Dealing with Medical Error as a Physician with Dr. Laura Vater

Doctor Laura Vater discusses medical error and compassion fatigue on Young Surgeon

Dr. Frances Mei Hardin: Welcome to this week’s episode of Promising Young Surgeon. This week, Doctor Laura Vater joins us to discuss medical error and compassion fatigue. But first, I want to talk about a specific idea related to these topics today that does exist at some institutions under one name or another. This is the code lavender, so when there’s a poor patient outcome, the provider involved is at risk of becoming a second victim. First developed in 2008 by the Cleveland Clinic, Code Lavender is a holistic rapid response program designed to help providers in the aftermath of stressful or traumatic events. Other institutions have since adopted the principle, but it does remain this rarer idea where provided free of charge are rapid physical, emotional, and spiritual support for hospital employees. Cleveland Clinic’s Code Lavender team utilizes the following methods, manual therapies including reflexive brushing, light massage, reflexology energy based tools such as reiki and healing touch expressive art with playing recorded music, singing, self driven art journaling, storytelling and mind body tools that involve guided imagery, meditation, movement and breathing exercises, acupressure and holistic coaching. Too often, our institutions fail to recognize the danger posed to the provider involved in a bad outcome. To the non healthcare worker, the idea of consistently being surrounded by death, gruesome injuries and illnesses, grieving families, and so forth on a daily basis would sound horrific. Yet to physicians, residents and other healthcare workers, it’s all part of the job. So while your institution may not have a code lavender response team, know that it is okay to seek help, support and therapy. And if you’re in a position where you can advocate for the creation of a code lavender response team, that is worthwhile as well. If you do experience any of these difficulties, you should not just have to tough it out alone. Doctor Laura Vater is an oncologist, mom, writer, speaker, and advocate for clinician well being. She obtained her Bachelor of Science from the University of Notre Dame, master of public health from the University of Pittsburgh, and medical degree from Indiana University School of Medicine. She then went on to complete her internal medicine residency and oncology fellowship at Indiana University. In her time outside the hospital, doctor Vater enjoys spending time with her husband, daughter and golden retriever, as well as reading and hiking. Thank you so much for joining me.

Dr. Laura Vater: Today, Doctor Vater hi Doctor Hardin, thank you so much for having me.

All of my partners have experienced some type of medical error at some point

I’m thrilled to be here for this really important discussion today.

Dr. Frances Mei Hardin: Well, I’m so excited to get started. We’ll just jump right in and I would love to hear your thoughts on medical error and what it means to navigate those as physicians.

Dr. Laura Vater: If we’re practicing medicine long enough at some point in our career, something’s going to happen. It could be that it’s the wrong medicine that’s ordered the wrong dose of a medication. It may be something that happens with a procedure or with a surgery. It may be something that happens when a person has been sleep deprived for 24 hours, 36 hours, 72 hours, 100 hours, because those things happen both in training and practice. It may happen when you’re being paged and called and you have all these distractions. You have a number of people that need your attention all at once. But at some point in time, all of my partners, all of the doctors that I know have experienced some type of medical error. And when this happens, not if this happens, but when this happens, that can cause a huge, huge negative downstream of consequences for a physician. First, it can feel like shame crawling into a hole, never wanting to emerge, never wanting to practice medicine again. It can feel like depression, anxiety, even thoughts of self harm. There’s higher risk of both drug and alcohol use for physicians that are going through this, and even thoughts of just, you know what? I’m done leaving the field of medicine altogether. So I think this is a really important topic. I’m so glad that we’re talking about this, especially for, doctors who are in training and who are entering into their first few years of practice. I think it’s really important to normalize these conversations and to know that when these things happen, we need support. We need to have colleagues who are supportive, and we need to help make these types of conversations more normal so that people feel less alone and feel less shame.

Dr. Frances Mei Hardin: I love that, and I totally agree. I certainly. I think that everyone benefits from open conversation about this.

There’s a lot of things that happen in medicine when you’re exhausted

And so I guess the first thing that I think of as you’re talking about this is I would love to know how much your residents, you know, at, your institution, hear from the attending level. Hey, this is part of a long career in medicine. Hey, these are things that I have experienced. Do you feel like that’s very openly discussed with trainees there?

Dr. Laura Vater: You know, it’s really interesting. When I went through my medical school training, and even I had a, you know, I went through a graduate program before that within public health, I had never had a formal lecture that I can remember about this, nor did I ever have an attending that I worked with in my training that was really open about that type of thing, because these are things that, if they happen, when they happen, especially as an attending physician, I’m sure it’s not something you really want to share with your trainees. It’s something that many people try to keep hidden and try to forget about. And so it was not something that was openly talked about, to my knowledge. I then had some experiences as a senior level resident where I was working on some night shifts, working with groups of interns. We would work three or four days and then have a couple of days off work three or four days. And I remember coming back to this group of interns, and one of. One of these interns just being completely different, withdrawn, just not himself. And I kind of pulled him aside, and I said, is everything okay? He’s like, no, it’s not okay. And so we were able to find a private conference room and just talk. And it was through this experience with one intern kind of sharing something that had happened when I was not present in the hospital because, you know, and there were other teams covering, surrounding a bad outcome with a patient. When certain objective measures were not reading correctly, certain decisions were made. I’m not going to say it was necessarily one person in one era. It’s a multitude of factors, but really led to a decline in this young person’s mental health. And it was in that moment that I thought, wow, this is not something that we talk about enough. This is something I need to start exploring. As an internal medicine resident, I worked a lot of long calls, you know, 28 hours shifts as a fellow. I worked a lot of home. I did a lot of home call week at a time where we were kind of day and night for a week straight, being at home and getting really short stints of sleep, if at all. And so there were times in my training where there were either near misses or things that. Right. There’s a lot of things that happen in medicine when you’re exhausted that I know we’re going to talk about. Things like compassion fatigue. Right. But that also, puts us at risk for error. And so I actually was asked because it’s something that I’ve started talking about both openly on social media as well as with residency groups. I now give grand rounds across the nation. People ask me to say, hey, I just gave a dean’s grand round at my institution this spring. I just gave a grand rounds this week on this topic. I think often to residency groups is, I think, where the interest is, but it’s something that we need to normalize, we need to talk more about, because it does have serious repercussions. And now that we talk more openly about it, I hope that we look at some of the data and we can talk about it, but there are some in the literature, some steps. They call it a four step process for self compassion after a medical mistake. And there are really things that we should not just try to ignore and pretend that these things aren’t happening. But really trying to set up all of our learners, medical students, residents, fellows, is for success by saying try not as much as possible. Let’s protect the sleep of our learners if we can. Let’s try to protect them from burnout, which increases the risk of medical errors. Let’s try to eliminate bombarding them with messages that aren’t needed. That may distract them and pull them away from the things that they’re doing. But then also, if something catastrophic happens, how can they handle it? I think a few things that really help this part of this four step process is, of course, if you’re in training, it’s of course talking with your leaders and your attending physician and talking about it and figuring out what’s the right time and the right way to disclose this to the patient. But it’s really about restoring that trust, sharing what’s happened with the patient, being open and caring. And really even before that, the steps or two before that are caring compassionately and creating relationships with patients and, building that trust to begin with so that if something unexpected happens, that relationship’s already there. But then it comes to honesty, and then it comes to repairing damage, if possible. And then it really comes down to seeing if there are bigger issues with why did this happen? Right. Maybe it’s. Maybe it’s something with an electronic medical record. Maybe it’s something with the pharmacy, maybe it’s something with the way your operating room is set up or the flow of, you know, surgeries. Maybe it’s whatever that is. Can you make some type of fix to help prevent this from someone, for someone else? And then it comes down to healing. And many of the physicians who’ve openly shared their stories with me, they talk that, they say that it can take years, healing can take years. Often helps, therapy helps, journaling helps. But really, the key to what helps support a physician that goes through a medical error is the support that they get from their colleagues. That is really the most predictive factor of how they’re going to do long term.

Dr. Frances Mei Hardin: That’s all very interesting. I appreciate you walking us through that four step process, which definitely makes sense.

Do your institution have a code lavender for mental health after medical error

I guess from my standpoint, I’d be interested to know, does your institution have anything like a response team or a code lavender esque program where a person you, know, a healthcare worker, physician, any healthcare workers mental health is in question or deteriorating after a medical error. Is there one designated great team or one designated even person or representative who they can reach out to in a pinch?

Dr. Laura Vater: Our institution has support for residents, and that support is actually kind of through, an organic process, through our palliative care team, actually. So this support really comes especially for physicians who are working in the ICU and for the residents in the ICU. That support has come through the palliative care team. So there has been a lot of initiatives for things like debriefing and support immediately after an event. we’re also doing initiatives surrounding narrative medicine and parallel charting, which is this concept that I know you had mentioned. Part of the code lavender can be journaling or storytelling, and that’s an initiative that I’m helping to spearhead on our campus, is really narrative medicine and parallel charting. We don’t, at least that I’m aware of, have a code lavender where the moment this happens, there’s a team that kind of descends upon the person. It’s an interesting concept, and I really like the concept of it. I’m trying to think. I just want to ask you, too. So if you’re ever in a situation like this, would you call a code lavender on yourself or what would it feel like to do so for your peer? And I think it was something you would certainly need their permission for, but I think that there’s nuances to it, right. Because so many of these things, when even someone shares something so vulnerable as a medical mistake or that their mental health is declining, it’s wonderful to have resources. As long as those resources are in my mind, I’m thinking, what does it look like? I don’t know if you have experience, but, like, you think of a code blue and it’s like, go overhead, code blue.

Dr. Frances Mei Hardin: I know, draw tons of attention to yourself when you’re already maybe feeling shameful.

Dr. Laura Vater: So I think if it’s a process that could be. I love the concept of it. I think that if it was somehow kept in privacy, where it was, the person was reached out to, and they were offered services and encouraged to utilize whichever service worked for them best. I think that my only caveat would be if it became this public thing that made a person, that could possibly increase, you know, shame. I’m just curious if you have experience with it. I personally have experience with things like debriefing, journaling, therapy, and processing in other ways. But I. There’s certain concepts there that I haven’t personally had experience with. I’d love to hear more if you’ve had experience with those.

Dr. Frances Mei Hardin: No, that’s awesome. I did do part of my training back during medical school at the Cleveland clinic, and so that’s why I happened. I was aware of it. I have not seen this called, in real time, although, you know, like you mentioned, I definitely. I don’t think it goes on the overhead pager. No one would do that. Everyone would just take the hit and they, you know, I think that. That being said, when I think back to even, like, my residency training experience, I have seen, you know, through various, like, m and m type settings, which, is morbidity and mortality. I have seen at that conference, other trainees get to more the point that you describe your intern in the past going through. And so I don’t think that it’s far fetched that somebody in need could, you know, maybe not the day of the event. Like, certainly, you know, and, like you talked about, this is a multi step process. Patient care does take a very, high priority. You know, so kind of like writing that, doing the root cause analysis, looking for holes. Sure. But what I’ve seen personally is just how insidious it can be for days to a couple weeks after. And so to me, that’s where it would be really cool to have a resource like this. And that way, like, you know, say it’s five days later, you’re still not sleeping well, you don’t feel like you’re really bouncing back from this, which that doesn’t mean there’s something wrong with you. Like, these are really big things to, quote, unquote, bounce back from, or just, you know, squash it down and keep on going with your day. So to me, I could almost, in a very practical sense, answer your question. I could see more people calling it in the first two weeks after the event.

Dr. Laura Vater: Yeah, I think that that’s. And finding a way to do it that maintains that person’s privacy and schedule and ability to continue to process and continue to function in their roles. I love that idea, though. I think that what’s most important here is that whether you have this type of system in your institution or not, I think it’s really important to check in with your colleagues, even if you’re rotating with them for only a week or two, trying to be that type of person that is aware of their emotions, their body language. And if something were to come up, just being able to say, hey, do you wanna talk? And creating that safe space for that. If you’re leading a team as an attending, physician. I do this on my consult services. In oncology, we often have very hard conversations. I’m sure you do in the work that you do all the time, too. And here we are coming in as this big team, or either telling a person their cancer has progressed or that they have a new diagnosis of cancer. We’re walking them through their options, and sometimes, depending on how they’re doing, we’re often having end of life conversations. We’re having family meetings, and these things are highly emotional. They are just difficult. Right. There’s a lot of emotions that we can experience, and so I think even just checking in with your team or even saying aloud as the leader of that team, saying, oh, my gosh, that was hard. How was. How’s everyone doing? That was hard. Just take some time. It’s going to take some time to process through that. What we do in our work is not normal. It’s not normal to walk into one room and tell someone that, the end of their life is near or to share life altering news in the next moment. Walk in and everything’s fine in the next room. Right. There’s a lot of challenges in the work that we do, and just being able to be aware of that, that the work we do is not normal. And checking in with your teams, I think, is really important.

Dr. Frances Mei Hardin: Yeah. And doctors are master compartmentalizers, but I don’t. I think that anything can be, you know, a strength in moderation, but people do it to a fault. And I definitely identify with everything that you’re saying, because I’m in a rural solo ent practice, but I have a lot of advanced head and neck cancer walk in. This is their first time seeking care, and so, unfortunately, we do do a lot of the primary workup, a lot of delivering the news, and I really love. I want to emphasize for everyone how much the leader of the team can set the tone, though. So to imagine, like, an attending in the academic setting just being like, yeah, that was tough. Like, I’m not. I’m not totally desensitized to this. Like, this is a big deal. Again, we just provided life changing news.

One thing that we’ve been able to do in clinic is treat cancer with sacredness

One thing that we’ve been able to do in clinic is because I do treat that with kind of, like, this sacredness. I mean, yeah, if somebody’s coming back with their biopsy results, and this is the formal, okay, you have a glottic squamous cell carcinoma talk. Yes, I’ve prepared them because if I meet someone and, you know, it just looks classic, and clinically, it’s classic. I’ll tell them I’m worried. I’ll say I’m suspicious that this could be a cancer of the vocal cord, you know, of the voice box, things like that. But, you know, I do, of course, think that, understandably, patients hold out hope until you give them, you know, the biopsy results. But we’ve been able to change clinic workflow a little bit. Like, we have nurses who will help on that side, come in for those visits. Like, they do have a lot of the hospital’s cancer support resources, things like that. So even though we’re not a big cancer center, we legitimately do even change our general Ent clinic workflow to give some more of, like, the sacredness of that conversation back to the families, you know, instead of, I can’t imagine, like, running through it and then just being like, anyway, good luck and, like, you’ll meet your oncologist soon.

Dr. Laura Vater: Wow. Thank you for the work that you do. Being in an underserved area, being in a rural area, and being the only ent there, often the first person that’s seeing these people that have. Are having devastating cancers. I mean, that is such important work. And those moments where you’re conveying those really hard results, they’re going to remember those for the rest of their lives. Right? And I think that as much as we can care for our patients with compassion and kindness, just to make those conversations just a little easier, to help them feel more supported, I mean, that makes a huge difference for patients. A huge difference. Thanks for the work you do.

Dr. Frances Mei Hardin: Oh, my gosh. Well, thank you, of course, ditto to you as well. And I do think because, of course, like, I’ve read a lot of your work. I mean, I really love, a lot of your speaking and writing on these related topics. But from my standpoint, too, I think of how a lot of doctors, particularly doctors who are in this line of work, do have an experience with a family member or close friend. And I just know for myself when you talked about, people will remember this conversation for the rest of their lives. I was 19 years old when my grandmother, who I grew up with at home, who, in part raised me, you know, she was like a sister to me. And, she hadn’t been able to eat for a couple weeks. Like, wasn’t keeping anything down. You know, she’d been having back pain for months and months, but not really telling anybody about it and things like that. So eventually, she finally let me take to the emergency room, and I was home from Notre Dame. And so, you know, I kind of tucked her into it. We drive to the emergency room together, and ultimately it was a pancreatic cancer, and she passed away a couple weeks after that er visit that we did together. But what’s wild is that I do remember the diagnosis because, you know, we’re sitting in the hospital waiting. They’d done some imaging, you know, at the time. Who knows what it was at the time. Probably like a CT abdomen, something like that. But what I remember is that, you know, like, a resident gave the news and they used the term lit up like a Christmas tree about. Yeah, about her abdomen and, like, about. And I kind of was like, you know, I mean, again, this woman was like a sister, grand grandmother, like one of my closest family members of my life. And it just. It was really tough. And there wasn’t, like, time for questions because I had a lot of questions. She was very, gracious and zen about the whole thing. But, like, I was kind of like, oh, I have several questions, you know? And, ultimately, she did pass away in hospice at home, surrounded by her family and everything like that. But, I mean, that was several years ago now, so hopefully people know not to use that language because that’s really scary, and people will remember that forever.

Dr. Laura Vater: That is. It is so hard when we all have people we love, we all have people we’re close to, and we will all have an experience in healthcare. I remember when my mom became very ill when I was a first year medical student, and she had a subarachnoid hemorrhage that was very severe. and she was lifelined to a neural critical care unit. And I remember just sitting by her bedside, trying to be, like, this first year medical student who had no medical experience, really, and then trying to search all these things and up to date and being told that her chance of death was very high. And feeling like the doctors, I knew that they were exhausted. You know, their scrubs were wrinkled, and their hair was in this. And I could tell that they’d been up for a long time, especially the. Looking back, it was actually an intern that was, like, supervising that I. That I probably saw the most face to face. And I know that they did their best in the moment, but I had similar feelings of I just needed someone to say things to me in words that I could understand. And thankfully, my mom recovered and did very well. But it’s so hard when you have a loved one and you’re on the other side of that conversation. It’s really hard because sometimes people that go into medicine, myself included, you’re learning all these new language. You’re learning a new language, all these words. And then you get to a point where you forget you speak a foreign language, whether it’s the jargon of that language, like lit up like a Christmas tree, or it’s these really complicated words, like endoscopic, retrograde, cholangiopancreatography, whatever those words are, we forget that we speak those foreign words. And so, as much as we can, like you do with your patients, very clear language, a, cancer of the vocal box or whatever it is, just breaking it down, really simple language. And it takes a lot of skill to do that. It’s actually easier to say the hard words and a lot harder to make it simple and then doing so with compassion. I think things that when I teach learners, it’s go in the room and sit down, put your stool at their eye level or below right away, set that dynamic that you are not standing above them, you’re not superior to them, you’re not above them. You are their equal in this moment, or even squatting down if they’re in excruciating pain, putting up as much as possible, silencing your phone or leaving it outside, not being on your computer the whole time, using simple words, being right there with them, showing support. So if it’s appropriate, you know, putting your hand on their shoulder or even holding their hand, if you know them well, expressing a statement of support, something like this is really difficult, and we’re here to support you. We’ll be here with you every step of the way. Those things significantly matter to patients. They change their experience in healthcare. They’re very simple to do. They take almost no time. And I think that they make a profound impact in the lives of our patients.

Dr. Frances Mei Hardin: Yeah. And I like that you just encourage people to kind of go the extra mile and provide that support, even if appropriate. And if they’re reading the room and they know the audience like to reach out and touch the patient. Because I agree where I’ve seen that often, patients really appreciate that, especially when used correctly. But I do think that part of becoming a student, transitioning into training as a resident physician, and training beyond is kind of knowing when to do that and just not to be too afraid to try. Because I do think that at the end of the day, patients do recognize a good faith effort to attempt to connect with them and truly show that your heart is going out to them. I mean, sometimes I literally say my heart goes out to you. I’m a less physically touchy person, although I would if I see that a patient would be very comforted by that, you know, then and again, I have, the gift of, like, a team. And so my nurses, who are a little bit more touchy feely, maybe they’re touching. I say sincerely, like, my heart goes out to you, and we kind of have a conversation that way. But I just don’t think that, especially as we talk about training the next generation, that they should be afraid of or shy away from giving that true, heartfelt support. And your own opinion, if your own opinion is, hey, my heart goes out to you, because I guess it sounds like a soft thing to say in a clinic visit.

Dr. Laura Vater: Absolutely. I think that that’s so true. There’s so many things that our palliative care teams, I think anyone that’s in training would benefit from rotating through a palliative care rotation. And just some of the language, just picking up some of the language of, I wish we were meeting in different circumstances. I wish I had a tool that could make this go away, especially in oncology.

There is a benefit in learning from experts about how to communicate with terminally ill patients

I do mostly GI oncology, so I take care of my patients have pancreatic colorectal cancers, cholangiocarcinoma is very aggressive tumors, and often metastatic. And we do everything we can to help patients feel as well as possible for as long as possible. For many of our patients, there comes a time where more therapy is not going to cause them further benefit, but may actually cause harm. And those are often the hardest conversations of, I wish so badly that I had a tool that could make this go away. and I find that our palliative care colleagues use those terms a lot. And I think that it does express your desire, because it really is, deep down that you want to help a person. And conveying that through those statements, I think, can be really helpful. And I don’t know, in your training, if you had this, we had these, we call them vital talks. They started at the University of Pittsburgh, actually, where I did my master’s in public health, and my mentor for a long time, long time doctor Yale Shanker. She’s a palliative care researcher there, her and her team with Bob Arnold. I think Bob was really the kind of the first spearhead, but they created these talks for people in training, really, to have patient actors. And so we did this throughout my residency and into my fellowship, where you do a full day or two, a, year, where you’d have patient actors come in, and you’d have hard conversations, you’d deliver bad news, you would do all these things actually, with people who were skilled actors. And then the palliative care team would, like, pause, and then you would try it a different way. And then they’d pause and you try it a different way. Not that these conversations can be rehearsed, but there is a benefit in learning from experts and doing your best to communicate in a way that is as compassionate as possible.

Dr. Frances Mei Hardin: Wow, that’s incredible. So that’s called vital talks. Is that right? And, like, people. Oh, yeah, I have to check that out. We did not do anything like that in my residency training. but, you know, it’s never too late. I definitely. So, like I said, I would really benefit from that. I wish I’d spent more time with palliative care services, certainly, like, over the decade of prep and training, because, like I said, now I’m kind of out, like at a community hospital, alone. And this comes up a lot. So any bit that I can improve, you know, the way that I show up for those visits and those patients, like, that’s incredible.

Palliative care team is part of response or support available for resident physicians

So, the other thing that I wanted to mention that I loved about the palliative care team is how you described that they are part of the response or support available for resident physicians. And that’s just even soothing to think of. Like, I did have a really difficult time during residency, you know, particularly just in a one or two year chunk out of the five years. But, yeah, I mean, I think that. I think that that team, they’re the experts and they have a lot to offer residents. I’ve just. I had not heard of and I hadn’t thought about until today, like, what an incredible resource. If there is something worked out that. That a resident could contact them.

Dr. Laura Vater: Yeah. Because our palliative, at least our palliative care team here on campus, they are highly involved in the teaching of our residents, and they’re just such wonderful human beings who. Who just have this deep well of caring not just for patients, but for learners as well. And so. And they’re so, they’re such good communicators. And even to have someone, see you, see you in your hurting and say you’re not alone, and you did your best with the knowledge that you had and the skill that you had and the ability that you had in that moment, I think that that’s very healing.

Dr. Frances Mei Hardin: Yes, I love that. I think that that’s definitely something I’m going to chew on because, you know, any bit that we can bring that to more spots, I think is very helpful for residents. because, you know, that last piece about, like, inter collegiate support and things like that. Not every resident physician, or not every physician does have that where they are. And so, you know, it’s awesome to create these redundant systems or create protocols, have whole teams who are involved.

Sleep deprivation is a major contributor to medical error, you agree

But the last thing that I wanted to mention just on the topic of medical error is that you touched upon, you know, these two prongs. Number one, sleep deprivation is a major contributor. 100% agree. I used to take home call as a senior ent resident, and that was Friday morning at 07:00 a.m. Until Friday morning at 07:00 a.m., and, my husband just still kind of roasts me because two different last Fridays. So, like, the 7th day, the garage door was opening, so I could back out and go to work, and I drove right into it.

Dr. Laura Vater: I did that. I’ve done that, too. When I did home call as a resident, too. So, hey, guess what? We are not alone in that.

Dr. Frances Mei Hardin: Oh, my gosh. No, I know. We’re like the garage door club. Well, I’m definitely going to tell him, like, it’s not just me, because that’s a pricey, you know, like, little error to make at home, but it really does show how out of your mind and body you can be on the 7th day, you know, of these seven day calls. So. For sure.

Fear and the effect on people’s likelihood to make medical errors

So, number one was sleep deprivation, and the other thing that you mentioned was, of course, like, burnout. So. And then any contributors to burnout. What I think is interesting, and what I propose is kind of like this third major prong. And again, I just say that because it did play a lot into my personal surgical, you know, subspecialty residency experience. But fear. Fear and the effect that it has on people’s likelihood to make medical errors. And so one story that I just wanted to share really quickly to kind of illustrate my point, is that, way, way back when I was an intern, I did my first just little direct laryngoscopy, you know, with biopsy, a little baby case with this one attending. And I was fearful of him, as most people were. Like, I learned that somewhere, you know what I mean? That was just. It wasn’t even that that person had even spooked me. It was actually that it was such a prolific reputation, one of those things that. That spooked me. So I just, like, you know, tangentially knew to be afraid. Case went smoothly. You know, case went fine. But, I mean, it was so much stress leading up to it. It was so much apprehension. Yes, I prepared and studied for the case, but there’s also the mental load of fear. And then when I rounded with my chief that afternoon, it was just the two of us on PM rounds that day. And I kind of said. I was like, you know, wow. And they said, hey, did that go okay? I said, honestly, it went fine. Like, nothing went wrong. Seemed like I was well prepared, patient, did well. They’re. They’re out of here, no problems. But I was like, does it get better in terms of, again, the intimidation, just the fear to go in, and learn from or work with this person, etcetera? And the chief said, no. he doesn’t treat me any differently now as a chief resident, and I make mistakes with him that I would never normally make. She was like, the other day, I dropped a suture on the ground, like, in the middle of surgery. And again, this resident had some of the best hands in the program. Like, it was just really not, you know. Yeah, that was extraordinarily out of character. I think even other people would be shocked to hear that. But this chief was just sharing with me like, it never got better. And so, you know, there’s a million stories like this. But I do feel like people very much, anecdotally, talk a lot about how they feel more prone to making medical errors if they’re under duress at work, as in, you know, it’s a culture of fear, of intimidation or somebody’s being bullied. Like that could lend itself to also a higher risk scenario.

Dr. Laura Vater: Thank you for sharing that. Wow. Wow. Just having someone that has such a reputation that even before you even set foot in that room with them, their reputation precedes them in such a way that you already tense up or that affects the way you practice, and that a chief resident would not have earned respect or whatever it may be, or better treatment after five years, four and a half years. Wow. I know that throughout medical training, we are trying to create a culture of consideration and mutual respect and. Right. I know that we are working to make progress, but the truth is, like you’ve said, there are hundreds, millions of stories like these. And thank you for putting words to that, especially in a highly procedural field like yours, where being tense, having your heart rate faster, feeling additional anxiety, maybe it’s the sweat in your surgical gloves, maybe it’s your breath is a little bit more tight in your chest, maybe it’s that fast heart rate, or it’s just the strain or all of those things put together that fear with the amygdala. Right. And all the physiologic responses of that and how that changes the way that you can deliver a service to a patient. Certainly there’s no doubt that that plays a role, and I’m sure you said that you’ve already had anecdotal experience with that, and I’m sure it’d be really interesting to see if anyone has captured that yet. Right. In the literature. I think that, for me, I had fear surrounding procedures, nothing like yours, but things like central lines, intubations, but that when I had a supportive attending, you can just feel your body relax. You’ve got someone behind you. You say, okay, worst case scenario, I need support. They’re right here. I think the most difficult situation is when you’re stepping onto rotation with a person that has a reputation, and you can already feel yourself tensing up, whether it’s the medical knowledge you’re trying to revert, you’re trying to come up with a treatment plan and come work through all the diagnosis or actually doing a procedure right then and there and how much that impacts that and how. As much as possible. How can we not. That those, I don’t want to. You know, I know that those physicians have their own perspective on their teaching and the way that they’re. They’re. They’re trying to, you know, teach residents. But in my mind, if it’s causing distress, if there is an element of bullying, discrimination, harassment, fear. Right. Is there a way that we could limit their interaction with learners? And then the challenge is. Right. What if you have someone, a partner that you’re practicing with who also is similar? Thankfully, I’m not in that situation, but certainly people are where they’ve got someone that’s one of their peers and they’re treating them that way and how does that impact them? Right. And I think that that’s a real. That’s a real challenge within medicine. And how in the world do we deal with that? And how do we find a way to create the culture of medical school and training a place where people want to be and where they feel valued, even if they’ve never done a single procedure as an Ent intern. Right. How can we make that learner feel valued in that first day? Wow.

Dr. Frances Mei Hardin: That’s really. That’s lovely. And you put it so well. But just the idea that if someone, you know, had a teaching style that could be described as more malignant and it wasn’t compatible with what the next generation of physicians, you know, requests for a teaching style, like, you know, sometimes people say, hey, my learning style, respectfully, is not being screamed at in public. And, you know, so it’s just like, with respect. with respect. But. And I guess that limiting those people’s access to have learners, which like learners do bring something to the table, like resident physicians, that’s not. Having a medical student on the team brings something to the table, you know, like, it’s not truly just indentured servitude. So I think it’s very,

The way that attending physicians interact with learners affects our career trajectory

It’s always wonderful anytime that attendings, you know, both of us are in earlier career attending life. And I just think that it’s great to even posit, hey, what if people who really did care about learning and also teaching styles and creating that supportive culture were the ones who were maybe more exposed to learners or things like that? And even when you talked about the difference between the fear response or not, I was kind of, you know, it reminded me of some happy memories in my mind where I, operate with a head and neck attending who was like, really incredible. And it’s that feeling of just, they’ll let you work, but you know, that they’re there and they’re very supportive. You don’t feel like, hey, if I asked a question, my head will get bitten off. And just knowing that they’re there, those are some of my like, happiest operative memories. Whereas in contrast, I definitely remember doing the same case, the same neck dissection with a different person. Exact same clinical scenario, exact same dissection. Let’s say that the operating room table is at the same height because like I’m 6ft tall, so I might have to bend over a little bit. But let’s say these two people are the same height, but you’re just terrified of one of them. Well, at the end of the day, I leave that case in actually excruciating pain, like the cervical tension, the cervicalgia, the issues that I have like in my occipitalis trap muscles and things like that. It’s actually extraordinary. And, you know, so in my own little fake case control trials, without that additional component of like terror and tension. Yes, surgery can be arduous and long and certainly you want to be smart about your ergonomics, but it is like 300% more doable.

Dr. Laura Vater: Definitely. And I was. I had this thought that it. You have very little exposure to certain specialties in your medical school. On your clerkships. It might be two weeks on a certain field or a month on a certain field. And I had. I’ve had some personal experiences with some, this doctor you described in your intern year with a reputation that precedes them. I had similar experiences certain months of my third year medical training. And I remember my first day on one of them. I walked in and all three residents were female and they were sitting, surgical residents. They were like hunched over in their chairs in like this dark work room. And this attending male physician was like standing over them and like screaming at them, very early in the morning. And I remember just staying in like the corner, not moving and just that, fear and being like, how in the world these are adult women who are doctors. How in the world are they being treated this way? And just feeling like I could never go into this field. Like it was that one experience thinking I was actually considering that field. And it was really. It’s really interesting how single moments like that can change our complete career trajectory and how important it is when we have teachers and attending physicians who are interacting with our learners at all levels. Our learners need mentors. They need people who ideally see them as not just in the way, but valuable. And I think that that’s something that has stuck with me as well. I think that it’s really important that, we think about this for learners of all levels, medical students, residents, fellows, even our peers, because certainly the way that we interact with attending physicians and our learning affects our career trajectory and.

Dr. Frances Mei Hardin: The career that we choose and quality of knowledge and ability to practice clinically.

Dr. Laura Vater: Absolutely.

Compassion fatigue is defined as an extreme state of tension and preoccupation

Dr. Frances Mei Hardin: So, you know, I could talk about, these topics for a hundred hours, but we are going to move on to compassion fatigue next. Compassion fatigue is defined as, quote, an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it can create a secondary traumatic stress for the helper. That’s a definition pulled from a 1995 book by Doctor Figley. While classic burnout more often involves a component of, like, physical exhaustion, in addition to everything else, compassion fatigue is more focused on the emotional because, and I think this is the really important point. And it doesn’t, you know, it doesn’t make me a bad guy to say it, but compassion and empathy are finite resources and they can be depleted.

Dr. Laura Vater: They can be. I think that something that I’ve learned in my training, I, Actually, this is the topic of the TEDx talk that I gave was on empathy and exhaustion. And I didn’t know this in my training, but there were moments in my training where I would be awake for sometimes 24 hours, sometimes much more, and I’d be standing in front of a person wanting to care, wanting to be present with them. but I was so drained that I just was not myself. And I carried a lot of shame surrounding those interactions for sometimes months, and if not years to come, just feeling like I was not the doctor that I had wanted to be in that moment. It was only later that I learned that they even have done multiple studies on this. If you look at MRI scans of people after a night of no sleep, they have far less activity in the empathy parts of the brain. They actually find if you survey, if they look at doctors, they actually find that doctors who are exhausted, they actually feel less empathy for a patient’s pain and are less likely to prescribe pain medicine. We’re seeing it on MRI scans. We’re seeing it in actual practice of physicians that our empathy is not something, like you said, that is just always there. It’s something that can be depleted. And when you’re exhausted, either it’s from overwork and a rushed, fast pace of the day, or it’s sleep deprivation. Oftentimes, it’s both, especially in training or on a call within practice. I think that recognizing that there’s a physiologic depletion that’s happening in those moments, doing your best, caring for your body as much as you can, caring for your patients in that moment as much as you can, but also knowing that the person that you are at hour one is not going to be the same person that you can be. You can’t deliver the same care and compassion at hour 72 or hour 100. It’s just not physically possible.

Dr. Frances Mei Hardin: Yes. And so important, the takeaway just being that’s not a reflection of your character, because, you know, like, the evidence based findings, you know, from the literature, I love that you really pull it all back to that physiologic response because, you know, does that absolve all behavior? No, not at all. Like, of course, we still have our autonomy even when we are exhausted, like, 30 hours in. But I. I do think that the physiologic component of it is very real. And it is not surprising to think of somebody who normally has very deep reserves of compassion getting depleted from a schedule like that, you know, super demanding. I mean, if it’s over 24 hours in the hospital, absolutely. What I think is cool and almost like the contrapositive to empathy and compassion as a finite resource is also the thought that it is almost a muscle that can be worked out and, you know, trained for and prepped for. And we can do these things like focusing on gratitude, you know, doing our own gratitude practice, meditation practice, mind having your own mindfulness practice can maybe increase the well. Again, it does not mean that you’re going to feel like Zen and feel like a million bucks 30 hours in, but it still may deepen the well, which I think is a worthwhile exercise.

Dr. Laura Vater: Yeah, I think the more that you are in the habit of being present with your patients, and the more that you really strive to provide present, compassionate care to them, even in those moments when you really are just depleted, those habits will serve you well. It may not be to the same level that you may internally feel, but I still think that your patients will feel cared for. We talked about some of those communication strategies, just having tools at your disposal that you can reach for, even when you feel like you’re on autopilot and.

Dr. Frances Mei Hardin: Have you again in your capacity as a GI oncologist, and you are doing all of these very high stakes emotional visits one after another. you know, it’s natural to want the pick me up at times.

I like the spirit list for patients. I call it a joy list

And I wanted to ask if you’ve ever heard of something called. It has different names, but I like the spirit list. And the spirit list is the things that make you feel most alive, like, bring you back to yourself, make the spirit happy. And, you know, I think of just different, like, cards, photos that you love, but maybe cards from patients or things like that, that you keep in the reserves for times when you need them.

Dr. Laura Vater: I love that. I don’t know that I’ve heard of that term used. I actually tell that to my patients. I call it a joy list for them. I ask them to make a list of the things that bring them joy and to put it somewhere where they’re going to see it with some regularity. And I have that list for me, too. For me, it’s things like hanging out with my golden retriever and just having her on my lap. It’s cozying up with a good book by a fire, a warm drink. It is going for a walk in nature. It’s listening to worship music. It’s. Sometimes it’s just silence. As I’m driving home, I also like to reach for, like, Jane Austen, either the audiobooks or, like, the movie renditions. Things that I know have helped me to cope in my own way. And then, of course, I have deeper levels of things that help me. Things like my. Have, a deep practice of journaling. And I go to Thera. You know, I have a telehealth therapist and I have a husband who I can just say, I just need to. I just need to dump for a few minutes. You know, so sometimes even just calling him on my way home when. Even when he’s at home, I think that knowing the things that can help us to kind of fill. Fill back up that well or fill back up that cup can definitely help. But I love that list, that spirit list. I love that name. That’s beautiful.

Dr. Frances Mei Hardin: Yes. Yes. I thought. I thought it was incredible. And so, yeah, I have a spirit list. I have a photo album in my iPhone that’s a spirit list. But then I also have a notep because some of the stuff is not photos, it’s just vibes. And so more like what you’re talking about kind of my joy list. And I just, I don’t think you can have too many of those. That’s not. There’s no such thing as too much of that good thing. But,

Dr. Laura Vater: Or sunshine file. I have a sunshine file on my computer where if, you know, you got a, someone reached out to you and sent you an email or a message or even a picture of, like, a card or something like that, just if you’re feeling, especially in seasons of rejection or criticism, I faced that a lot as a writer.

Dr. Frances Mei Hardin: Right.

Dr. Laura Vater: That sometimes reach for, reaching for that sunshine file can be helpful.

Dr. Frances Mei Hardin: Yes. And I think that for physicians, especially, like, part of that list for me is, you know, photos of cards or just, you know, like, some positive feedback from a kind patient or a colleague, something like that. And I’m reminded of, I thought it was so funny, your post the other day. You were posting some reviews that people got, you know, and one of the reviews that, like, this doctor got was, you know, Doctor Mark saved my life, four stars out of five. And everyone was like, oh, my gosh, how do I even get that fifth star? But, you know, we joke, but with getting even with part of getting reviews and, you know, getting goofy patient reviews and stuff like that, I think it is so nice to keep, you know, just, a nice collection of, like, the very sincere kind, positive feedback and things like that.

Dr. Laura Vater: Yeah. I love that you called them goofy reviews because it’s so true. I think that I heard, someone told me this, that, you know, the patients that you’ve cared for that are doing well in the world, they’re doing so well that they’re not going to take time to leave a review. But if you sometimes, if you are in a career where you have to share a lot of bad news or you’re restricted in prescribing certain medicines because they have another doctor that’s already doing that, there can be perceptions that can affect how patient reviews you and knowing that you’re just walking into your day doing your absolute best with the tools that you have, knowing that we’re all human, none of us are perfect, we’re not going to be able to give every patient the exact thing that they want to hear or the exact medication that they’re asking for in that moment, either because of our practice limitations or just honesty of what’s going on with them. just knowing that we all get bad reviews and something else I’m trying to normalize because I think it’s something else that we just don’t talk enough about. So thank you for saying that.

Dr. Frances Mei Hardin: Exactly. Yeah. But we all also get good reviews. And so, you know, I think, a lot of us do have negativity biases. And so, like, if you can’t fall asleep, you just maybe do think of the one bad review. But we maybe don’t give enough credit to the nine out of ten positive reviews.

Dr. Laura Vater: Absolutely. Exactly.

You mentioned that you’re writing your second novel currently

Dr. Frances Mei Hardin: And so I did want to finish up by touching upon, and as you mentioned, that you’re writing your second novel currently. And, you know, I’m, I’m very excited. I’m definitely going to read your first novel when it’s out. I’m excited for you. But I just love to hear about, you know, your experience as a physician writer. And if you have any tips for people, whether that is in the form of, you know, sunshine files for the physician writer or, you know, just any pearls from your experience.

Dr. Laura Vater: Well, thank you for asking about that. I love writing. I could write all the time. It took me seven years to write my first novel. I had the idea for it. My daughter was two months old. She’s now almost eight. So I was thinking, out of all the times, God, when you can give me an idea for a novel, why do. My daughter’s two months old, and so I was, and I was a medical student, and so it was really just like anything, I think, be open to learning and know that it’s going to take a long time. Just like our process going from, you know, studying organic chemistry to now being an independent ent physician. Right. That takes so much learning and skill and practice to get from one place to another. And there’s a lot of ups and downs in that trajectory. And the same is true with writing. I think most of us, we need to try to let go of perfectionism when it comes to a creative pursuit, especially like writing. But just being kind to yourself, being gentle, keeping your hand in it, keep practicing, knowing there’s going to be a lot of rejection, probably more rejection in writing than you’ve ever faced in your life, especially if you’re a person who generally did well in school and. Right. And, But there’s so much. There’s so much to be found in writing or another creative pursuit, whether that’s music or that’s art, other forms, just knowing that it can provide so much meaning in your life. That’s what writing has been for me. A lot of what I write about are these things we talk about, compassion fatigue and mental health within medicine. Sometimes the things that are, I see, are not the best and how to fix them within healthcare. And I write novels, and so these are real characters experiencing these things in real time, and it’s been fun. I’m writing my second novel now. I’m working on finding an agent for my first, and we’ll see. I’m just going to be patient with the process. It’ll probably be at least another year or two or three before I even have a novel published, but I’m going to just keep at it. And that’s just like anything. I think that if you find joy in it and you want to build it as a craft, just be patient with yourself. Keep putting in the time, try to learn how to do it, and try to enjoy the process.

Dr. Frances Mei Hardin: Well, like I said, I will be in line for a signed copy when the first novel is out and probably the second one as well. You know, I’ve been working on my first book, but, you know, so I can identify a little bit, although mine’s more of nonfiction, but.

Dr. Laura Vater: Oh, I’d love to hear more about that sometime when you’re ready to share. Yeah.

Dr. Frances Mei Hardin: Yes. Oh, my gosh. Well, but what I think is so interesting, and, of course, like, this is not the reason you do it. You do it because, obviously, it brings your spirit joy, and you benefit from, like, the therapeutic effects of it, and it’s your chosen art form. But what I think is so interesting, and I put this plug out there for, like, younger students, resident physicians, maybe they’re thinking, oh, I don’t have time, detracts from the goal, or that detracts from, like, my overall vision for practice. But I would not be shocked if it makes you a better oncologist and a better communicator, you know, in every way. So it’s just cool to think about how the creative arts do make doctors, probably arguably better people, but also better doctors.

Dr. Laura Vater: I think there’s a slowing down that inevitably happens. You process things. I do a lot of journaling. I think that helps me to think through certain things that I’ve been through in my training, not just to process and cope and to stay in the field. I think it helps protect my longevity in the field of medicine. But I also think that it does shape the way that I see patients with greater detail. And I think caring. I spend a lot of time getting to know my patients as people and caring about them as whole people. Part of that is because I do a lot of character development work before I even start a novel, but also just because I’m curious about human beings. And I think that helps me to provide nuanced care for each patient of mine and also to really enjoy the care that I get to provide to them.

Dr. Frances Mei Hardin: Yes. So because that’s the thing is these are related. Like, they’re synergistic. And it definitely, you know, younger people who might feel like their creative art pursuits detract from their medical career, I would actually think of it as a boon in many cases.

Dr. Laura Vater: I agree. I agree. I think don’t let your perceptions that people won’t take you seriously. Don’t let those perceptions affect your ability to pursue those things if you really care about them.

Dr. Frances Mei Hardin: Yes, absolutely.

Doctor Vater discusses medical error and compassion fatigue on rethinking residency podcast

Well, thank you again for joining me today, Doctor Vater. It is such a pleasure to learn from you and to discuss medical error and compassion fatigue.

Dr. Laura Vater: Well, thank you, Doctor Hardin. It’s been great.

Dr. Frances Mei Hardin: Next week we will have Colin Royal on the podcast to discuss navigating relationships in residency. Follow me on Instagram at Francesmay, Md. And rethinking residency, visit my website, rethinkingresidency.com to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.