Correction Appended
One morning not long ago, I got a call from the emergency room at my hospital. A young man — an intern, in fact, who had been on rounds that morning — had been admitted with chest pains. Could I come to evaluate him?
He was 30, a Pakistani man with a long face and a disconnected look, which I attributed to anxiety. I asked him about the pain. It had started after dinner the night before, lasting about 10 minutes. He had slept comfortably, but the pain recurred while he was walking to the bus stop that morning, persisting almost an hour. It was a dense pressure in the center of his chest. To be on the safe side, he had decided to leave rounds and come to the E.R.
His blood tests were normal, as was his first electrocardiogram. He had none of the traditional risk factors for heart disease. I suspected he was suffering from acute pericarditis, a usually benign inflammation of the membrane around the heart often treated with over-the-counter anti-inflammatory drugs. Characteristic of pericarditis, the pain worsened when he took a deep breath. I told him that if blood tests in six hours were normal, we would send him home. I joked that there were easier ways to get out of internship duty.
Later that morning, I got a call from an E.R. physician informing me that my patient’s pain had resolved completely after he took ibuprofen, further confirming the diagnosis of pericarditis. For a moment I considered sending him home right then, but I decided to wait until the next set of blood tests was complete.
Just before leaving the hospital that evening, I ran into a physicians’ assistant. He told me that my patient’s subsequent blood tests showed evidence of minor cardiac muscle damage. Though surprised, I quickly explained that the problem was probably myopericarditis, where inflammation of the surrounding membrane can partially involve the heart muscle.
He asked me whether the young doctor should have an angiogram to rule out artery blockages. It was late; I told him that any work-up could wait until morning. I assured him that a 30-year-old with no risk factors did not have coronary artery disease. I told him to draw more enzymes and to order a cardiac ultrasound for the morning, and to call me at home if there were problems.
My patient had chest pains through the night. Doctors who were called to see him attributed them to myopericarditis, the diagnosis written in the chart. Further blood tests showed evidence of continuing heart muscle injury. An EKG the following morning showed nonspecific signs consistent with a heart attack. Though I still doubted that he had coronary disease, I reluctantly sent him to the cardiac catheterization lab for an angiogram.
I received a call about an hour later asking me to come over to the lab. When I arrived, the angiogram was playing on a computer screen. It showed a complete blockage of the left anterior descending artery, the so-called widow-maker lesion. The artery looked like a lobster tail, unnaturally terminating after several centimeters. Within minutes, the blockage was opened with a balloon and a stent.
Afterward, in the control room, heat rose to my face as colleagues wandered in to inquire about what was going on. “How could we have missed this?” I asked aloud. I was well aware of the disturbing prevalence of heart disease in South Asians, whose risk is up to four times that of other ethnic groups. I knew that heart attacks in this population often occurred in men under 40, who often do not exhibit classic coronary risk factors. I knew all this, but somehow my mind had suffered a block.
“Don’t beat yourself up,” a colleague said sympathetically. “Every doctor I know would have done the same thing.” Another told me that it was his policy to “cath” almost anyone who came to the E.R. complaining of chest pains. In his opinion, the risks posed by routine angiograms were much less than that of a missed heart attack.
What now? I knew I had to explain myself, but how much should I say? Like all doctors, I had made errors before, but never one this big — and in my own specialty, too. Should I just tell my patient the facts? Should I apologize?
Most doctors are afraid to take responsibility for medical errors. We are acutely aware of the potential hazards — legal and professional — of taking ownership of a mistake. But studies have shown that physicians’ apologies do not necessarily increase malpractice lawsuits. In fact, they may protect against litigation. Twenty-nine states have enacted legislation encouraging such apologies, some even making physicians’ expressions of remorse inadmissible in court.
It was not always this way. Hospital legal departments routinely used to advise doctors never to admit responsibility for an error.
During my internship orientation nearly a decade ago, a lawyer for the hospital said that at some point in our careers every one of us would likely be sued. The lawyer offered some advice: document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and, finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice.
I couldn’t bring myself to talk to my patient in the cath lab, while everyone was watching, so I decided to wait until he got to the recovery room, where it was more private.
I found him there lying on a stretcher. The pain in his chest was gone, he happily informed me. However, the groin, where the catheter had been inserted, now hurt. “They substituted one pain for another,” he said, laughing.
I grasped the rails of the gurney. “I thought you had pericarditis,” I said carefully. “I was obviously wrong. I’m sorry.”
He seemed embarrassed. “No, no, please, the past is finished,” he replied. “I am more interested in the future.”
He asked about his prognosis. I told him that I thought it was good, though he would have to be on medications for the rest of his life. He nodded, looking disappointed.
A few days later, just before he was to be discharged, I stopped by his room. I asked him with whom he was going to follow up. He told me that he had been given the name of another cardiologist but that he had decided to go with me. “You have been terrific,” he said. “Thank you.”
I nodded silently, feeling empty. “You are much too generous,” I said.
