Guilt can be used to learn, to recover

This is a story about a young doctor (I will call her doctor B.) and her patient, George. More precisely, it is a story about guilt. It’s 4 a.m. in a crowded emergency room. Doctor B. was the resident-on-call. She was wearing green scrubs, a white coat, a Littmann stethoscope. She wore no makeup. Her eyes were tired and red. She was sleep-deprived and exhausted. And yet, it took her only a brief moment to realize that something was terribly wrong with her new patient, George. She added it all up: a narrow, long face; a prominent, wide nose; an upper lip drawn as a thin, straight, faint line; and slightly crossed, empty eyes. This boy, she thought, must have some kind of syndrome.

George’s mom recognized the look on Dr. B.’s face. “Our son,” she told Dr. B.,” has Prader-Willi Syndrome. He was doing okay, but since midnight, he isn’t himself, he holds and pulls his testicles, as if he is trying to tell us something, that something is wrong, that he is in pain.”

Dr. B. rummaged in her memory for all she knew about Prader-Willi syndrome. She found bits and pieces of information occupying the most remote and forgotten places of her mind: Prader-Willi Syndrome is a rare genetic disease leading to characteristic facial features, low muscle tone, short stature, small hands and feet, cognitive disabilities, and a constant feeling of hunger that leads to binge eating and obesity.

Doctor B. tried to communicate with George: “Does it hurt you when I press here,” she asked as she was examining his abdomen, palpating his scrotum and testicles. George seemed not to understand. He did not seem to be in severe pain.

Doctor B. ordered laboratory tests and an ultrasound examination of George’s testicles. She discussed the case with other residents on-call. She called her attending doctor. Specialists were consulted. Decisions were made.

About the medical case of George, I will tell you this: it was not the easiest of cases. It did not end happily. Looking back, it was evident that George was misdiagnosed and that there was nothing acutely wrong with his testicles. Looking back, it became clear that George had pancreatitis, that enzymes produced in his pancreas (an organ in the upper abdomen that produces insulin, and other important hormones as well as potent digestive enzymes) were seeping out, breaking down the tissues around the pancreas into tiny molecules, causing severe, intense inflammatory response. Later, it would become clear that George was digesting himself to death.

When doctor B. visited George in the Intensive Care Unit. She saw his mother and father sitting next to George’s bed, holding his hand, their eyes were tearing. She pulled up a chair and sat next to them. There was little said. There was little that could be said. “I am sorry,” doctor B. whispered, not sure whether they even heard her.

About doctor B., I would add: she felt guilty. Obsessed with the events that had transpired, she read all she could about Prader-Willi Syndrome. She found, for example, that patients with Prader-Willi syndrome have very high pain tolerance and that often they cannot clearly indicate where their pain stems from. “Had I researched the facts better,” she thought, “I could have done a better job. Perhaps another blood test, another imaging study could have made a difference. Perhaps the life of the poor boy could have been saved.” Guilt and self-doubt, like two buddy cops working on a murder case investigation, did not just visit Dr. B. They dwelled in her soul.

In their review of the scientific literature about guilt, Dr. Serena Carni and her colleagues from the University of Rome, Italy, state that guilt, like shame, like pride, belongs to a group of emotions that “have the function of orienting people toward ethical actions” and “affects humans’ behavior when they carry out transgressions that violate social and cultural standards.”

At times, guilt is a self-punishing, paralyzing emotion. But not always. After several weeks of self-examination, Dr. B. found within herself answers to questions she always had about medicine, about herself. She learned that her powers as a human being and as a doctor are limited: not all medical mysteries can be solved, not all lives can be saved.

She realized that at each moment, with each patient she sees, she should be diligent as if a man’s life is on the line. She learned that the visit of guilt and self-doubt is inevitable. But if she practices her art mindfully, with care, guilt’s unpleasant visit would be short.

Editor’s note: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com.