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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Nicola Orlov talking about medical errors.
[00:00:11] Dr. Orlov: They don't want to admit to making mistakes because like, well, if we admit to making mistakes, and maybe our patients won't want to come to us, or people won't trust us, and I think that admitting to your mistakes is important in the healing process and also in the process of improving how you provide care in the future.
[00:00:32] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.
I'm Adam Cifu, and I'm joined today by Dr. Nicola Orlov. Dr. Orlov is an associate professor of pediatrics in the section of pediatric hospital medicine, associate program director for the pediatric residency training program and director for clinical coaching in the pediatric clerkship at the Pritzker School of Medicine.
She's a proud graduate of the Pritzker School of Medicine. She stayed on to do her residency here and a chief resident year. She then headed to my hometown for an MPH at Columbia. Her research focuses on improving the sleep and health of hospitalized children, as well as on ways of teaching communication skills, empathy, and humanism.
She currently serves as the chapter advisor at the Pritzker School of Medicine for the Gold Humanism Honor Society, and a career advisor for Pritzker students, and she is a junior faculty scholar in the Bucksbaum Institute for Clinical Excellence. And because I don't quite want to stop yet, as a colleague I know Dr. Orlov to be particularly calm, thoughtful, and a real creative educator who's deeply respected by her students. She's also the mom of two wonderful daughters, one of whom was once a little buddy of my mother. Thanks so much for joining me, Nikki.
[00:02:06] Dr. Orlov: Of course.
[00:02:08] Dr. Cifu: So, Nikki, today we're going to talk about a particularly difficult topic, medical errors, to give listeners a sense of kind of what we're talking about, are you comfortable, you know, removing patient information, but telling us about an error you made? I can always come back and tell you one of mine if you need.
[00:02:24] Dr. Orlov: I hope you know me well enough to know that I'm always happy to talk about my errors and I definitely don't hesitate to share because I think there's really an opportunity to learn there. So, yeah, one really comes to mind. There are many, but the one that comes to mind was from early in my time as an attending, I was about two years into attending life, but I was here at UChicago for my very first week on service and truly like, just anxiety-ridden the whole time, you know, just so scared I was going to miss something. The volume was just so much higher and I was not really sleeping that much. I was running numbers constantly obsessing and worrying about all the patients. And I remember I finally made it to Sunday and I was like, holy, I made it to Sunday, like I don't know how I managed to get through this week. And I, you know, made it through my day and was getting ready to go home and I couldn't wait to get home to my family. I had not seen them much that week. And as I was getting ready to leave, I got a page from my senior resident that we had a new admit and he texted that it was pretty straightforward. It was a kiddo coming in with appendicitis and I just so happened to have a sick call call resident called in that day. I had really gotten to know my team well, but this person I didn't know well. The vibe was different that day. I actually hadn't, he was a senior resident, I didn't know him that well, but I had just gotten bad energy from him that day, like he just, um, something rubbed me the wrong way. I just got the sense that he was really comfortable hanging out in the workroom.
[00:04:02] Dr. Cifu: Got it.
[00:04:02] Dr. Orlov: You know that type?
[00:04:03] Dr. Cifu: Yes.
[00:04:03] Dr. Orlov: Like I didn't get the sense that he was doing much, but like typing in orders. Um, but anyway, he told me this kid was in the ER, he had really bad gastro and was getting admitted for IV fluids. So I said, "Great." And I went and saw the patient and I remember like the second I walked into the room, I thought to myself, "Whoa, like, doesn't look like gastro."
[00:04:24] Dr. Cifu: Right, right, right.
[00:04:25] Dr. Orlov: "This kid looks really, really sick." Um, he was lying in the bed, he was diapered. He was, sorry, I forgot to mention, he was like an adolescent, right? So a diapered adolescent. He was super tachycardic, like his heart was just racing.
[00:04:41] Dr. Cifu: Yeah.
[00:04:42] Dr. Orlov: His mom was, you know, wiping rags on his forehead. He just looked really ill.
[00:04:47] Dr. Cifu: Oh my God.
[00:04:47] Dr. Orlov: And I remember I examined him and the whole time I was thinking to myself, this is not appendicitis, like this kid needs more, he does not just need IV fluids.
[00:04:55] Dr. Cifu: Yeah.
[00:04:55] Dr. Orlov: His belly exam was not rigid in any way. It was not an acute abdomen, but he was very diffusely tender.
[00:05:01] Dr. Cifu: Yeah, yeah.
[00:05:02] Dr. Orlov: I went up to the workroom and I said to the team, like, "Okay, I saw him. He's in the room now, I don't think this is gastro. I think this kid has something more. I think we need to image his belly. I think we need to call surgery. I'm worried he might have an appy, and we should get labs on him as well." And I remember like, the look on that resident's face, the sheer, just like...
[00:05:28] Dr. Cifu: Right, "You're wrong and you're creating work for me."
[00:05:31] Dr. Orlov: You got it.
[00:05:32] Dr. Cifu: Yeah.
[00:05:32] Dr. Orlov: Right? And I went from so confident in my exam, so sure of my diagnosis to 100% second-guessing myself, right? It was my first week on service. They knew me as a chief now as like, they were, you know, actually that's not right, they... Whatever. We'll back up. Um, you know, I went from being so confident to totally unsure of myself and he questioned me and he said, "I really think this kid just has gastro and I don't think that the surgeons are even going to take us seriously if we call."
And I, um, let him rock my confidence. And I said, "Okay, that's fine, like you're the senior resident in-house. I'm going to trust that you'll keep a really close eye on him, and if anything changes, you'll call surgery." But for now, you know, and I asked him what he wanted to do, he just wanted to run fluids. And, um, even though I was totally uneasy, I said, "Okay." And I remember I went home and um, really just like passed out, you know, I like maybe ate something, put my head on the pillow and I like bolted up out of my sleep that night at like 2:00 AM and thought to myself, it was like that line in Madeline, right? Something is not right. And I logged into EPIC and I remember seeing this kid's heart rate, like, you know, multiple beats per minute higher than it had been. And I called the team and I said, "Oh my God, like you have got to call surgery right now. You have to get a STAT CT, and it turned out that he had had a ruptured appy.
[00:07:07] Dr. Cifu: Oh god.
[00:07:08] Dr. Orlov: Um, and he ended up going to the OR, he had multiple tubes placed. He ended up in the ICU.
[00:07:14] Dr. Cifu: Yeah, yeah.
[00:07:15] Dr. Orlov: I was literally, like sick to my stomach and nauseous.
[00:07:20] Dr. Cifu: Is that... We're going to talk obviously much more generally about errors, but to ask sort of about, you know, the reaction to a single case, um, does that come back to you in sort of similar situations where you think, "Look, I'm worried, I need to stand my ground. Even if I'm wrong, I'm going to feel better having done X, Y, and Z."
[00:07:44] Dr. Orlov: Yeah.
[00:07:44] Dr. Cifu: Um, or do you think it's more kind of diffuse as part of your past and your current practice?
[00:07:50] Dr. Orlov: Um, it plays a role in much of what I do every day. So I will say that I think, you know, people probably don't question me in the same way now. I was really young. I was a brand new attending. This was a man, I was a young woman, right? I think there was definitely, um, a dynamic plane there.
[00:08:09] Dr. Cifu: But now you have gray hair.
[00:08:11] Dr. Orlov: A lot, yes, it's really unfortunate. Um, but I talk all the time to the residents about what I call trusting my normometer. It was actually a phrase that my program director used a lot back when I was a resident.
And basically what I say to them is, I trust my gut. If my stomach is telling me something is not right, I trust that even if I can't put my finger on why it's not right, and even if it doesn't make sense to you. Even if you think I'm being hysterical in ordering extra labs or keeping a patient another day or getting an echo, whatever it is that I'm asking you for, I'm doing it because I have seen enough patients that I know that this child is not following his or her illness script. There's something not right here, and I know that I'm not going to be able to put my head down on that pillow at night. And so I, and I use that example, this case, often when I'm talking to my, and other mistakes that I've made, often with my residents when they question me in my decision-making, and I use it as a, sort of like a story to give them some insight or to give them some perspective onto why I'm doing that.
[00:09:15] Dr. Cifu: Um, maybe it's not as hard for you as for a lot of people, but why do you think we as physicians, like, have such a hard time, you know, talking about medical errors, admitting to medical errors? I think the default for a lot of physicians is to sort of, you know, bite down on it and live with it and not talk about it with other physicians, certainly with patients. Um, why is that?
[00:09:38] Dr. Orlov: I think there are two parts to that question, and maybe I'll answer the second part first, which is the part of the question where you sort of mentioned that physicians tend to like bite down, suppress...
[00:09:52] Dr. Cifu: Yeah.
[00:09:52] Dr. Orlov: ...not face the errors, and I think that ends up causing deep insecurities for that individual, for that physician. Right? And it contributes to that sort of like imposter syndrome that we have, right? I have to look like I'm perfect. I have to... Right? I think doctors are type A naturally, right? And they don't want to admit to making mistakes because like, well, if we admit to making mistakes and maybe our patients won't want to come to us, or people won't trust us, or... Right? People won't trust us. And I think that really admitting to your mistakes, admitting to your mistakes is important in the healing process and also in the process of improving how you provide care in the future. And it's critical for our trainees...
[00:10:43] Dr. Cifu: Right.
[00:10:44] Dr. Orlov: ...because like bottom line, we have a hierarchical system.
[00:10:47] Dr. Cifu: Yeah.
[00:10:47] Dr. Orlov: And I remember 100% when I was a medical student looking at my attendings, actually you included, because you might not remember, but you were the clerkship director when I was a third-year and like everybody was godly and holy and perfect and never made mistakes, and if we let the students believe that we're, or let the students sort of like fall into that mindset, then they won't feel like there's acceptance around the idea of making mistakes. And so if we're open about it, then we teach them or role model for them that making mistakes is acceptable and normal and a part of being human.
[00:11:24] Dr. Cifu: Yeah. I think your point is so well said that there's the two-pronged problem with suppressing it, right? It's just personal healing and it's a terrible way to live...
[00:11:33] Dr. Orlov: Right.
[00:11:34] Dr. Cifu: ...but it absolutely is the ability to sort of practice in some sort of, I don't know, mindful and forever improving way. It absolutely takes, you know, meditating on the errors and figuring out why did that happen? How am I going do better the next time? And then going further, boy, the education has to be, let me tell you about the 20 things I've done wrong in this situation, and so you can figure out, you know, why those mistakes happen on your own, you know, as the trainee.
[00:12:05] Dr. Orlov: And we don't do enough of it because when I am on rounds and I say, "Hey, this kid has a neck mass, let me tell you about the time that I admitted a kid with a neck mass that I diagnosed as an abscess and sent home, and he came back with neuroblastoma and needed a stem cell transplant." Their eyes like pop out. I think they can't believe it that I'm telling them that I made such a huge mistake. So it's clear that like, we don't normalize this enough.
[00:12:34] Dr. Cifu: Yeah. Do you think as an educator that that's something you had to learn? Is that sort of you, that like from day one you're like, "Okay, I'm going use my errors as a way of teaching." Because I certainly feel like in my career I had to get to a place where I'm like, I'm fine with myself and I'm very comfortable with where I am, and now I'm going to admit to everything. And it was about that time that I sat down, you know, typed up my CV of failures...
[00:13:03] Dr. Orlov: I remember that.
[00:13:03] Dr. Cifu: ...and sort of embraced them all because I think that for the first, I don't know, five years that I was attending, I really needed to think like, I'm great and I know everything and I don't make mistakes, which was obviously a complete myth at the time.
[00:13:17] Dr. Orlov: Yeah. I think I said a few sentences ago that doctors are type A.
[00:13:22] Dr. Cifu: Yeah.
[00:13:22] Dr. Orlov: I'm not.
[00:13:23] Dr. Cifu: Yeah.
[00:13:24] Dr. Orlov: I have a sort of atypical path. I was a really... Maybe I shouldn't even be saying this, but I was like a bad kid, and I did horribly in school. I know my high school teachers are like, you know, shocked that I'm actually a doctor now. I was...
[00:13:39] Dr. Cifu: You actually switched places with someone.
[00:13:41] Dr. Orlov: Right. They're like, it's literally impossible because she was always in trouble, like how did you make it out of the principal's office enough to like, you know, study. And so I think I have a past that's full of mistakes.
[00:13:52] Dr. Cifu: Right.
[00:13:52] Dr. Orlov: So I'm accustomed to face... My parents got really good at helping me like sort of face my mistakes and learn from them. So maybe that's just sort of embedded in who I am.
[00:14:00] Dr. Cifu: Right.
[00:14:00] Dr. Orlov: But I mean, I also suffer from imposter syndrome.
[00:14:05] Dr. Cifu: Yeah.
[00:14:05] Dr. Orlov: And so it seems a little like counterintuitive that somebody who suffers from imposter syndrome would feel so comfortable talking about their mistakes. I'm not sure I know exactly why those two go hand in hand.
[00:14:18] Dr. Cifu: Well, this is a little off topic, but we do this on this show, you know, I think that's one of the arguments for having a real, you know, diversity of people in medicine, right? And trying to get away from like we're looking at people just to have perfect grades and perfect test scores from these twelve universities because it's getting people who've had different life experience and can actually teach from that life experience in a different way is really powerful.
[00:14:44] Dr. Orlov: Yeah, and allows you to connect to the students who...
[00:14:47] Dr. Cifu: Who maybe came from that.
[00:14:48] Dr. Orlov: Correct.
[00:14:50] Dr. Cifu: Okay, last question. So in an ideal world, after we make an error and kind of clean up the mess, how have you gotten comfortable with kind of conversations with patients or family members or the team to, I don't know, make things okay or as good as possible with your patient, and then actually educate your team, whether it be, you know, medical students, residents, or the other sort of health providers who we work with.
[00:15:16] Dr. Orlov: Mm-hmm. This part feels like the hardest and the easiest part.
[00:15:23] Dr. Cifu: Mm-hmm.
[00:15:24] Dr. Orlov: I think it feels like the easiest part because it has really become clear to me that the best way to heal the relationship with the patient is to just apologize.
[00:15:36] Dr. Cifu: Yeah.
[00:15:36] Dr. Orlov: And to admit to the mistake that you made and to offer potential solutions for the future so that similar mistakes won't happen, obviously not for them, but for other patients.
[00:15:51] Dr. Cifu: Right.
[00:15:51] Dr. Orlov: And I think they appreciate hearing that, but I feel like if it isn't just tackled head on, it becomes this awkward sort of elephant in the room or this thing that you're avoiding talking about or worry that they know or, I don't know, for me it feels like just a super awkward, it feels awkward.
[00:16:09] Dr. Cifu: Yeah.
[00:16:09] Dr. Orlov: And so it feels like an easy conversation because you really just have to be honest and be prepared and willing to take whatever they're going to give you. And it really can be whatever they're going to give you. I've had patients who have been like, as gracious as the day is long and far different from anything I would, any way I would ever respond had that been my child.
[00:16:32] Dr. Cifu: Yeah. Yeah.
[00:16:33] Dr. Orlov: And then other patients who just are so angry, understandably and you know, are yelling, and going through the sort of like emotional response and sometimes I feel like I should be hearing this, like, I deserve this. Right? And so it's okay and appropriate for me to be sitting there and this is where I should be, I should be hearing this from them. And I bring my team along unless it's not appropriate.
[00:17:03] Dr. Cifu: Yeah.
[00:17:03] Dr. Orlov: Unless there was something that, I can think of one case where like my case manager and I really felt like we should probably do this one on our own, but the majority of the time, I try to just bring the students and the residents along, because I think it's important for them to see that and experience it so that they have some frame of reference and knowledge of how to do it themselves when they're in that situation.
[00:17:24] Dr. Cifu: Yeah. It's funny, you know, as I said the last part of that question, I realized that that might be a question which was appropriate to ask 20 years ago. Not that either of us were asking these questions 20 years ago, but I feel like we've all gotten so comfortable with, you know, rounding outside the room of the patient who died or you know, discussing these things with the team, and recognizing that some of the easiest ways to teach things are from, certainly from cases, but also from errors, from mistakes, from difficult situations. Um, and I also really liked how you put it that in today's world of caring for people on a team of healthcare providers, you kind of have no other option but to be really upfront about errors because what are you going to do? You know, everybody's got to keep this quiet. Right? It's not going to happen. You know, you have to do it. Um, and I have to say my experience has been similar to yours that overwhelmingly it's a much easier experience, the conversation, than it is, and I have to say that even when there's anger there, often weeks, months later, you know, the relationship has improved because of the conversation.
[00:18:37] Dr. Orlov: Totally.
[00:18:38] Dr. Cifu: And sometimes people kind of, I've been sort of shocked at this, but end up apologizing to me, "Ah, I'm sorry. I blew up at you about that."
[00:18:44] Dr. Orlov: Totally.
[00:18:45] Dr. Cifu: "I was mad at, you know, the situation, the illness, the outcome rather than you."
[00:18:51] Dr. Orlov: "And I know you guys are doing your best." Yes, and there is an arc of anger even in that moment.
[00:18:57] Dr. Cifu: Yeah, yeah.
[00:18:57] Dr. Orlov: Right? When you first come in to talk to them, there's a lot of anger, but like by the time I find... Most of the time, like when I walk out of the room, we are already in a much better place.
[00:19:08] Dr. Cifu: Yeah.
[00:19:08] Dr. Orlov: And, you know, I don't just walk out while they're like screaming, like we get past that point. So...
[00:19:14] Dr. Cifu: It's funny, it's easy for me to have this conversation having, you know, obviously had a lot of the same experiences, you know, over the course of my career clearly that you have, I have to say though, that whenever you remind me that you're taking care of children, I like catch my breath a little bit, I think just because what I'm used to is, you know, the important decisions, which maybe change outcomes at the end of people's lives, and that I realize why I didn't go into pediatrics.
[00:19:46] Dr. Orlov: Well, our patients are amazingly resilient in a way that yours aren't, and that makes it totally doable, but you're right, when a real error or bad outcome happens, there's just no recovery from that.
[00:20:00] Dr. Cifu: Well, Dr. Orlov, thank you so much for joining us on this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.
[00:20:22] Dr. Orlov: Thank you.
[00:20:22] Dr. Cifu: Thanks.