Philip Berry is a consultant hepatologist working in London, UK. Outside his specialty, he writes regularly on medical ethics, patient-physician relationships and the psychology of medical decision-making. His article "Semantics in an Elevator" appe… — Philip Berry is a consultant hepatologist working in London, UK. Outside his specialty, he writes regularly on medical ethics, patient-physician relationships and the psychology of medical decision-making. His article "Semantics in an Elevator" *appears in the Fall 2016 Intima.*

Vic Reddy's reflective piece, “Physician as Enabler,” (Spring 2016 Intima) on how patients and doctors respond to complications contains a juxtaposition I recognize well:

“The surgery went well, and Ms. Brown’s immediate postoperative course was without any complications. Three weeks afterwards, however, she developed an opening along the abdominal incision.”

The surgery went well... really? Technically, in the moment, perhaps, but the outcome was not good. Infection, hernia, an opiate addiction. The truth is, all that occurs after an operation will be linked to that intervention. So how should we respond when things go bad?

The author, a surgeon in Illinois, goes on to say, “...many complications and bad outcomes are out of a doctor’s hands…”.

Absolutely. How can we be blamed for the entry of a bacterium into a wound? How can we modify a patient’s intrinsic response to analgesics? On what, ultimately, do we judge a procedure’s merit (and, by implication, the merit of the doctor who performed it); is it the dexterity and accuracy with which it was done, or the patient’s quality of life six months down the line? As doctors, we know the honest answer to this—the latter.

Yet, it is natural for us to rationalize the circumstances and deflect blame when a deterioration occurs.

In my essay ‘Semantics in the Elevator’ a doctor reflects on his culpability after a colonoscopic perforation (not based on a real incident). The patient’s anatomy is fleetingly blamed; then he considers the fact that he just happened to be in the wrong place at the right time—the perforation could well have happened if a colleague had been doing the procedure. The doctor, who is preparing to apologize for the error, ends up doubting his own sincerity; it wasn’t really his fault so why say sorry? He would agree with Dr Reddy’s line, “relentless self-flagellation is not productive...”.

However, “ruminating on cases can allow one to find areas where mistakes can be acknowledged and, hopefully, avoided.’” This is the message. A balance must be found between self-criticism and constructive analysis. While we must think carefully about any harm that is done, we must not become paralysed by it. Brush yourself down. Move on. See the next patient with a clear mind—or they surely, do not want to see a doctor who has half a mind on the last one. Equally, they will want to see a doctor who has not lost the capacity to learn

Philip Berry is a consultant hepatologist working in London, UK. Outside his specialty, he writes regularly on medical ethics, patient-physician relationships and the psychology of medical decision-making. His blog 'Illusions of Autonomy' has been running for 3 years and has attracted over 50,000 readers. Dr. Berry also writes mainstream and speculative fiction. His writing activities can be explored at www.philberrycreative.wordpress.com and on Twitter @philaberry.