You can do everything right, and still be wrong

I haven’t had the best time at work the last couple of weeks.

Having been in Melbourne, at the same hospital, for over a year now I have somewhat gotten into my stride. I have stopped second guessing myself and adjusted to the new way of practicing medicine, which if anything has been refreshing. I have enjoyed being able to be a diagnostician instead of a triage monkey.

As is inevitably the case, just as I feel confident, I have been hit with several difficulties in the last fortnight. There have been multiple patients whom I have seen, discharged home, and who have then represented with really weird, serious stuff.

Going over the cases with the head of ACEM (who by the way just happens to work at my hospital 😍), it is decided that I didn’t miss anything the first time around. Far from finding this reassuring, it is freaking me out.

I have always been able to deal with the uncertainty of medicine better than most. I am lucky in that I very rarely take my work home with me, and it is unusual for me to be thinking about patients after I have discharged them.

However, I naively thought that the degree of risk and uncertainty would decrease throughout my career. I hoped that with my increasing knowledge base and experience, I would become more sure of myself. Instead, the opposite has occurred.

It turns out that with more experience comes more uncertainty. You can risk stratify to your heart’s content and still miss important diagnoses. You no longer run your thinking past seniors in the same way, and as such the risk of missing things rests squarely on your shoulders.

It would be easier to deal with if I was being told that I failed to request a certain blood test or scan, or missed a vital detail in the history. But instead, I am being faced with the reality that you can do everything right and people will still surprise you.

Everyone that I have discussed my recent cases with has commented that they would have done the same thing, but the fact remains that I have a group of patients that I have seen over the last 2 weeks, who have represented and had adverse outcomes, and I am not sure how to make myself ok with that.

You have to be able to accept a degree of risk as an emergency doctor, and I don’t think anyone who I work with would say that I struggle with making decisions. Maybe I have just had a bad run, but it has significantly knocked my confidence and in my most recent set of nights I have noticed myself over-investigating, stalling, and keeping people for observation, whereas a week ago I would almost definitely have discharged them.

I am sure it is a medical coming-of-age; a realisation that you will never be good enough to prevent bad outcomes 100% of the time, but it is a difficult adjustment period and I have lost all faith in myself. I’m sure my equilibrium will be restored soon, but in the meantime I would be grateful if all my patients could show their cards early, and obviously, so that I don’t compound my lack of faith in medicine.

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