I missed cancer.
I met a 16-month-old in the emergency room with a chief complaint of four days of high fever, cough, and rapid breathing. On exam, he was mildly ill, appearing with wheezing, coarse breath sounds, and mild respiratory distress. The working diagnosis was viral bronchiolitis or community-acquired pneumonia. He was discharged from the emergency department (ED) with antibiotics and close outpatient follow up.
Four weeks later, as the nighttime admitting resident on the Oncology service, I received an admission call from the emergency room. “I have a patient down here that you saw a month ago in the ED. It seems like he has cancer.” I clicked into his chart and read my own note. I was struck with a combination of confusion, panic, nausea … and then guilt. How did I miss this? I listened numbly before trudging down to the emergency department to see the family.
As the family graciously shared the details with me, I felt further shock. Despite resolution of his respiratory symptoms, their child had remained febrile. He no longer wanted to walk. He had multiple unexplained bruises on his body. The family had been seen by medical providers seven times in one month. Then, one of those providers ordered labs, which revealed a likely diagnosis of leukemia.
As a young physician, processing a missed cancer diagnosis was overwhelming, to say the least. I had some colleagues tell me not to worry about it, that it happens to all of us. Another colleague accusingly asked me why I hadn’t checked labs when I saw the patient initially. The regret was all-consuming.
When doctor number one misses cancer, and then doctor number seven diagnoses cancer, who is the better physician? This uncomfortable question is subconsciously answered on a near daily basis by medical providers of all specialties. The question suggests that the utmost marker of success is based on making a diagnosis — as if all of medicine hinges on the moment of diagnostic clarity. The notion of “hindsight bias” is disregarded. The concept of a medical condition becoming more clear with additional time and symptomatology development is also disregarded. Resting our measure of medical success on whether we made or missed the ultimate diagnosis fosters two extreme cultures: of outsized pride or utter failure. Neither is desirable.
After meeting with my mentor, though, I had a radical perspective change. What makes a physician truly excellent? Polished bedside manner? Detailed medical knowledge? Astute interpretation of lab results? I’m convinced that the character trait that consistently defines a great physician is humility.
The unfortunate truth is that we are a handful of imperfect doctors taking care of imperfect patients. We are provided clinical information in a snapshot of the patient’s clinical course, from which we strive to develop an excellent care plan for the patient at that moment. Whether we make a diagnosis or miss a diagnosis during our finite patient encounter, the ultimate trajectory and prognosis of each patient is largely out of our control. What truly matters is our perspective on humility. Humility means compassionately dedicating our acquired medical knowledge for each unique patient. Humility is putting the patient’s needs above our own agenda. Humility is deciding that though we are neither all-knowing nor wholly in control of outcomes, we will work with utmost diligence daily. And, humility is sharpened by how we react to each patient encounter. Are we overly enthusiastic when we make a difficult diagnosis, thinking that success is attributed to our own skill set? Or, on the other side of the coin, do we cower with deep remorse when we miss a diagnosis, overcome by hindsight bias?
The physician that is rooted in humility understands that very little is in our control in life. Thus, it is probably best to try to minimize our emotional reactions to presumed successes and failures. Instead, we should try to relentlessly focus on providing the best care to every patient we encounter, with the time and resources graciously allotted to us.
As we serve as physicians, may the refinement of clinical skills be coupled with an exponential increase in humility. Whether we are doctor number one … or doctor number seven.
Kelley Ward is a pediatric resident in Florida. She strives to reignite the passion for humble, patient care that we all desire to never lose.