By Joe Kita
"Heavy perspiration, shortness of breath-his symptoms were textbook. the only thing was, I hadn't read that chapter yet."
By Robert M. Wachter, MD
I was a second-year medical student at the University of Pennsylvania, and on my second day of rounds at a nearby VA hospital. Penn's philosophy was to get students seeing patients early in their education. Nice idea, but it overlooked one detail: Second-year students know next to nothing about medicine.
Assigned to my team that day was an attending-a senior faculty member who was there mostly to make patients feel they weren't in the hands of amateurs. Many attendings were researchers who didn't have much recent hospital experience. Mine was actually an arthritis specialist. Also along was a resident (the real boss, with a staggering mastery of medicine, at least to a rookie like myself). In addition, there were two interns. These guys were just as green as I was, but in a scarier way: They had recently graduated med school, so they were technically MDs.
I began the day at 6:30 a.m. with a "pre-round," a reconnaissance mission in which an intern and I did a quick once-over of our eight patients: later, we were to present our findings to the resident and then to the attending. I had three patients and the intern had the other five-piece of cake.
But when I arrived in the room of 71-year-old Mr. Adams,* he was sitting up in bed, sweating profusely and panting. He'd just had a hip operation and looked terrible. I listened to his lungs with my stethoscope, but they sounded clear. Next I checked the log of his vital signs and saw that his respiration and heart rate had been climbing, but his temperature was steady. It didn't seem like heart failure, nor did it appear to be pneumonia. So I asked Mr. Adams what he thought was going on.
"It's really hot in here, Doc," he replied.
So I attributed his condition to the stuffy room and told him the rest of the team would return in a few hours. He smiled gamely and feebly waved goodbye.
At 8:40 a.m., during our team meeting, "Code Blue Room 307! Code Blue 307!" blared from the loudspeaker. I froze.
That was Mr. Adams's room. When we arrived, he was motionless. The resident immediately began CPR while yelling: "Wachter! What did he look like this morning?"
I stammered, then lied: "He was a tiny bit short of breath, but he was okay."
The autopsy later found Mr. Adams had suffered a massive pulmonary embolism. A blood clot had formed in his leg, worked its way to his lungs, and cut his breathing capacity in half. His symptoms had been textbook: heavy perspiration and shortness of breath despite clear lungs, with the right interval between his major hip surgery and the onset of respiratory problems. The only this was, I hadn't read that chapter in the textbook yet. And I was too scared, insecure, and proud to ask a real doctor for help.
This mistake has haunted me for nearly 30 years, but what's particularly frustrating is that the same medical education system persists. Who knows how many people have died or suffered harm at the hands of students as naive as I, and how many more will? What's needed is this:
Students and residents should participate in teamwork training, just like commercial airline pilots do. Such training stresses the importance of speaking up when they see something they don't understand.
What's more, before they start working on the wards, students should do exercises with computers or actors to help them better recognize the symptoms of common clinical syndromes.
Finally, attending physicians should be up-to-date in hospital care, and should have undergone special training to help them balance the amount of supervision needed for patient safety with the graded independence that will help trainees become practitioners.
Robert M. Wachter, MD, is associate chairman of the Department of Medicine at the University of California, San Francisco, and author of a blog and six books on health safety and policy, including Internal Bleeding, from which this story is adapted.