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The Devastating Emotional Impact Of Missed Diagnoses

Bongi is an amazing writer, and if you haven’t, I strongly urge you to read his latest post, titled “The Graveyard.”

I imagine that a huge number of doctors know exactly what he means. I remember being told by a surgeon, while I was in medical school, that “you’re not a real doctor until you’ve killed someone.” I thought at the time (and still think) that there was a puerile bravado behind that admonition, but there is also a grain of truth. I have my own graveyard. Curiously, not all of its inhabitants are dead. They are the cases where I screwed up, or, charitably, cases that went bad where I feel that maybe I could’ve/should’ve done things differently.

The missed SAH

The missed DVT/PE

The missed AAA

The missed Aortic dissection

The missed MI

I remember them all, clearly and in detail. I remember which room each one of them was in while they were in the ER. (seven, eleven, ten, nine, five) I remember what they looked like. I remember what the ECGs looked like. Like Bongi, I tend to blame myself even when the lawyers and quality committees have exonerated me. I should count myself lucky that after ten+ years in practice the body count is so low (at least as far as I know). Rationally, I can see that these cases were not my fault, and in fact I am comfortable defending them, if I had to, which I am glad to say that I have not. But I carry the scars. The Aortic aneurysm died in front of me after a three-hour battle for stability. The dissection I found about the next day when I came back to work (she survived, miraculously). The horror of realizing that you were wrong in your assessment of this patient, and he or she died because of it is really something. It changes you. You carry it with you, on some level, every single day.

This is, I think, what the surgeon meant when he said ”you’re not a real doctor until you’ve killed someone.” I thought he was full of bravado and being cavalier about the fact that your patients will die sometimes; I thought he was glorifying the toughness that some surgeons so revel in. Maybe he was; I don’t know. But I have learned this — it changes you, and until you have to go home and lay in your bed and consider how that person died and whether it was your fault, it’s hard to understand. But it is true, that you are not really a doctor until you have confronted and surmounted that moral burden. Some never do. Some practice in terror of that moment, and some leave the profession because they cannot bear that moral responsibility. Some become jaded and cynical and try to blind themselves to the consequences by dehumanizing their patients (a failing particularly easy for ER docs to succumb to). Most of us don’t talk about it — especially surgeons, which is one reason to highly commend Bongi for putting it out there so starkly. I play at being cavalier in the ER; it’s a facade, my clinical persona. But the memory of these cases where I was so catastrophically wrong also keeps me humble (yes, really) and keeps me alert to the possibility that I might just be wrong again, reminds me to keep an open mind. I like to think this is wisdom, hard earned.

I don’t want to seem in any way like I am looking down on my colleagues in specialties with low mortality rates. They’re doctors as much as I am. I always hated the “It’s a black thing, you wouldn’t understand,” or the idea that you couldn’t really understand what it is to have kids until you have your own. I don’t like that sort of exclusionary thinking. But wisdom comes in part from experience, and experience forms us. So I won’t say that someone cannot understand the weight of this responsibility until they have gone through it. But I will say that I am a different person now for having done so, and I understand things differently for it.

Well done, Bongi, for illustrating it so eloquently.

*This blog post was originally published at Movin' Meat*


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2 Responses to “The Devastating Emotional Impact Of Missed Diagnoses”

  1. tyredoldnurse says:

    I’ve been a nurse for a long time. I appreciate MDs who actually listen, b/c even though all of them should, many don’t. It is, after all, my job to advocate for my pts, which means I need to be the eyes & ears of the physician, as well as to carry out orders or ask the physician about concerns I might have in regard to a potentially dangerous order. I know some RNs just call constantly for things that, ostensibly, they should be able to handle on their own. Please remember, though, that right now, a new RN waits for over a year before he/she can get a job; that day shift RNs have to contend w/ rounds, meetings, & a high patient load (8-14 pts) while dealing with multiple discharges & admissions during a shift. With no ratios except for a few states, RNs are taking care of a dangerous number of patients in most hospitals on all shifts, esp day shifts, which are filled with procedures, surgeries, tests, consults, etc. We don’t have time, either. We sometimes call for you to check a patient because we don’t have the time, which could be because someone else’s patient is crashing. I apologize for the ones who are truthfully just lazy. BUT YOU STILL NEED TO LISTEN, NOT BULLY US.

    And those of you who are decent, QUIT PUTTING UP WITH BULLYING PEERS. You know who they are as well as we do. Deal with it. If you really want RNs to do their jobs, we need to know you have our backs when we report something & a doctor doesn’t respond, then gets huffy if we go over his/her head to get help for the patient, or comes in late while the patient is having an entirely preventable crash & blames the nurse for “not reporting significant changes in the patient’s condition.” Listen to us, & make sure other MDs do as well. It’s in everyone’s best interest to avoid the AMA “bury your mistakes” attitude that hides the deeds of dangerous MDs & tarnishes the names of good ones who make honest mistakes. Documenting all the attempts to contact a physician doesn’t always help. You see, MDs are viewed by hospitals as “revenue generators.” RNs are viewed as a drain, on a par with linens, bedpans, IV fluids, dressing supplies, gowns, housekeeping services, & bad hospital food delivery. If we were to charge for our services as you do for yours, that could be turned around. Efforts to that effect have so far failed. That means anything the MD wants to do to RNs is just fine w/ admin, including verbal &/or physical bullying. And if you’re a RN, don’t even try to block the punches unless you want to be disciplined; you don’t even have to throw one; avoiding being hit is often enough for a MD to complain of being the victim of battery rather than the perpetrator. (BTW, when it comes to patients/visitors, the charge is patient abuse or assault & battery for blocking, sometimes even just ducking, a punch – but I always defended myself anyway, & I’m VERY good at crisis mgt. I know how to defuse most situations; IMO if someone tries to hit me, they just want to hit someone who’s not legally allowed to defend themselves, & IMO I’m allowed to block & duck, & fully intend to do so).

    It’s also my job to teach the patient & those who will assist with their care on discharge, about their medications & treatments, & to try & discover what barriers might exist to carrying out their post-discharge regime so that I can address those. I know that addressing potential discharge needs can mean a barrage of paperwork for the physician. I hate that because of fraud & rampant idiotic bureaucracy, doctors now have overwhelming paperwork that “only MDs” can fill out. And, despite government demands for HIS in all facilities right now, they still insist on PAPER, esp. for LTC & HHC. Heck, in LTC facilities, everything has to be on paper per Federal regs; you can’t even put the same form in a computer, fill it out, print it, & sign it. It has to be hand written. The same applies to all PMR therapists, SW, & CM even in acute care. All paper. Per Federal regs, yeah, the same feds that are demanding MDs have expensive computer systems, that hospitals have fully-integrated HIS costing millions, on the blind faith that all computer systems “talk” to each other & that they’re all easy to use. They’re not Apple based, they’re PC based, & PCs crash constantly-of COURSE they’re time consuming, dollar-devouring messes that are difficult to use a lot of the time. There are only 2 ways that all hospitals can have their HIS “talk” to each other. 1. Print it out & fax it, the most common & cheapest method & the one where 1 misdialed number = HIPAA violations w/ 5-6, even 9 figure fines. 2. Create expensive interfaces for each system to which your hospital might “talk,” & hire the 6 figure salaried IT people to maintain them (this is not the same 6 figure IT people who maintain the hospital’s databases, BTW). Realize they’ll still crash regularly & be down for extended periods of time. Any doctor or RN could’ve told the Presidents Bush & Obama that, even those who aren’t “informaticist” trained in their profession. In fact, the grass-roots caregivers are the ones who know exactly 2 things; 1. System usability is a dream most of the time, & 2. Badly designed systems, purchased by people who’ll never have to use them, take caregivers of ALL HC professions away from the bedside. THAT is where far too many “medical mistakes” occur. Too many patients, balky HIS, too much stuff that has to be either on paper only or done in both the HIS & on paper, & while the JCAHO pt safety regs weren’t too bad at first, they’re now so balky it’s a miracle anything gets done at all. And I doubt the politicians have ever looked at the real cost of installing HIS/CIS, or the time required (esp since just as the vendor has programmed the system for federal, state, & local law, at least one of those will make a significant change that means the programming has to be changed yet again & will delay rollout a few more months). Unless, that is, they secretly have stock in several HIS vendor companies…which, you have to admit, would explain quite a bit. Government “stupidity” is often really politician “cupidity.”

    Work with us. Respect our workload & share what you have to do so we understand each other. Don’t assume stupidity & we won’t assume laziness. RNs right now have better physical assessment skills than a lot of interns as med schools train for “evidence based” medicine w/o including the most impt “evidence” of all-the findings of a physical assessment. When caregiving my mom prior to her death, I’d hear rales & she’d be severely SOB, I’d call 911 (after making sure her sugar wasn’t too high or too low & thus exacerbating things & after calling her MD about increasing the diuretics to try & avoid the ER). I’d get an intern who’d tell me she/he couldn’t hear anything. I’d whip out my steth, put it in place, clean off the eartips, & they STILL couldn’t hear it-they wouldn’t believe it until a CXR showed it! What kind of idiocy is that??? Even freshly graduated BSN nurses can hear that. So can ADN nurses; even good LPNs can hear it, so what’s wrong w/ the interns? NOW can you see why we call you for things they should be able to treat? It’s bad enough as a floor RN; it’s worse when you’re a caregiver.

    Here’s one more comment in passing. Reaching the age of 60 does NOT mean you’re senile. My husband turned 60 in Feb. We’ve been going to a wonderful MD for nearly 3 yr now. Same clinic, same MDs, they’ll listen to me but now have a hard time listening to him! Why? They had no trouble before…age is the only change. My mom & grandmother were both clear-headed, intelligent, mentally “with it,” stable people until they went into a coma & died. Mom & I made sure my GM’s death was one of dignity; I did the same w/ Mom. Yet, Mom & I had to tell them what my GM wanted; no one would listen to her; she was 83, she had to be senile. It was the same w/ Mom; my son & I had to tell them what Mom wanted, they didn’t all listen to her. Now, for the next year, they’ll listen to me as regards my husband, but in 14 mo, I’ll also be 60. Despite my intelligence, I’ll be consigned to the ranks of the senile. Everyone will ask our son what we want, & he’ll be the only one to whom they’ll listen. Not both of us, just the person under 60. People are living to be articulate & independent into their 90s, sometimes longer, & doctors treat everyone like they’re brain dead starting at 60. For a centenarian, that’s 40 years of fighting to be treated like a human being with an IQ higher than room temperature. Yeah, a lot of old people seem senile. Maybe they’ve given up fighting to be viewed as “with it,” so they just shut up. Maybe they figure if the MD thinks they’re senile, they must be senile. Maybe it just depresses the heck out of them & they need a counselor-but they also generally believe anyone 60 or older is senile, so who’s going to do the CBT to help them cope w/ age related changes? Antidepressants often make older ppl worse; monitoring is necessary, but all changes from antidepressant side effects are likely to be blamed on senility.

    Those are some of the things that need to change. When I turn 60, I don’t intend to be dismissed as a senile old bat. A fat, often mouthy old b—h is very much preferable to me, as I believe that stands for Beautiful, Intelligent, Talented, Caring Human.

  2. Health Blog says:

    Yes, a missed or wrong diagnosis can be devastating to the patient and their family. But the fact is that, the doctors are also human and “to err is human”. The idea should be to reduce misdiagnosis and wrong diagnosis to as low as possible.

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