S8E9: Human Error in Medicine. Learning, Accountability, and Trust

Sanila: Welcome back, "Bundle of Hers" listeners, to Episode 9 of Season 8. Today I have two new guests joining me today, so I'm super excited. I have Abby Hamilton, who's a fellow MS4, a close friend of mine, and a phenomenal future emergency medicine doctor. She really emphasizes humanistic medicine, which is something that I look up to her for.

And then I also have Dr. Julie Thomas, who practices as a rheumatologist, and she was also the Layers of Medicine, which is our ethics course in the legacy curriculum, facilitator for both Abby and I. She's a wonderful role model. Throughout my clinical years, AKA just two years, I've met so many patients that have nothing but good things to say about Dr. Thomas. So it always makes me excited when we have patients that overlap.

And in today's episode, I wanted to talk about what our duty is as physicians and what it means to do no harm, which is what we say, our first words when we're inaugurated as student doctors, and how we can adapt and recover when mistakes are made and if harm does happen. I don't think that's a topic that is too often talked about in medical school, so I'm excited to dive into it today.

And then just a reminder, thoughts and opinions expressed on this podcast are our own and do not necessarily reflect those of our respective schools or employers.

Before we dive in, I just wanted to acknowledge the emotional weight of this topic. Part of our conversation will talk about the fear, shame, guilt, and silence around medical mistakes. And I think in a field that so strongly emphasizes learning, this can cause a lot of cognitive dissonance and make you feel like you have to be perfect. At least it does for me.

And as I've learned in the last 2 years, sometimes making mistakes is inevitable, whether they're really small or really big, and I think what matters is how we respond, which no one really taught me how to do. So we'll talk about it today.

First, to start out with, I wanted to jump back into the Hippocratic Oath and what "first, do no harm" means and how this kind of shows up in our practice. To me, it kind of feels not like a promise of perfection, but rather a commitment to intention and accountability. And I've kind of been pondering on if this is an ideal, a goal, or a moral compass recently.

Abby: I really like that question. I think I had seen you write about that before. And I today was just thinking through it a little bit, but I have been thinking it feels a little bit more like a goal.

I like the word "intentionality" a lot. I like that you brought that up. I like to feel how intentional we are with patients in doing no harm, especially in introductory spaces into the medical field where we're talking to patients maybe when they're first interacting with us and making sure that we aren't doing any harm just at the beginning and encouraging patients to feel comfortable to come back. And I think that being intentional in that space is very important.

Going into emergency medicine, I think about that a lot, about when I first meet a patient, how am I talking to them? How am I making them feel comfortable? And I just have found that to be very important.

Sometimes I say things like, "I'm sorry you're here, but I'm happy you felt comfortable coming in." And I think establishing that relationship can be very important, and making sure that patients feel like we want them to be there and how important that is. I think that's the start to doing no harm kind of sometimes.

Sanila: Abby, that is so beautiful. And this is why I think you're the epitome of humanism. But I agree, I think wording becomes especially important when we think about intentionality and the impact that we want to have on our patients. And in a world where there are so many different ways to say one thing, it can kind of feel a little bit daunting and scary.

I know I often get really worried that what I'm going to say is going to cause some harm or have an unintended impact on the patients that I help take care of. And I think it's just kind of been a lifelong learning thing for me. It kind of feels scary to think that I'm going to get to a point where I can just kind of speak about things.

For those of our listeners that don't know, I just applied OB/GYN. And OB/GYN is a field that is often wrought with a lot of gray spaces and ethical questions. And so that's something that I definitely think about, is how am I talking about things, and how is that going to land when I actually say them?

Dr. Thomas: I was actually thinking more along the lines of a moral compass, but I can definitely see goal, because the end goal is to not harm anyone. But I see it as a moral compass, and I wonder if it's because I've had that clinical practice and I'm midway through my career.

There are definitely opportunities for growth where, retrospectively, I see the unintended mistake that I made, and that do-no-harm direction can lead me potentially to reflect on those mistakes and then be wiser the next time.

Sanila: Thanks, Dr. Thomas. I feel like I don't really have that much experience because I'm not in my clinical practice yet, but I do worry that if unintended harm happens, am I going to be resilient enough to adapt to it and overcome? And I was curious how this kind of shows up in your practice when you work with patients.

Dr. Thomas: So I can think of two experiences reflectively, one that just happened last week where there was a patient, early 50s, who needed to start a medication which can be contraindicated in case of pregnancy. And the reason why I brought this up is because I just assumed that this patient was not interested in pregnancy.

Then when she filled the medication, it comes in with the teratogenic exposure and need to have two forms of birth control. And she immediately messaged me and said, "I'm interested still in conceiving, and we didn't have this conversation."

I realized then and there even though my intent was not to harm her and to treat her, I just assumed that, because she was in her 50s, she had no intent to become pregnant. And on reflecting, it made me think, "I need to be more aware of that bias."

And then the second instance where I didn't have direct interaction with the patient but made recommendation to another physician who was taking care of the patient. Even though I meant not to harm anyone and I gave medical advice based on the scenario, even though my intent was good, to process that there are emotions that I have to walk through to make sure that everything is okay.

Sanila: Dr. Thomas, I really appreciate you sharing what your experiences in clinic have been, and I just wanted to say thank you for being so transparent with us.

Abby, I don't know how you feel, but I personally feel like this doesn't get talked enough. Maybe it's part of the hidden curriculum, but in terms of our actual curriculum, I feel like we learn best medical practices and what we should be doing in various situations, and we don't really get taught or have much guidance on how to process things when, like you said, we cause unintended harm, which I think, secondary to human error, sometimes is going to happen.

It's helpful to know that there are people who are resilient, and even if mistakes happen, they kind of adopt a growth mindset and learn from that. And I just wish it was something that was taught more in our school.

Abby: Yeah, Sanila, I completely agree. I also think this is where I feel like we've been very lucky, and just between us, our individual medical education is having Dr. Thomas as such a wonderful role model.

Like you said, in general, I don't think that this is talked about in medicine. We don't talk about mistakes. We sometimes brush them under the rug or don't talk to other people maybe when you're going through a malpractice suit or have had a mistake happen in the past and you think of that as almost a failure, as though it's not a place for growth and a place for learning.

I think it's been very beneficial that we have had incredible role models and guidance of faculty and physicians above us when we started medical school who really were willing to have those conversations and be very open and teach us from an early point about growth mindset.

And I think that our ethics classes and having Dr. Thomas around, you've always shared these kinds of stories, and they have been so impactful for the last four years.

Dr. Thomas: That's really kind of both of you. I didn't realize how impactful they are. I think I also view it as almost therapeutic to share this experience to you guys, because you're right, we don't talk about it. I don't think in my medical career we ever talked about being involved in a malpractice claim. And so I had a lot of anxiety, and I actually honestly was depressed because I thought, "Maybe I'm just not a good physician."

And I think that process of reflecting, walking through, thinking, reviewing the chart, seeing, "Where could I have perhaps done better?" really helps me grow.

Abby: I also think that because there isn't as much transparency and it doesn't really get talked about as much, it means that people feel a lot of shame and maybe depression in themselves when they hear about this and maybe aren't talking to other people who have gone through similar experiences, don't understand that it is so common, and also that it's not just their fault.

It may feel like it's really resting on your shoulders, but it is such a systemic thing. But that kind of can get brushed away when we aren't maybe talking about it as much and being really open about when these things are happening and making people feel more seen and not alone.

Sanila: Yeah, I agree. And to your point, Abby, right now, I don't feel necessarily the burden of being in charge of someone's healthcare completely just because I know there are people who are supervising me. And as a medical student, when I do pick up a patient and I present, ultimately, it's the resident in charge of them that will be making healthcare changes.

But I know that's going to be short-lived because as we graduate and become residents in three or four months-ish, I think I am going to feel that weight on my shoulders. And I think even right now I feel scared in anticipation.

I know that I'll have a supervising attending looking over me as well, but it does kind of feel like you have a slightly higher amount of responsibility and accountability when you become a resident. And so that's really scary.

And I think it's also helpful to kind of know what resources you have available to you in a hospital. Who can you talk to if you are involved in a malpractice suit? Or who can help you process these things when harm happens or you feel upset with yourself because maybe you didn't meet the expectations you had for yourself or someone else had for you?

I think medicine is full of expectations like that that sometimes we don't even realize. And I think sometimes when I do make mistakes, either when I get a pimping question wrong, or I have a differential diagnosis that's completely incorrect, or I present a plan that my attending tells me he would never do in a million years, I realize that I have these expectations for myself of getting everything correct all the time that I wasn't aware of.

Then it just hits me harder when I don't meet those expectations and I'm like, "Wow, why did this make me so sad? Now I feel incompetent, and maybe I should not be a physician going into OB/GYN."

So I think that's really difficult, but it's helpful to know that you are a part of a team. And I think if medicine is going to emphasize learning, then they have to accept helping learners through this process too.

Dr. Thomas, I wanted to touch back on your point you made about assumptions and how sometimes we assume things of other people or other care teams.

Actually, right now, I'm on a cardiology consult rotation as part of my advanced IM rotation. And pretty relevant to me, yesterday, our Morbidity and Mortality conference was about a patient case, and they had a ruptured ectopic pregnancy, but their presentation was pretty abnormal. Ultimately, in the large plethora of images and lab tests that were drawn, it took a little bit of time to figure out why this patient was bleeding so much. And ultimately, the end diagnosis was a ruptured ectopic.

But I think somewhere along the line, it just got missed to run a pregnancy test because this patient was a little bit older, so it's not really something we think of. And had this been caught sooner, maybe it would've resulted in a shortened hospital stay or just faster treatment.

And so even if it's not necessarily direct harm, like I said something that hurt a patient, it could be even just a mistake in letting something slip by. In hindsight, it's easier to be like, "Oh, I should have caught that," or, "That makes a lot of sense now that I'm looking at it." And I think, in the moment, we just forget that it's easy to get lost in the sauce, for lack of better terms. I feel like hindsight is also a primary suspect in determining how we feel about ourselves in terms of our competency too.

Dr. Thomas: There are so many instances where I'll have a conversation with a patient, and then when I'm writing the note at night, I'm thinking, "I could have had that conversation much better," or, "I could have said this instead."

Sanila: I do that all the time where I'm writing down something that I talked about, and I'm like, "Oh my gosh, why didn't I think about asking this question?" or, "I definitely should have worded this differently." And I guess all that really is, is information on how we can do better next time, I guess, is one way of looking at it.

It kind of reminds me how much of medicine is trial and error. It's a very imperfect science. There's lots of uncertainty. Evidence is always evolving, and we think about that in terms of a larger research sphere of all these medical advancements, but I think we have to remember that individually it's also a lot of trial and error, especially when we're determining what kind of physicians we want to be or what values we want to embody.

One interaction I have with one patient might not be how I interact with another patient the next time. And I think you can only really learn things once you do them and figure out how it makes you feel or how it makes the people you're taking care of feel too.

Abby: Sanila, I like that a lot. I also think about language and how we're talking to patients and how it makes them feel all the time. What I say or what we say may . . . when I say something, maybe I'm thinking of it in a certain way, but it's not always coming across in that exact particular way.

I had a very impactful experience last year when I was on my pediatrics rotation working with a pediatric rheumatologist, where I was like, "Oh, I round on this patient. I would love to present on them." And we do family-centered rounding in pediatrics too, which is a fabulous thing, but it also means you have to be very intentional about how you're talking about the medicine to the family and to the kid and making it accessible, but also not acting like they don't understand anything.

And this doctor had me practice the whole presentation to her before walking in, which was definitely an experience. I was like, "Okay. I've been giving presentations forever."

But it was actually really important because she knew this family very well, who was very cautious about the healthcare system and it was just a lot of hesitancy. She was like, "We have to be so incredibly validating, and we have to think of what they are going to say before they say it about where they are scared. We have to make sure that they know that we are hearing them." And I found that to be super beneficial.

But also, you can't do that every time. Sometimes you will make a mistake. You will not always have that person telling you, "This is how this family wants to be talked to. This is how they want . . ."

And so it's really hard when you go into an interaction with someone new and you're like, "Oh, I won't always know exactly the right things to say to you, but I'm going to keep trying and I'm going to learn. And if I do say something wrong, I'm going to learn from that and try and say something better the next time and really make you feel that where this is coming from is a good space."

Sanila: Yeah, it can be so hard to know what to say sometimes. When I'm in a pretty emotional conversation with patients, sometimes I feel like my mind is buffering. I'm like, "The next five words out of my mouth are going to dictate how this patient interacts with healthcare for the rest of their life." And it's really stressful.

I'm going to say here that my guilty pleasure sometimes is reading palliative care notes because I think they are so wonderful at elucidating how patients want to be talked to about their diagnoses. And it's really helpful.

Sometimes that information doesn't make it out to the rest of the care team or anyone who's interacting with the patient, and I wish it was somewhere in bright neon letters on a patient's door.

For example, when I was on my pediatric neurology rotation, there was this patient and they had some pretty severe neurodevelopmental deficiencies. I remember reading a palliative care note that said the parents liked to talk in terms of hope. So instead of saying, "It's unlikely that so-and-so will make a full recovery," say something along the lines of, "Here's what's happening. Here's what we know. We hope that this will happen, but here's what we can do to work through it together," or, "These are the things that we're going to watch for." So kind of talking a little bit more in terms of specifics and not being like, "This will never happen again."

I think that sort of language is really important, especially when you are talking about a diagnosis that is very personally impactful, or if someone's in a very vulnerable moment.

And I almost wish that we all had to do a palliative care fellowship, which maybe that's a little bit more work than people want to sign up for, but I just think palliative care doctors are so wonderful. And I think this goes back to the point, too, of knowing your resources in the hospital and knowing who can help you figure out how to work through a patient case that might be a little tough.

Dr. Thomas: I'm curious about why specifically palliative care. I've never actually read their notes, and so what attracts you to reading the palliative care? Like you mentioned, it was your guilty pleasure, Sanila.

Sanila: I don't know. I actually don't remember why I did it the first time. I think I was just curious because usually palliative care discussions, in my experience, have happened surrounding goals of care.

The patient that I'm talking about, their case just really hit home for me. It made me so sad, and I feel like I have zero resiliency when it comes to kids. And I was just really curious to see how this kiddo's family was coping with everything.

I guess I opened up the palliative care note to see if there was anything in there that would maybe be helpful. And then once I realized that it was actually super helpful, then I just started reading them when I had time for patients, if it was applicable. 

And I guess that's one of the benefits of being a student at this stage in my learning. I can actually afford the time to do that. And I'm certain when I have a busier clinic schedule or have a larger patient load, that might not always be possible. So I guess in a way it's nice to be able to kind of get some of that training now, even if it's not directly.

Abby: Sanila, I have to . . . I don't read the notes, I will say. I sometimes do when they are a part of a patient that I'm taking care of, but it's not a guilty pleasure of mine.

But something I do enjoy doing is . . . Palliative care is so important about talking about goals of care and just finding ways to get on the same level as a patient. I've spent some time with Rainbow Kids, and I thought that was such a lovely place to be. But also, when I was on some of my internal medicine rotations and we were having a palliative care talk with one of my patients, I would make it a priority to try and get done with my patients and leave rounds so that I could go be present in those talks. I think that there's so much to learn about talking with patients and their families. So I've also found it very valuable.

And even when it is about, "How do we talk to this group and these people?" whether it is in terms of joy or whether people sometimes just want to know the exact facts, I think that sometimes when you have more time, like we do as students, to really elucidate that and uncover how people want to discuss things, that can be so valuable. But it's just not always possible, which also causes me a lot of strife sometimes about what next year is going to be like.

Sanila: Yeah, totally.

Dr. Thomas: No, not to give you anxiety . . .

Abby: I already have it. It's okay.

Sanila: Well, many of us know that physicians often operate in really complex systems. To your point, Abby, about not having enough time or feeling more stressed, a lot of the time there are things like burnout, having not enough time to do all of these things, feeling a lot of pressure to be perfect or take good care of your patients. And then also, some failures that are system-wide, I think, contribute to a lot of this.

I was reading about this thing called second victim phenomenon when harm happens. And I'm going to read the definition to our listeners because I had never heard of this before. The second victim phenomenon refers to the emotional and psychological distress experienced by healthcare professionals after they're involved in an adverse patient event, medical error, or unexpected patient outcome.

And so the core idea of this is that the first victim is the patient and then adjacent family harmed by the event, and then the second victim sometimes is the clinician who feels personally affected by what happened.

And so this can manifest in the form of guilt, shame, self-blame, burnout, depression, anxiety, fear of malpractice suit, or a loss of confidence, all things we've just touched base on earlier in this episode.

I guess I was trying to think of why this happens, because we have such a strong professional identity that is tied to resiliency, and we have an internal moral commitment to do no harm. And when that is just so closely tied to the core of who we're supposed to be in our careers, I think this blame-oriented culture sometimes just turns into a critique of ourselves and how we practice medicine.

Dr. Thomas: I've heard about the second victim phenomenon specifically around COVID, especially when the outbreak was occurring and a lot of the healthcare professionals were experiencing burnout six years ago now.

Sanila: Yeah, I wish I had a good answer to how we can fix this.

Dr. Thomas: I can identify with this, and I definitely had a lot of self-doubt. The biggest emotion that I felt was shame because I felt alone, especially since nobody really talks about it ever.

And so I actually met with a therapist through the Resiliency Center and met with them on a regular basis because I was like, "Now that I'm involved in a malpractice claim, this easily signifies that I'm just not good enough to be taking care of patients, and maybe I just need to give this up. I'm just not good."

It really took therapy and talking out loud and just talking also to friends who were not involved in a malpractice claim to see that it's an isolated sense of shame.

I think it's something that I had to go through. It's a process that I needed to go through to reflect, "The system is flawed. The system holds us to these high standards of being perfect and almost always choosing the right answer, but it denies us of our humanistic ability. We're not robots. We are going to make mistakes even with the best intentions."

And it took that whole experience and going through that shame to come to this point, this output right now of me today, to realize I'm not perfect. Healthcare is definitely not perfect. There's a facade, and behind the facade, there are real humans that are capable of making mistakes even with the best intentions, and that's completely okay.

Sanila: Thank you for sharing that, Dr. Thomas. Abby and I just think you're one of the most wonderful doctors we've ever met. But I think there's a lot of truth to what you say in that. And honestly, I feel like that's kind of what patients want. They want to see that the person that's taking care of them is also human, can be accountable, and will kind of translate any sort of mistake into future safer care.

And I think that's kind of partly how we begin to build trust with patients in the first place, is, "I'm a person, you're a person, I want to share my medical knowledge with you and help you get to a point where you feel like you can take control of your healthcare, and then also just be a healthier human to be able to do the things that mean a lot to you."

I just think that's what we're supposed to do. And I think when you do that and you are a human and you can't expect it to be a robot, then it's kind of unrealistic to never expect to make a mistake.

Abby: I agree, Sanila. I think I remember somebody saying when I first was talking or thinking of going into medicine . . . During undergrad I was working as a CNA, but somebody was telling me that going into medicine is the process of humans taking care of humans. We still all suffer from a very human trait, which is making mistakes, but we also get the very human privilege of learning from those mistakes and faults and getting to grow from that.

The joy of being human is being able to grow and find new places from potentially past scars. You can make new, stronger skin in that place. Where can you grow and get better? And that is a lot of what doing medicine is.

But sometimes people in medicine are put up on a pedestal and expected to be perfect because we don't want to cause harm, like this conversation is about. But it's just really, truly not possible. It's where can we grow from there?

Dr. Thomas: Yes. Many times, even going back to that first scenario with the first patient . . . So I had called her and I said, "Look, I'm really sorry that I made this assumption that you weren't thinking about or you are thinking about becoming pregnant. And so let's change your medication." It's this acknowledgement of, "Hey, I had this bias in making this medical choice for you. Let me own up to that, and then here's a different pathway." And the patient really appreciated that.

And then the sense of seeing patients just in general, especially with AI all over the place where patients put in their symptoms and they get potential diagnostic plan and treatment options, I think patients really enjoy meeting a human who is there, has emotions, feels sad when they feel sad, starts tearing up when they start tearing up, and can definitely understand their depth of their journey that they're going through as opposed to an automated artificial intelligence Google chatbox or ChatGPT box that really doesn't have that human or humanity component to it.

Sanila: I think personally, too, practicing emotional humility should not translate to you being a less resilient physician. In a lot of ways, I think shifting the narrative to saying that being resilient does mean being able to empathize with people when it's appropriate and being able to share in those emotions is important.

I can't remember who told me this, but I remember years ago someone told me that in order to share bad news, you have to be able to sit with it yourself, because otherwise it's going to come off as you disclosing something. And if you don't process that within yourself first, then it's just going to build up to a point where you might not realize it's building up, and then at some point it's going to come crashing down.

I feel like that's been something that I try and remind myself of, where it's okay to process my emotions when I'm taking care of people. And I think that's important in helping us figure out just how to be better caretakers and meet the people we're taking care of where they're at.

Dr. Thomas: One hundred percent.

Abby: I'm curious, Sanila, how have you gone about doing that? Because I feel like it's so hard to sit with that and still really be a human in those interactions where you're talking about bad news. And obviously, we haven't given bad news in that same way yet. We are still medical students. So I guess, Dr. Thomas, if you have any options, but I still think it's very hard to really put that into practice.

Sanila: It is, and I'm very bad at it, Abby. I think that's also something that's going to be a lifelong learning thing for me, because I do think it's a balance of being able to process something to the point where you can still do your responsibilities and carry on with your day and see the many people that you have to take care of.

And so even if it's taking a 10-second breather and then processing it later when you have more time, just to kind of find a small way to regulate yourself can be helpful.

I can't say that I am an expert in that, or I've found the best way to do that either. So I agree, I think it's a very hard thing to do.

Dr. Thomas: I think I unfortunately have a lot of experience with it, especially during residency, internal medicine residency, and having to diagnose cancers and HIV or AIDS to patients.

I have a couple of coping mechanisms. One is actually, when you get the bad news, just going to the bathroom and locking yourself in the stall and just sitting there and reflecting and taking as long as you need. The second strategy that I have is actually washing my face. And then the third is sometimes practicing how to deliver the bad news.

I've found that those strategies were really helpful, especially in residency, and then they translated to when I'm an attending and then there's bad news that I have to deliver, especially on the inpatient service. It's just been very helpful to take a deep breath, a moment to myself.

Sometimes I have to talk to someone, either a person on the team or even one of the fellows or the residents, to unpack the emotional weight of this, and that actually . . . I wonder if it's the camaraderie of the emotional weight that really helps me sift through and then get the strength to talk to the patient about bad news.

And then the other thing that I always do is I'm always mindful of the impact on the patient. So sometimes when I'm saying something, I don't want to harm them, but they may not be in the emotional space to accept a bad diagnosis. And so it's almost like that art of reading the room that I don't think you can be taught. I think it just comes with practice. I think that's really key.

Sanila: Dr. Thomas, it sounds like you've identified almost a reflective reset, an emotional reset, and a physical reset to kind of help you navigate these tough situations. And I wonder if that's something that we as students can start working on now, just writing down little ways that help us regulate ourselves. So that's really helpful to hear. Thank you for sharing that. 

Dr. Thomas: Yeah, of course.

Sanila: And I just want to say thank you for all of our listeners tuning in today. I think this was a difficult but important conversation to have just in terms of making mistakes and recovering from them. My personal motto for 2026 is "adapt, overcome, and recover."

And there are just some key takeaways that I want y'all to have for this episode, the first one being that medicine takes a lot of courage. It takes a lot of action, maybe repairing relationships in some situations, and then growing from that as well.

Then kind of going along that, I feel like in my residency interviews, I've been asked so often how I adopt a growth mindset. So for those of you listening, that is my reflective question for y'all, and you can start practicing your interview by thinking about that too, in case you get asked.

And then just a reminder, if you liked what you heard today, please subscribe, share the episode, and then you can join us on our conversations on Instagram @bundleofhers. Thanks, everyone.