My weekday job involves writing and doing other communications work for an online veterinary community. One of the longstanding features of this community is the Message Board area where veterinarians post questions, comments, or quandaries regarding cases, clients, life, and almost anything you can think of. It’s sort of like a giant doctors’ rounds.
Two concepts that pop up in the Message Boards fairly often are ideas that cross over neatly into everyday life.
The Bone Pile -- (Spoiler alert: Do not read the following if you still operate under the belief that “doctors” possess superpowers.)
Whenever someone, often but not always a new graduate, posts about a case that went wrong and about their fear, horror, anxiety, and shame surrounding the case, almost inevitably, a more experienced veterinarian will chime in with this phrase. “Every practitioner has a bone pile.”
It’s true. Medical practitioners -- whether veterinarians, dentists, or physicians -- are human. And human beings make mistakes. We make errors. We have failures. Sometimes we fail to communicate. Sometimes we miss something. Sometimes we forget something. Sometimes our skills prove to be insufficient. Sometimes we fail to follow through. Sometimes fate and physiology are not on our side. Sometimes we just plain screw up. These errors, failures, and losses stack one upon the other, forming the “bone pile” of the career.
In life, we all have our bone piles. All of our failures, mistakes, cruelties, and inadequacies pile in the corners of our lives. The cutting words spoken to a friend, the failure to listen to our children’s stories, the relationship that we blew entirely, the addictions, the jobs that we’ve lost, the financial setbacks, the burnt pie crusts. The bone pile isn’t always stocked with T-rex femurs. Some of the bones are tiny – wispy fish bones that poke and annoy, but are almost invisible.
Most of us don’t like to look at our bone piles. We stack furniture in front of them, cover them with pretty clothes or expensive electronics, blur the outlines with food, drugs, sex, or alcohol, run from them into the next ill-considered job or relationship. We call this “moving on.” And, indeed, one can’t set up residence in the bone pile. It’s a creepy, hard, and uncomfortable place that lacks the things we need in order to sustain us. There is no love or nutrition in the bone pile. It’s haunted by the ghosts of shame and failure.
But, to deny it, is to deny ourselves.
Here’s where medical practitioners do something right. We speak of the bone pile almost fondly and return to it on occasion, but not with self-flagellation – with a purpose. You see, doctors (of all stripes and spots) have learned that the purpose of the bone pile is education. We perform necropsies on our mistakes – carefully dissecting away the layers to discover exactly what happened. In hospitals, human physicians hold Morbidity and Mortality rounds, in which a case that produced an undesirable outcome is selected and presented in a peer group. The purpose of these rounds isn’t to shame the doctor in charge. It isn’t a public flogging. The M and M is meant to highlight where mistakes occurred and ways of preventing those errors in the future.
We can’t “move on” from our failures or losses until we understand why they happened, and until we learn what we can do to keep the same pattern from repeating. The bone pile will always grow – that’s the nature of human existence. Yet, acknowledging the bone pile and its usefulness helps us to grow, to build our experience, and to move away from past errors. Yes, so that we can make new ones!
If the inevitability of failure depresses you (it depresses all of us a bit, I think), then you may be glad to see the next tool.
The IDS File
The IDS file is usually mentioned in the same message threads that reference the bone pile. New practitioners often have to be told about this tool, and sometimes experienced practitioners need a reminder to return to the IDS file periodically. IDS stands for one simple principle: I Don’t Suck.
“I Don’t Suck” is a hard concept for most humans to grasp. For veterinarians (and I suspect physicians) who tend to be goal-oriented perfectionists, the IDS concept is both incomprehensible and essential. After all, if we tell ourselves that we are horrible, that we have failed, that we suck, that makes us good people, right? Self-flagellation is virtuous, isn’t it? After all, beating ourselves up over a mistake will keep us from making that same mistake again.
It sounds good. And we all do it. We writhe in guilt over the case that went wrong – obsessing, losing sleep, researching until our eyeballs pop out of our heads like Boston Terriers with glaucoma. We label ourselves – “I did it again. I can’t be in relationships. I should just die alone.” “I can’t believe I said that to her. I’m a horrible mother.” The problem with the “I Suck” approach to our humanity is that it doesn’t prevent us from making mistakes, and it doesn’t make us any better in the areas where we’ve failed. I’d argue that it makes us worse.
This is a hard story to tell. A number of years ago, I was called out to castrate a horse. Gelding is a common surgery, and I’d performed hundreds by that time. The patient was a gorgeous, 6 year old, well-mannered stallion who was only being gelded because he was being moved to a stable that didn’t allow stallions and he wasn’t going to be used as a breeding animal anyway. The surgery went well. I never could pinpoint a moment where anything went wrong. When he stood there was no bleeding beyond the typical few drips. I watched him in his stall for about 20 minutes to be sure. I wasn’t on call that night, and I’ll never know what happened exactly, but he began bleeding that evening. I still don’t fully know the chain of events, but the upshot was that my patient wound up bleeding to death in the trailer on the way to the referral facility.
Realistically, I don’t know if I committed an error in surgery, if the horse did something later on that opened a clot, or if there was an error on the part of one of the other practitioners that saw him that evening. I never will know. But, this horse looms large in my bone pile.
Here’s what happened to me. I excel at self-flagellation. For months, I spent the drive to work wracked in nausea, my vision blurred so badly I could barely see the road. I was terrified to do any surgeries. At all. The record lurked in my stack of files because I couldn’t face writing it. I told myself that I could never geld another horse again.
None of this made me a better veterinarian. Clinical acumen and anxiety-ridden paralysis don’t exactly go hand-in-hand. Telling myself I sucked only got in the way of the confidence I needed to treat my other patients properly.
Fortunately for me, I had a boss who was more than willing to share the stories of his own bone pile, an office manager who had no intention of coddling me and booked surgeries for me (including geldings) just as she always had, and a technician who blessedly saw the shakes I tried so hard to hide and made certain that she could be there to assist me and who always had the phrase that got me through many a tough case, “I know you can do it. I have great faith in you.”
And I had my IDS file. It’s a literal file these days, still hanging in the rack in my home office. Back then, my IDS file was a collection of cards, notes, and pictures from clients jammed into my cubby slot and briefcase. Each of those cards said essentially the same thing: “Thank you for caring for our animal. You are a wonderful veterinarian. We are grateful for you.”
Human nature is a funny thing. Even though I said that the story of the gelding disaster was hard to tell, those words were much easier to type than the messages of the IDS file. We are much more comfortable with our failings than we are with our strengths. Typing the phrase “you are a wonderful veterinarian” feels awkward and self-aggrandizing. Even alone in my office in pre-dawn quiet, I feel embarrassed, as though I should duck my head and blush. Yet, in this same office, I can glance around the room and see at least three mementos belonging to my IDS file.
In our everyday lives, the IDS file may be harder to compile. I’m learning to build mine from bits and pieces. Some of it lives in my email folders: kind or funny notes from friends, compliments on articles, thank yous from school or other organizations. Some of it lives on my refrigerator, dresser, and bulletin boards in the form of art and gifts from my children. Some of it lives in boxes of old letters (remember those?) and cards. Some of it lives in the objects about me – my Alice in Wonderland teapot from my husband. Some of it lives in my mind – in the memories of conversations, small triumphs, and unbelievable joys. But, I’m learning, on the days when the bone pile seems unmanageably high, to go to the IDS file in whatever form is handy and to find the things that tell me that “I don’t suck” or to find the people who will let me know in their own ways that they “have great faith” in me.
Yes, our pains and failures have to be moved on from, but they must also be learned from. And we need to learn from and embrace our triumphs and joys to the same degree. Ultimately, we are the only ones who truly create both our bone piles and our IDS files, and it is up to us to decide how to use them.