now, before I continue, in the interest of protecting myself from offended commenters and readers, I am aware that the business world is more than this, I am aware that it is competitive, stressful, and complex. However, very generally speaking, in business, income means success, financial loss means failure. It is a two way street, or a fork in the road. One direction equals success, the opposite yields failure.

Success and failure in medicine, on the other hand, is a complex woven maze of uncertainty. Similar to a poorly designed city highway system, the winding over and underpasses forced to grow with time in no organized fashion. The kind that has you constantly lost or headed in the wrong direction, the kind that result in frequent if not constant failure.

I have worked a rather unfortunate schedule lately, mostly of my own doing because of trips home and other obligations. I feel like I am at work all the time and rarely get a long enough break away to really recuperate. The result has been some serious disillusionment, exhaustion, and to be honest, burnout. In my run-down state last Tuesday, in the midst of another frustrating day of PICU life, I started feeling like I was failing my patients and then my coworkers. I felt physically tired, but more than that, I was emotionally drained and frustrated to be spending another hour providing patient care. Subsequently, I became even more frustrated that inevitably an attitude like that is read by other medical professionals, observed by stressed parents, and sensed by sick kids.

I felt like I was failing everyone. I started to think about these feelings of failure, about failure in medicine. I realized that unlike in business, failure here is so broad that it feels almost constant, inevitable. It comes in different varieties, yet it seems almost inescapable that we fail each patient, each family at least once. If the medical world functioned on the same plane as the business world we would have gone bankrupt ages ago, the auto industry would have nothing on our complete depth of failure. Sometimes I am less aware of it, but lately this failure feels constant. I decided to spend my last few days at work focused on this failure, focused on fleshing out where and how it manifests.

I was a little surprised by what I found, startled by the vast ways in which we the medical community fail our clients, our patients. So, for this post I decided to break down the ways we fail into what I observed as the most common categories. It helped me to see that our failures are so broad that although it feels frequent it isn’t always the same. It also allowed me to start addressing these common failures for my future practice, and may allow my medical readers to do the same. As a bonus, maybe this will allow my non-medical readers, who perhaps detest everything healthcare related in America these days to feel validated that we know we aren’t perfect, but we are working on it. So here goes.

Death

This is a big one, a big fail. The root goal of the medical community is to restore health, which inevitably requires the presence of life. Losing a patient is a painful failure for all of us. I work in pediatrics so deaths that can be followed by the self-assuring, “Well she lived a long and full life.” are even less common, less appropriate, and less true than the deaths experienced in adult medicine. This is not to say that the loss of an adult’s life is less valuable, nor am I excluding the situations where a child’s long and painful illness is ended and results in a peaceful transition to the other side. Yet, regardless of the age or status of a patient, the loss of their life is a failure to restore health, a failure to succeed at what we strive to do.

The problem with this fail is that, at times, death is inevitable. We can try to prevent it, or delay it, yet death is one of the only constants in life. So it will happen, and only sometimes is it a failure or error on our part.

What is hard about this particular failure is that, regardless of the inevitability, a death runs us down, leaves us defeated. For a moment it sucks the love out of what we do and a piece of the passion for medicine dies with each patient we lose. At least, for me it does. It makes us powerless and small, it makes our interventions and technology feel inadequate or futile.

It is hard to prevent or treat these feelings. Maybe as a medical community we would be well served to support each other better through this. Talk about it, remind each other that it is ok that it is hard, ask each other for help coping when it hits too close to home.

Oops

Another way we fail is in making mistakes. Everyone messes up, it’s part of being human. But in medicine, these mistakes are, or can be, huge. Safety standards in the medical world are often addressed and intervened upon in similar ways to the aviation industry. They are both big-oops fields. If your hairdresser shows up to work drunk or is thinking about her break-up or vacation plans and loses focus on what she is doing for a moment, you may have a few months of emotional pain from a bad look, but these mistakes rarely result in serious injury or death. (If they do, please consider a new hairdresser.) In medicine however, like aviation, almost every mistake has potential to be a harmful if not fatal situation.

This pressure is huge! It makes going to work stressful. There is so much to be aware of and focused on. The risk of messing up is scary.

It hasn’t helped that the medical world is now forced to work on the defensive to medical malpractice. This is not to say that people aren’t entitled to compensation when terrible things happen to them, especially as the result of medical neglect or incompetence, but things have gotten out of control.

What I really want to say about this, though, is that with every small error or missed intervention having the potential to be a big harmful event, it is easy to feel like we are constantly failing. And sometimes we are. Sometimes we miss things, often they are little things but sometimes they are big. Sharing our mistakes with each other can help to prevent future errors. I would be willing to bet that every time the cause of a plane crash is identified as a specific equipment failure, every commercial jet is checked right away for the same issue. We need to learn to share our mistakes without the fear of admitting to them.

Enough is Enough

In medicine, we are good at almost everything but giving up. No one wants to be the one to say “stop.” Lately I have felt that one of our big fails is that we just keep going and going, and trying and trying, and forget that living life involves more than a pulse and an acceptable blood pressure. At a certain point we need to be willing to say it’s time to stop. Families aren’t going to ask for it.

When I was growing up, we had a stray cat that adopted our family. He had a series of accidents involving high speed moving vehicles and his little cat body. Each time my mom would take him to the vet who would suggest intervention after intervention. I remember my mom joking that she was always waiting for them to say “or, you could just put him out of his pain.”

I do NOT mean to be insensitive or make light of a serious matter, I simply use that as an analogy to what families are experiencing. My mom would never have asked to put the cat down. In her mind it was the responsibility of the vet to offer that to us. Similarly, families need us to be honest about what we are thinking. I am so sick of sitting in family meetings giving a list of options to a family only to have everyone walk away and roll their eyes at the fact that the family is choosing to push on, do more, try more, even when everyone thinks it is futile. However, we never tell them that. We suck at being honest. And maybe it needs to be that way, because we don’t know for certain what an outcome can or will be.

But either way, we fail here. We fail here every single day. And this one is draining. It drains all of us. Doctors, nurses, social workers, parents, loved ones, and patients alike.

Talk to me

Ok, here’s another big one. It is big for two reasons. First, because it happens so much and effects so many of the fails I observe and experience. Second, because its impact is so large. Having been a patient for many years with a good number of inpatient stays, especially in the last two years, I can say from experience that the medical community falls short with communication.

Team communication is the first issue. Once I started looking for failures, I was overwhelmed by how poorly we communicate with each other. There are huge lapses in communication almost constantly. Again, this is inevitable since humans are involved, but we don’t update each other, we don’t share the plan. Sometimes it seems like we wait for the last possible moment to talk to each other.

What’s even worse though, is the way we communicate with each other. I think there are excusable exceptions, as in a code or stressful event. In these situations I am all for ignoring snippy remarks, or a condescending tone. Outside of these events though, it is amazing how poorly we address each other. I am as guilty, if not more so, than most are of this exact thing. I am often shocked at the way I allow myself to speak to people. However, I am definitely not alone on this.

Our communication with families can use some improvement too. The most common complaints patients have are related to the lack of communication or conflicting communication. We would be leaps and bounds ahead of where we are in patient satisfaction if we improved the way we communicated amongst ourselves, and then improved the manner and frequency with which we share information with families.

I dealt with a difficult family for the last few days. The first day, members of the family were frequently angry and nothing pleased them. They were sick of waiting on updates, waiting on tests. Honestly, they were really just sick of having a sick child. I went into my second day irritated to have to deal with it again. After a near melt down at the omni-cell, about 20 minutes into my shift, I decided to change my approach.

I often joke in my personal life that I am a hyper-communicator. Those close to me will confirm this as true, if you are interested. So I decided to hyper-communicate with the family. I went into the room at least once an hour simply to say that I had no new information but would keep them informed. Each time I asked if they needed anything or had any questions. This is similar to the hourly rounding method most hospitals now require of nurses.

I found that over the course of the day they became less angry. I didn’t just say I would check in, I did it. I never gave them new information, or really any information at all, but I was present, and I was communicating. There is no way to say whether my constant check–ins made any difference in their attitude, there are so many other variables that could have cause the calmer day, but the day was better. Perhaps because they felt in the loop, they were able to be confident that they would be updated if new updates were available.

If I am upset and given time to brew my frustration, I eventually explode. If you catch me early into it, though, and address my concerns, communicate the information you have and open a dialogue with me, dissatisfaction is kept from brewing and the explosion is often prevented.

My bad

“I’m Sorry.”

I recently wrote about how often I say those two words, but also how rarely I mean them. A hospital I once worked in had given us cards to place behind our ID badges with a prewritten apology for dissatisfied patients and families, “I am sorry this happened to you…” It created lots of opportunities for jokes and laughs among the employees. But realistically, how often are our apologies like that, a rehearsed ritual rather than an empathetic and humble request for forgiveness?

So much can be accomplished in life, and in medicine, with a heartfelt honest apology. There really isn’t much more for me to say here except that I see over and over areas where we fail to do this, and subsequently, areas where so much could be accomplished by taking a minute to own up and apologize.

I don’t know about you, but after that list, I feel like a failure as a nurse and member of the healthcare team. It is no wonder burnout is so high, turnover is so constant. Although, I think there are things we can improve. And as clients of the medical field, please cut us some slack. We are trying. But if you feel like we aren’t, then tell us, nicely, so we can hear it without writing off your concerns as unwarranted complaints.

This list is far from comprehensive, but it is a start, and gives us somewhere to begin making improvements. Failures of the medical field are incredibly complex, but like so many other things, fixing them is started with lessons learned in kindergarten.

Stay safe
Wash your hands
Tell the truth
Say you’re sorry
Use your words

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