Guest: Dr. Danielle Ofri
Guest Bio: Associate Professor of Medicine at NYU School of Medicine, Physician at Bellevue Hospital in New York
City, Editor-in-Chief of the Bellevue Literary Review and Author of four books, including her most recent:
What Doctors Feel: How Emotions Affect the Practice of Medicine.
Dr. Ofri’s tells me a story of one memorable experience from her practice, and what she learned. We go on to discuss empathy and the doctor-patient connection.
Health Professional Radio
Emily: You’re listening to Health Professional Radio. This is Emily, and my guest today is Dr. Danielle Ofri, an associate professor of medicine at NYU School of medicine, a physician at Bellevue Hospital in New York City, editor-in-chief of the Bellevue Literary Review, and an author of four books, including her most recent What Doctors Feel: How Emotions Affect the Practice of Medicine. Dr. Ofri, thanks so much for speaking with me today.
Dr. Danielle: Thank you. It’s a pleasure.
Emily: You write about allowing doctors to be human, to accept and discuss mistakes. Has that changed the conversation in your hospital?
Dr. Danielle: It’s beginning to. It’s a long process. I think in the past we didn’t talk about mistakes much for a number of reasons. One is we’re all afraid of being sued and another is that it’s so shameful and humiliating to make an error, because we expect perfection from ourselves. I remember one of my first errors. I was a second year resident.
My first time being in charge of taking care of a patient, and a patient came in with severe diabetes, almost comatose. It’s an interesting condition, because the patient is near death, but you can actually rescue them with the correct use of insulin. I had my intern next to me and I was talking him through this and we put him on an insulin drip. The patient got better, woke up, got hungry, got grumpy.
So I gave the nurse the DC insulin drip order, stop the drip. The nurse said to me, “Do you want to inject some long-acting insulin before you turn off the drips?” I thought for a second. I turned to my intern and said, “No, why should we use a sledgehammer on this guy? We’ve just been so meticulous, let’s just, we’ll watch him every hour and check his sugar and we’ll fine-tune things from there.”
Of course I was wrong, dead wrong. The very thing you’re supposed to do before you turn off an insulin drip is give a bolus injection of long-acting insulin so they don’t turn around and become comatose again, which is what my patient did. So as I realized what happened, I quickly called the senior. She came over, she looked at the case, and she turned to me and said, “What were you thinking? What were you thinking?” All of a sudden, my brain melted to nothing. What was I thinking?
Had I forgotten that part? Did I sleep through that lecture? She began to yell at me in front of my intern, in front of the whole emergency room. It was horrible. Now, of course, I made an out-and-out error. She was correct. She saved the patient. But I was so ashamed and so humiliated. I just wanted to crawl under a rock. I never wrote about that or spoke about it for a good 20 years, because of the difficulty about it.
I think now, “What a missed opportunity.” My senior could’ve taken me aside and said, “Listen, you made a big error, you really screwed it up. Here’s what we have to do to save the patient. Here’s how we prevent this in the future. What was going on in your head? Let’s talk about it.” Maybe I could have learned something from it. I could have rescued my ego. I could have taught my intern.
Maybe she could have taken me to patient’s room and together we could have explained to the patient what happened. As it stood, the patient never knew what happened. I never owned up because I was simply too ashamed. So I feel that now when I am involved in an error, I treat it much differently. When it’s someone junior to me, I want to go to them in private, talk about the error, be honest.
They have to own up and we have to talk with the patient. But I also try and help them through that difficult ego-bruising time, because they’re not bad people. Most errors are committed by good doctors and good nurses, and our goal is not to drive them out of medicine out of shame, but to help them fix it, do it better, and then help the next person.
Emily: Right. You seem so able to be vulnerable with your stories and so open and so honest. How did you get from the place of being ashamed and not being able to talk about a mistake, not being able to own up to it, to being able to accept that doctors are human and that you are human? How did that transformation occur?
Dr. Danielle: Well, it takes a lot of time. Some of its growth and maturity, wisdom from others. Kind of going through the hard knocks part of life. But part of it was also writing. I took off time after my residency for about a year and a half, and that’s when I started writing without any goal of a book. Just to write about these powerful experiences. The act of writing is so much slower than the act of experiencing it.
You have a chance to revisit, to revise, to go back and have a chance to poke through the emotions, the fallout, and with a little bit of time and distance realise that you can open up about this. But for me it took a little time away from medicine and some time to grow up, and also some good mentors who also helped me – which reminds me that I need to then do that for the next generation, to offer the time and space.
Part of my goal with my writings and my new book is to show that at any level we can be open and it’s okay. I’m still a pretty good doctor. I still practice medicine. I can still survive despite all the difficult times.
Emily: Right. Well, as you look back on your practice, at this point, is there anything you would change?
Dr. Danielle: Well, I obviously wish I could have come to some of these conclusions earlier, and it might have saved me and my patients a lot of grief. Some of that could have been my own work, some of it could have been seeking other mentors. I wish I had a little more time for art and music and writing along the way. I think there wasn’t any space for that, and I realise now that’s a key way to staying healthy through the process.
I think there’s a quote from John Stone in a wonderful poem, “All of us come to the arts too late.” That maybe if I could fit that in while I’m training, while I’m experiencing death and fear and vulnerability, that might have helped me gain some perspective earlier on.
Emily: Right. And maybe come down from the fantasy that doctors have to be superhuman all the time.
Dr. Danielle: And to know that we will never be perfect. We should strive for that, but we have to accept our imperfections. Work towards fixing them – we shouldn’t accept them and just let them go, but be accepting that we are human. It’s the price that humans pay, but again, none of us would want to be taken care of by a computer, we want to be cared for by humans and that involves human imperfection, human emotions, for good and for bad.
Emily: Right. You suggest in your writing that the culture of medical school, not only the kinds of personalities who might be drawn to that kind of rigorous, perfection-demanding work and study, but also the culture of throwing students in their third year into the wards and saying, “Keep up,” can really be destructive to their empathy, which lead them to the profession in the first place. Did you experience that with your own empathy level?
Dr. Danielle: I do. I think that we have to be very much attentive to that critical time when students are thrown into the wards, and that we need to recognise that they are feeling vulnerable and frightened, very much like our patients, and to give some time and attention to that to help them transition through that difficult time so that they can be there for their patients.
Emily: Right. Absolutely. I do think that the conversations that you have in the book with the reader, that those open, honest discussions of those feelings really are going to lead to others being able to say, “I can be honest about my mistakes. I can be honest about my shortcomings or times when I’ve been overwhelmed.” You actually describe a doctor who sort of falls off the cliff a little bit and is so overwhelmed that he needs to accept that he is too stressed out.
Another senior resident comes in and understands exactly what’s happening. That these are universal experiences in the field given that human beings are trying to take care of so many people and deal with so many tough emotions at once. Are doctors and nurses coming to you and saying, “Can I tell you my story?”
Dr. Danielle: Indeed. Certainly people write to me with their stories with each article that I publish. I just published a piece in the New York Times about respect. About how we often accept disrespectful behavior in the hospital environment between staff, and how it’s actually really damaging to our patients. People have written in about their experiences for good and for bad. Usually they’re sending us the bad experiences, patients, doctors and nurses.
It often gives people a focal point for sharing their experiences, and to me it’s a way of starting the conversation that, again, to be explicit, we see disrespectful things happening. Well, we shouldn’t be accepting that. We need talk about that clearly, concretely, and saying it’s not acceptable for a doctor to treat a nurse disrespectfully or for a nurse to insult a medical student, because it’s not right for these people and it’s not good for our patient care.
Emily: Right. Given that there are always going to be restraints at a public hospital on personnel and money and time and all of those things that make the profession of medicine so demanding, do you think that with respect and honesty and genuine personal connections between doctors and doctors, doctors and patients, that some of those issues can be ameliorated, even if nothing ever changes on a political or financial level?
Dr. Danielle: Indeed. Having the common courtesy when you introduce yourself to a patient to use your name, tell who you are. I just received a letter from a patient at our hospital who said, “Doctors walk in, they never introduce themselves.” It doesn’t cost any money and we assume patients know who we are, but they often don’t and maybe usually don’t. So that small thing of, “Hi. I’m doctor so-and-so. Is it okay if I talk to you now?”
To ask kind of permission to come in and talk. It costs nothing, takes one second, but makes all the difference in the world for the patient. I think we can stress these, and again, by example, but also by being explicit. It’s not okay to walk in without saying who you are. [laughs]
Emily: Right. Those small things make such a big difference, as you illuminate in your stories. Let me ask you another question – are you holding onto many stories that you haven’t told?
Dr. Danielle: Yes. One of the things people often ask is, “Do you get patients’ permission for stories?” I certainly try when I can. Often something happened many years ago. It’s not a patient I can track down. In that case I often ask myself, first of all, “Is this a story that will offer something more than just the gory details that might be intriguing?” and, “Is it a respectful rendering of the patient? If the patient were to stumble across this, would they be insulted? Would they be hurt? Or do you think they’d feel it was respectful?”
I have a couple of stories – I have a one story about a patient who lied to me. I was furious about the lie. It ended up impacting the care. I wrote about the experience of being lied to and I thought it would be interesting story that we could learn from and talk about. But I noticed that with this patient, if he were to come cross it I think he’d be very hurt. Although I think it’s a great story, it’s going to stay under the bed.
My advice is, when people ask, “You can write about anything you want, but whether you choose to publish it is a different question,” because the patient’s well-being really comes first. If it would be harmful in any way, it can be written, but it stays in your own personal journal.
Emily: Right. Do you have a daily writing practice?
Dr. Danielle: [laughs] I wish I was that organised. No. I have days in the hospital, and there’s no writing on those days. But the days when I’m not seeing patients, that’s when I try to take time for writing and cello practice and all other things.
Emily: I’m certainly in awe of your ability to fit in medical practice, teaching, editing of a literary magazine, writing books, playing the cello. I think that you got a lot of things figured out and I know that I and many, many other people will appreciate your sharing of your experiences.
Dr. Danielle: Well, when people ask when I sleep, I say, “Only during faculty meetings.”
Dr. Danielle: That’s my catch up.
Emily: That sounds very appropriate. Well, you’re listening to Health Professional Radio. This is Emily, and I’ve been speaking with Dr. Danielle Ofri, an associate professor of medicine at NYU School of Medicine, a physician at Bellevue Hospital in New York City, editor-in-chief of the Bellevue Literary Review, and an author of four books, including her most recent, What Doctors Feel: How Emotions Affect the Practice of Medicine. Dr. Ofri, it has been a pleasure to speak with you today.
Dr. Danielle: Thank you so much.