From Fear To Calm

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[This piece was written some time ago. Publication was held until after the trial concluded.]

I began this week with a fear of the unknown. I am going to trial for the first time in my career. The weird part is that it is for the legacy of a career I'd already left behind.

Nearly three years ago, I made the leap of faith from a clinical role to an administrative position to fulfill a dream I'd held of working in population health.

I've had the opportunity to work with and learn from people I respect and admire. It's been a (mostly) fascinating and somewhat surreal experience: I have a seat at the table where I previously might not have been offered a position as a waiter.

So it's a strange irony that years after leaving a career in emergency medicine behind, I have a case going to trial.

My only prior experience was a stressful case that was ultimately dismissed with the legal language equivalent of, "We dismiss all charges provided you don't countersue us for filing a frivolous lawsuit."

That long-ago case was extremely depleting. I had a toddler, my wife was pregnant with our second child, and we'd put in a bid on a home. The bank almost denied us a loan because it considered the lawsuit an uncertain risk. It was only after intercession by my attorney (to whom I feel eternal gratitude) that the loan was offered and we closed on the house.

It was an awful feeling to think that the vulnerable, often down on their luck folks in the ER I'd dedicated my life to assisting could turn on me in an instant. For a solid year after that experience, every patient I saw felt like a land mine just waiting to blow up in my face. I practiced a medicine that leaned more defensive. I charted excessively, thinking it my documentation might serve as legal armor in the future. Eventually my practice and outlook returned to normal and my paranoia faded.

I enjoyed a stable period where my practice of medicine was more rewarding than depleting, I extended my runway by cutting back my clinical workload, and I felt more present for those I cared about on a day to day basis. Until this case appeared.

Without getting into specifics, this case is the worst of my emergency medicine nightmares become reality, summarized as young person + bad outcome. All the fears I've felt at one point or another during a two decade career in medicine have converged in a perfect storm.

I've gone through the Kubler-Ross stages of anger, denial, bargaining and (a protracted state of) depression to arrive at acceptance. It took about a year and a half to get throguh those other stages. Arriving at acceptance before the trial has given me a clarity of purpose that the other stages denied me from seeing.

We gave great care to this patient. My goal is to convey to the jury how, amidst the uncertainty and chaos of the ER, we consider risk factors, clinical presentation and physical exam findings in their totality, and apply our knowledge of the prevalence of disease and judgment to arrive at the most likely diagnosis.

When you do that ethically and well, you do right by your patients.

Even for bright, thoughtful and reliable people, some diagnoses and presentations are going to be so rare or so outlandishly unusual that reasonable, experienced clinicians applying the best clinical judgment will not catch every case.

I have a clear mental picture of what I want to paint for the jury. This is what it is to be an emergency physician caring for someone during a period of uncertainty. This is what it is to try to separate signal from noise. This is what it is to go the extra mile for a patient.

This is why, if given the choice, you would want someone like me on the front line to care for you or your loved one.

It's an extremely weighty and fraught task to take on.

And despite the tremendous burden of having this trial held over me for years, like a sword of Damocles, I am resolute in wanting to make my case to those who will judge me.