A Knock on the Door

My office door was open just a crack. I had a deadline, was working feverishly, and didn’t want to be interrupted. But the slightly open door was a signal that I was still available for something important. And then there was a knock, at first tentative but then persistent. “Come in,” I shouted. One of our relatively new faculty members stood at the door.^* She hesitated. “Come in,” I repeated.

“I apologize for bothering you. It looks like you’re busy,” she said.

“No, no, actually I need a break.” I pulled myself away from the computer and looked up. “Grab a seat. What’s up?”

“I was wondering if I could talk to you about something that happened to me. Actually, to one of my patients.”

“Sure, sure,” I said.

“Well, it happened a few nights ago. I was working in the ER and there was a patient, an older man from out of town, just passing through.”

“Yeah, those are always the toughest ones. No records, no family. You are really at a disadvantage,” I said.

“Well, so this man.…” She paused, collecting herself. I could see that the story was becoming difficult for her to tell. “He came in because he didn’t feel right. He couldn’t put his finger on it. No chest pain, no weakness, no fever. Normal vital signs. He just didn’t feel right. But he couldn’t explain it. We asked all the usual questions, and because he was pretty old, like about 75, we did all of the usual things, a good physical, labs, an EKG, even a chest X-ray. Everything was normal. The resident and I were shaking our heads, and we were really busy; there were so many other patients waiting to be seen who really seemed sicker than this man. We needed his bed. The nurses kept asking whether he could go. So we sent him out.”

“Yes, that makes sense,” I said. “No real clues, and the guy looked good. I probably would have done the same thing,” I said.

She nodded, reassured by my comment, and continued: “Well, so the next day I got a call from an ER doctor at X hospital. The guy from the day before had just shown up with cardiac arrest. I guess he told the paramedics he had been to our ER just before he had the arrest. They couldn’t resuscitate him, and they were wondering about what we had done and what we had found.” Now her lips were trembling. There were tears running down her face. “I’m sorry,” she said. She could not continue.

“That’s terrible,” I said. “I am really sorry. I know how hard this must be.…” I paused to let her recover her composure. “I guess it’s the first time this has happened to you, that a patient who you saw and discharged died?”

“Yes,” she said. “I feel like quitting. I feel so bad for the patient and his family.” Now there were more tears and I walked over to comfort her. “What did I miss?” she said.

“I don’t know. Sometimes that’s how it is. The patients that look good are the ones we send out, and sometimes there are no warnings about what is to come. If he had looked sick, you would have admitted him or done more tests. But I can tell you that it has happened to every one of us in the department who has been working for a while.” And then I went on to tell her about a patient I had years before whom I saw and discharged and who died on his way to his car in the parking lot. I described what it was like to try and do CPR on a man I had been talking to minutes before, and then, later, what it was like to talk to the family and how I cried with them. “Unfortunately, sometimes it happens,” I said.

I tried to think of something to say that might ease the pain she was feeling. I remembered how my own confidence had been shattered after my case. “I know you are a good doctor, a great doctor. I would be happy to have you care for me or my family. For a while you will be second-guessing yourself every time you walk into a room and talk to a patient, and you will wonder what might be hiding behind a benign-sounding story. You will want to admit everyone to reduce the risk that this could happen again. Those are natural reactions. That’s how it was for me. However, you still have to make the tough decisions. But if you feel stumped or uneasy, you might bounce the case off another attending. I do it a lot. Fortunately, we always have other attendings around. Sometimes just presenting a case to someone else will suggest things you might have forgotten. And you can call me anytime.”

“Thank you,” she said. She looked around the room for a moment before turning and leaving. “Do you want the door open or closed?”

“Oh, you can just leave it cracked open,” I said.

This conversation reminded me about the importance of the relationships between faculty in academic medicine and the culture of support we can create for one another. Most published literature about faculty relationships concerns the features and importance of mentoring. A systematic review by Sambunjak et al¹ of research about mentoring in academic medicine demonstrates a wide variability in the prevalence of mentoring relationships and those relationships’ associations with career advancement and satisfaction. However, the authors concluded that the overall poor quality of the research designs made it impossible to quantify the association between mentoring and academic and professional development.

A recent article by Pfund et al² in this journal describes a randomized trial of a mentorship training program that demonstrated improvements, from both the mentors’ and mentees’ perspectives, for those mentors who completed the 8-hour curriculum. In an accompanying Commentary, Steiner³ notes that in addition to competent and committed mentors, it is also important to have a culture of mentorship in which the institution supports the mentorship process by allocating adequate time, space, physical resources, and adequate funding.

Another article published in this journal, by Travis et al,⁴ describes two other important relationships between faculty in addition to mentorship: sponsorship and coaching. The authors state that sponsorship involves the support and advocacy of a powerful person to assist in the advancement of someone more junior who has untapped potential, while coaching involves observation and feedback by an expert to improve performance. These relationships and mentoring ones are all necessary at different points during an academic career.

All these authors are describing the variety of ways that more senior faculty can assist more junior faculty to grow and flourish and the importance of institutional culture in providing encouragement and support for these activities. A theme for all relationships between faculty is leadership, which Gabel⁵ explores in this issue of the journal. He describes both formal and informal leadership and some of its common characteristics such as commitment to the organization’s values and goals, ability to negotiate differences of opinion, and a willingness to recognize the accomplishments of others. He emphasizes that even those without positions of authority or power can have enormous influence on others through their interpersonal relationships and their recognized personal attributes.

Also in this issue, Helitzer et al⁶ report the findings of a survey of women who have attended national career development programs. The authors describe the skills that these women identified as being most important to them in their professional lives, such as interpersonal skills, leadership, negotiation, and networking. Just as with mentoring, we need to facilitate the acquisition of these skills for all faculty through local and regional development programs and nurture their growth through a supportive institutional culture.

All that being said, there is something important that happens when faculty members knock on each others’ doors that is not fully encompassed in the concepts of mentoring, sponsorship, or coaching, or even the concept of institutional culture, and I think that what happens in such moments says a lot about the institution, its people, and their core values. I have experienced being on both sides of the door and can remember vividly those senior faculty who helped me through difficult times. I will be forever grateful to them for their generosity and wisdom. When the door opens, we create a space that did not exist before, a place of refuge, where sins imagined or real can be absolved or, in rare cases of wrongdoing, faced. This is important for healing and recovery. We expose and share our vulnerabilities and provide cover and protection for our faculty when they encounter difficulties. This is not a critical experience for the junior faculty member only. It is important for faculty and residents at all levels. It is also a fulfilling and empowering experience for the senior faculty member, who can share experiences and provide support. I believe this is an important part of informal leadership that Gabel⁵ describes.

Because most faculty will encounter difficulties—such as patient complaints; poor interactions with nurses, administrators, or colleagues; or even potentially devastating difficulties such as the one I described earlier—we should create social and work interactions between junior and senior faculty that will facilitate the mutual trust and support that is a necessary prerequisite for the knock on the door. And we must remember to leave that door at least a crack open and be ready to fully open it when the knock comes.

David P. Sklar, MD