There is something every doctor dreads. Something that pops into her head every time she sees an unfamiliar set of symptoms or sees a patient numerous times for the same complaint. Something that leads him to order lab tests and X-rays even as he reassures himself that all the bases have been covered and that the patient is most likely going to be fine. Every doctor fears the day he or she will miss someone’s cancer. The public skeptic thinks it’s because doctors fear lawsuits, but the truth is that we fear living with the fact that we could have prevented a life-threatening situation but didn’t because of our own incompetence.
No matter how many successes we have as doctors, at the end of the day the stories we swap are the ones we bear scars from. My personal gunshot wound is Bubba, a 16 year old kid I first met in the emergency room. He came in for back pain. Right away I focused on two things. One, at 15 he weighed 160 pounds; and two, he was a football player. I would have been shocked if he didn’t have back pain.
So I went through the motions. Got fever? Got cough? Runny nose? diarrhea? …Got milk? In the middle of all those questions I missed one key thing: he was also having pain in the right side of his neck. I lumped it together with the football-player-got-tackled-and-now-has-generalized-musculoskeletal-pain scenario and filed it away. At the end of the visit I handed him a referral to the orthopedist and moved on.
Three months later I’m breezing down a hospital corridor and I see a kid in a wheelchair. I’m about to walk right past when I hear his mother say, “Hey, we saw you in the ER.” I stop, look back, and with the practiced smile I give to everyone who says that to me I say, “Oh yeah, how are ya’ll?”
She cuts me a mean look and says, “You didn’t listen to us when we were worried about Bubba and you missed his cancer. He’s got Hodgkin’s lymphoma”.
There was a slow and subtle pain in my stomach that brought to life the phrase “gut wrenching”. Really? This was going to happen to me this early on in my career? It was like the time I got a speeding ticket two months after getting my driver’s license. It turned out that the pain in Bubba’s neck was actually an enlarging lymph node filling up with cancerous cells, not a strained muscle. The back pain was his bone marrow stretching as cancer cells filled up the vertebral bodies and pushed out the normal cells. I was caught so completely off guard I can’t even remember what I said or did.
I do know that for months I felt ashamed and replayed his case in my head over and over thinking about what I should have done differently. I felt insecure, wondering with each patient that I saw if I was somehow missing something else important. In a therapeutic attempt to help absolve myself I presented the case at a morning conference in front of my peers, confessing my sins. I spoke of how in an instant I got years worth of medical education. Listen to the patient, listen to the family. Keep an open mind and never dismiss a symptom that is getting worse. Our open discussion afterward made me realize that I was sitting in a room full of people that take their responsibilities very seriously and understand the gravity of having people’s very life in their hands. Many shared their own stories of missed appendicitis or meningitis. Whenever I see a story on the news about medical errors I feel sympathy for the patient, but my heart also goes out to the poor Jane Smith, MD who, unbeknownst to the public, is suffering silently at home about how such a thing could have happened on her watch.
I ran into Bubba at a deli recently. He is doing well, his cancer is in remission. He is eighteen now and doesn’t play football anymore, not because he is sick but because his Medicaid lapsed before he could have surgery to remove his portacath (a device to deliver medication and draw blood intravenously without multiple needle sticks). Wisely, the school district thought it would be better to keep a kid with a two thousand dollar piece of hardware implanted into his chest off the football field. He and his family have since forgiven me and I have had the privilege of continuing to be part of his medical team. The experience still guides me and helps me listen, understand, and analyze symptoms as I jump from patient to patient every fifteen minutes.
