by Dr. Kenneth H. Cohn

I am writing this post in the moment as I cover surgery at a rural hospital in New Hampshire over the weekend.

Yesterday, I had the humbling responsibility of telling a patient brought in by ambulance with severe abdominal pain that she needed an operation, and that I did not know what caused her pain. Her white blood count was elevated (over 17,000), and her computerized tomographic (CT) scan showed a large amount of fluid around the liver and in her pelvis, with a non-visualizing appendix. I told her that the source of her problem could be anywhere from her stomach to her rectum--including her reproductive organs--and asked a gynecologic surgeon to be on call to see her preoperatively and assist me in surgery.

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I gave her a drug to suppress her vomiting and fashioned a moist compress for her face and neck, admitting, "I am not a nurse, but I am married to one who has taught me about caring for patients."

I reviewed where I had trained and practiced, the possibilities of what we might do in the operating room, the incision (midline), and the possible complications she might experience. Finally, I told her about the recovery room (PACU, post-anesthesia care unit) and the drainage tubes with which she might have to deal with after the operation was over.

In retrospect, a day later, my most important sentences were as follows: "I'm truly sorry that I cannot tell you what is causing your pain. All I can tell you is that you need an operation to learn what is causing your pain and to fix or remove what is causing your pain. The only promise that I can make to you is that I will do everything in my power to care for you and help you recover from this process."

In Collaborate for Success, I mentioned that apology is an essential part of care, and that many malpractice cases result from patients and families being angry when physicians and hospitals refuse to talk with them in a straightforward way (p. 114).

In Before Alignment, I wrote that transparency was key to creating a safe environment for learning. I keep hearing Paul Wiles' words, "I am accountable," as I care for patients, and find his closing words some of the most moving that I have ever read:

"If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries."

It would be bad form to comment on the postoperative course, except to say, at this time, she is stable and resting comfortably after removal of a ruptured blood-filled cyst (and normal appendix), and that she and her husband are grateful for the care she is receiving at a wonderful rural hospital, where employees take pride in their service to their community. Both she and her husband looked at this note and gave me permission to publish it in Hospital Impact.

What do you think?

• What are the limits to our certainty that we must communicate to patients?
• How can we maintain a safe environment for continued learning?
• How do you deal with situations where you do not know the answer?

I welcome your input.

Ken is a practicing general surgeon who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations. Learn more about what he does by clicking here.