Saturday, October 3, 2015

Good At It

Friday, 4:55 pm. I am getting sign out from a colleague in order to cover the newborn nursery for the weekend. At one point, my young colleague sighs and says, “I just don’t think I’m very good at this.” I brush her off with a casual comment along the lines of: how much trouble can a bunch of normal babies cause? She isn’t satisfied. She is an excellent doctor as well as an excellent colleague, so she goes on: "I have this baby who was just born, with a pretty significant murmur and the nurses have already called me about it, so I don’t want to leave anything hanging over you for the weekend." She describes the situation in further detail. We talk it through and we decide that almost nothing would cause me to need an urgent echo for an otherwise well baby. Eventually we move on.

When we’re done, I come back to her expression of distress and “not being good at it”. I assure her that she is quite good at it. She worries she’ll miss something, a minor anomaly, a harbinger, a clue to impending disaster... I assure her that she will almost certainly do just that, and that we all do. I tell what I consider to be a funny story about a former colleague who missed an imperforate anus prior to discharge from the nursery. I pause to let that sink in ... but she can’t laugh just yet. She’s still too wound up from a busy week. She has already reviewed the prenatal ultrasounds, gotten pre- and post-ductal saturations and assured herself there are good femoral pulses on the baby in question. The baby is fine, but the physician is suffering. She finally says she is concerned about her physical diagnosis skills because somebody always manages to find something on the physical exam that she has missed. I say, oh like what? -the dreaded clinodactly of the fifth finger? Still... no laughter.

Our apparent belief that an obsessive pursuit of minor variations on the theme of normal makes you a good doctor has always been a pet peeve of mine, but suddenly I see how the phenomenon has shaken the confidence of a truly excellent junior faculty member. This matters because it is undermining her ability to say that any infant is normal. Of course, the infant in question wasn’t normal. Her mother had issues - advanced maternal age, a mildly abnormal glucose tolerance test, an “elevated” blood pressure, etc, etc. The infant herself was born at 37.5 weeks which also is not normal. The point being that normal no longer seems to exist. Still, how can I possibly find fault with a careful consideration of all the facts, including clinodactyly of the fifth digit (which is after all an anomaly, and furthermore, three such minor anomalies presenting in the same infant provide a 90% chance that the infant has a potentially significant underlying major anomaly - did I simply make that up? Do you like how I used "potentially" to modify the word significant? I swear I learned this factoid in residency, can you prove me wrong?*** Don't give up now, this story really does have an ending.)

I saw the baby the next morning and found the murmur to be present, but fairly soft and in no way provoking of further concern on my part. However, in the middle of the next night the baby had an “event” while undergoing a routine nursing assessment. Who knows what happened, but the baby appeared pale or blue or just “off” and had low sats, which prompted an ersatz 3 am resuscitation that included a few positive pressure breaths and an inevitable trip to the NICU. There, he received an evaluation for sepsis and an urgent echo…almost certainly because we had written murmur all over the chart. The labs were normal and the echo was normal, which you already knew because otherwise there would be no blog. Oh... but the baby did suffer a small pneumothorax, most likely due to the resuscitation - though there is no way to be certain of that. I am, however, certain that he spent a week in the NICU for culture-negative sepsis.

It is quite possible that the baby in this story really was intrinsically sick. I am aware that infection can be quite subtle in newborns. I am also aware that my own awareness often creates a tautology, a situation in which the conclusion is equivalent to the premise. For what is “culture negative sepsis” if not a circular argument? If you object to my characterization, consider the obverse: If I can never rule out infection in an infant with certainty then I can never be sure that I didn’t make a normal infant sick simply by suspecting that it might be so. I sincerely do not know which it was in this case.

Certainly, it’s necessary and useful to cultivate humility in the face of clinical uncertainty. But, it is equally useful to consider the harm we may do to our patients when trying to allay our own fears created by that uncertainty. And finally, it is also worth noticing, now and again, the harm we do to ourselves. I devote a large amount of time and energy to trying to elucidate the chain of events that lead us to provide unnecessary medical care. I never want that to stop me from providing necessary care. Yet, I can’t fail to notice that many, many times there is simply no way at all to tell the difference. I have days, like my young colleague described above, where I am profoundly depressed by the thought that I am not “good at it.” For me, the real impediment to feeling “good at it” comes down to the daily suspicion that at least half of what I do provides no tangible benefit to the patient. Which half? I simply don’t know.

***If you feel the need to go down the rabbit hole of the history of this factoid in medical education, here is a good start: J Pediatr. 1987 Apr;110(4):531-7. Predictive value of minor anomalies. I. Association with major malformations. Leppig KA, Werler MM, Cann CI, Cook CA, Holmes LB.

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