Sunday, 25 July 2010


Recently we cleared out the loft to prepare for the installation of a respectable amount of insulation, and this weekend I have been sorting through the clutter that we brought down. Among the junk I found a letter from my mother reassuring me when I felt overwhelmed at the start of my medical house job. Thanks, Mum. I also found the notes I made about my clinical experience in the early years as a doctor. It has been fascinating looking back across nearly thirty years, watching the doctor at work who eventually became the doctor I am today. He seems vaguely familiar, somehow...

Then I found a copy of the medical school magazine from when I was a final year student. There is an article from an academic surgeon entitled “why you lose at diagnosis”. He runs through some very salient reasons. Medical students and tyro doctors often don't ask the right questions, or ask leading questions, or misread the answers. Then they don't play the odds, failing to remember that common things are common. Or they don't know which things are in fact common. They may suffer from information overload, and not be able to see the wood for the trees. They may then fail to make an effective decision, or ignore the consequences of error (what is now known as “safety-netting”). He concludes by advising his readers to aim, not at perfect diagnoses but at winning decisions.

So far so good, but what really caught my eye was his last point: being unable to come to terms with the consequences of error. He wrote: “from time to time your own ignorance, or sheer stupidity, is going to result in decisions which harm patients or even lead to their deaths. But in clinical medicine this fact has to be faced, because you can't be right all the time. So somehow you have got to get used to the proposition that the decisions you make will occasionally have unhappy consequences, and you've got to strike a happy medium between callousness and the sort of emotional claptrap which passes for medical television series.”

That is how they used to talk thirty years ago. I doubt that such an article would be published today with its paternalistic attitude. Yet the advice was well meant, although the fear of harming a patient through my own inadequacy has haunted my clinical career these past three decades. I have either been very lucky, or careful (or possibly both) but I can only recall two occasions on which my sins of omission have caused serious harm to a patient. The first happened right at the start of my career, just a few weeks into my first house job, and I recorded the details in my log. A woman of 70 became short of breath with fever and tachycardia the day after her operation. I initially thought she had a chest infection but she deteriorated over several hours. The medical Registrar came and diagnosed supraventricular tachycardia, but despite his treatment she went into cardiogenic shock and arrested. I wrote “despite resus, crashed into asystole. Had to tell husband. I was really distressed myself afterwards.” No senior doctor spoke to me about it afterwards, of course. To this day I don't know whether she would have survived if the diagnosis had been made a few hours earlier.

To the best of my knowledge I did alright for the next thirty years, but came a cropper again earlier this year. A chap just a few years younger than me had developed a heart condition which was causing palpitations, and had an internal defibrillator fitted last year. Earlier this year I saw him several times trying to sort out his palpitations, and he gradually developed fatigue and breathlessness as well. This came on slowly at first, but then he began to lose weight. I was beginning to get seriously worried about him and ordered a number of blood tests and a chest X-ray, but before I got the results his wife became desperate and rang for an ambulance.

Have you made the diagnosis yet? He had subacute bacterial endocarditis (SBE) and went through a very stormy time in hospital where the two infected heart valves were replaced. The good news is that he has made an excellent recovery with no residual problems. But I felt very bad about the delay in diagnosis. Where did I go wrong?

Firstly I assumed his early symptoms were due to his underlying heart disease. Then I thought that he might have developed some new illness unrelated to his cardiac problems. In fact, when new symptoms arise they are much more likely to be due to an existing condition than a new one. In addition, I did not know that cardiac catheterisation (for angiography or the insertion of pacemakers or defibrillators) is a common cause of SBE. The annoying thing is that the diagnosis had gone through my mind. I listened to his heart and heard a mild “ejection” murmur. I discounted this because I thought that endocarditis would cause a loud, harsh “pansystolic” murmur, and his murmur had in fact been noted by the cardiologists the previous year. I have discussed this at a “significant event” meeting with my partners, who were very supportive. They pointed out that I was aware that there was a problem and I was taking steps to investigate it. The problem was that this illness develops insidiously over weeks or months. Usually in general practice we recognise when somebody is seriously ill and send them into hospital, even though we may not know the diagnosis. The last time I saw my patient before he went into hospital he did not look ill enough to require admission.

Nevertheless I still see this as a failure. I feel that I let my patient down and it has shaken me. Fortunately his wife has been very good about it. She expressed her feelings that her husband had been let down, and I was able to have an open discussion with her in which I expressed my feelings of failure but explained what had happened and where I had gone wrong. Luckily I have known her for many years and there was “money in the bank” which allowed her to accept my explanation and apology. Recently she came with her husband to see me for the first time since he was discharged, and they both looked very happy.

Of course there may have been other cock-ups over the past three decades which I have either forgotten or never knew about. But I don't think my record is too bad. And that's just as well, because I have found causing a patient harm to be extremely distressing. I have never “got used to the proposition that the decisions you make will occasionally have unhappy consequences” and I'm not sure whether I should try. But I still wonder, as I walk into work on a Monday morning, whether I am clever enough for all this.


Anonymous said...

My dearest dear of course you are good enough; of course you are not a failure. Some of us limp along knowing we are really failing everyday and some don't know or care. You castigate yourself unnecessarily - the patent and his wife came back to you which surely is a sign you have not failed.

You are almost unbearably too good to be true in your quest for perfection and so self-critical I fear you will either give up being the gifted doctor you are or worse, end up in self destruction as so many others have done.

Please step outside your own shoes and read your whole blog. Few of us are as diligent and sacrificially careful as you are for your patients. If you were standing where I am you would feel an inadequate fraud with such an example of excellence before you.

Dr Andrew Brown said...

Dear xxxx (for I know who you are),

It is very sweet of you to say all these things. And there was I thinking I had written a very positive blog entry!

I have become aware lately of how much some of my patients appreciate me. And I presume that yet more appreciate me without saying so.

But I do find being a GP difficult. You are one of the very important people in my life who keep me going.

Thank you.

GrumpyRN said...

A lot of years ago I attended my GP and told him I have recently had a lecture at college about testicular cancer and I think one of my testicles is larger than the other one. He had a feel and told me no, one is meant to be bigger. A year later after an episode of excruciating pain in my lower abdomen I was dignosed with a mixed Teratoma/Seminoma which had metastasised into my lung. Did this make him a 'bad' GP? Of course not, I was at the extreme age range and had a slight tendency to hypochondriasis at that time, but it did mean I got exceptionaly good care in the future.

Dr Grumble said...

One of our surgeons said to me recently, "Our patients don't know how much we worry about them." He's right. They have no idea.

Sam said...

Yes we do Dr Grumble, this is why doctors are the most trusted profssional of all.

And Dr Brown, please always remember you're only human after all - and by definition, you are not perfect - no human is. I must say, it is very touching you decided to share how you feel inside with us. I wish other docs show their human side more often too because, this is not only soothing for when you feel as you do, but makes us patients more appreciative of the good effort you do - and that we are really all in the same boat.

All the best

Jellyhead said...

I never feel clever enough either. I feel like I manage to be a halfway decent doctor only through being diligent and conscientious (and even then I am constantly worried I have 'missed something'). Maybe it is a characteristic of we 'A-type's?!

In the end, I do the best I can, knowing that I can neither know everything, nor diagnose and treat everything perfectly. None of us can. Some days I can feel at peace with that idea and others not so much.

I guess I just wanted to say that you're not alone.

steph said...

I echo Sam's words - both to Dr Grumble and to you and I feel privileged that you have shared those innermost thoughts here.

In reply to Dr Grumble, I would like to add that patients possess skills of observation too!

I'm aware that I've caused a scare or two in the past but you're not in a position to empathise with your doctor at the time as staying alive becomes your number one priority. I do feel it's important though to have a laugh about it, if you can, afterwards so that your doctor knows where you stand.

But as Sam says, nobody's perfect!