I was on medical admit, taking call for unassigned patients, when I was summoned to take care of a 79-year-old, mildly demented woman with a large pleural effusion. I decided to go over her chest x-ray with our radiologist.
"I don't know what's causing the effusion," I said. "That's why I ordered her scan."
"I can tell you what's causing it," John said. "She has a tumor in her chest."
"How do you know that?" I asked incredulously. "All I see is a white-out."
"She was an inpatient here six months ago," John said, pointing to an old film, "and she had a two-centimeter lesion then."
Mrs. Howell had been unable to tell me about her previous hospitalization, so I retrieved her medical record from the computer. Sure enough, she had been admitted after a fall, having sustained a pelvic fracture and a cerebral contusion. A routine chest film had been misread by the ER doctor and then apparently had been overlooked by the attending on call; he had neglected to read the radiologist's report as well. Now the patient was back, six months later, with a malignant pleural effusion.
What to do? Should I bring my colleague's blunder to the medicine committee meeting, which could lead to public humiliation for him, and possibly to bad blood between us? Or should I just inform him confidentially?
I also had to wrestle with another decision: whether or not to tell Mrs. Howell's family about the missed x-ray report. I felt conflicted, my professional conscientiousness butting heads with my empathy for a colleague who wasn't a bad physician but who, in this case, just hadn't been careful enough.
My thoughts squirreled round and round. Patients and their families deserve to know the truth, but in this case, what good would it do? The mistake had been made six months ago, and, given Mrs. Howell's mental status, I doubted that she would have been a candidate for aggressive therapy even then. Diagnosing her cancer six months earlier wouldn't have made any difference to her outcome, I told myself, and it would only have added to her family's distress...or was this just a rationalization? Whatever my decision, I knew I couldn't feel good about it.
In the end, I opted not to tell.
The next day, I placed a copy of my colleague's original discharge summary in his box, along with the old x-ray report, the current CT report and a brief note, and waited for his response. Several days later, I ran into him while making rounds. After thanking me and expressing his concern for Mrs. Howell, he wondered aloud, a bit feebly, why the radiologist hadn't personally notified him about the tumor.
I felt for him. Fundamentally, we all have feet of clay; sooner or later, we all miss a big one. If we don't learn from our mistakes and use those lessons to become better physicians, then no one really benefits.
Since I always beat myself up over bad outcomes, I vowed to be even more vigilant. I knew how uncomfortable I'd felt telling my colleague about his mistake; I didn't ever want to put a colleague in the position of having to tell me about mine.
About the author:
Sandy Brown practices family and preventive medicine in Fort Bragg, CA. For more than six years he wrote the column "Practice Diary" for Family Practice Management. He now writes the "Family Medicine Practice Diary" for Medscape Family Medicine at www.medscape.com/index/section_2925_0, as well as facilitating their family medicine and internal medicine discussion boards. When not writing or seeing patients, he enjoys dirt and mountain bike riding and counseling premeds about how to get into medical school.