Wednesday, December 20, 2017

When Doctors Are Wrong

As medical students and resident physicians gain experience they also gain knowledge and confidence. Consequently, young trainees eventually reach a level of comfort in speaking with families and patients about prognosis and disease course. This is part of the purpose of training, as these conversations happen so often that they are an integral part of practicing medicine. But it isn’t certain that with experience and confidence also comes accuracy.
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Soon after finishing sign-out on a night shift I received a page. The nurses told me that a patient’s daughter had arrived and wanted to speak with me about her father. The patient was an elderly but relatively healthy gentleman who had been admitted with abdominal pain. Multiple imaging studies had shown little to account for his discomfort. But the pain was so intense that he could not eat anything. Even going to the bathroom was difficult — he held in his stool to avoid the agonizing act of defecating. As a result, he became constipated, which then exacerbated the pain. Thus, the medical team administered anti-inflammatory treatments, stool softeners, and IV fluids as they searched for the etiology of this troublesome symptom.

The patient’s daughter asked me about the latest imaging studies and labs as she sat holding her father’s hand. Buried to his chin under the covers, the patient participated in the discussion, asking when he would be able to eat and go to the bathroom easily again. I explained that all the tests had been negative so far and we were unsure of what was going on. I then left the room, and the daughter caught up to me in the hallway. She seemed worried, speaking hurriedly and pleadingly: “How long do you think my father has left to live? How much time do I have left with him? Should I start making funeral arrangements?”

The questions took me aback. I had seen plenty of patients in the intensive care unit who were on the verge of death and they looked so different from her father — a profound pallor, somnolence, lethargy, disinterest in conversation and food. But this patient wanted to eat again, he wanted to see his family, he wanted to watch basketball on TV, and he was interactive and conversational. His cheeks certainly did not exhibit the deathly pale hue of those crossing over to the other side. I assured the daughter of this: “I don’t think you have to worry about that. The most important thing right now is that we figure out what is going on. I can’t tell you how long he’s going to live but I would be shocked if he had only days or weeks left.”

This interaction repeated itself for the next three nights, always with the same diagnostic uncertainty. On further imaging there was evidence of some abnormal fluid in the abdominal cavity. Interventional radiologists extracted the fluid to test it for any cancerous or infectious cells, but it would take perhaps a week or more for definitive results to come back. In the meantime, the patient’s pain improved and he moved his bowels without issue. Even though we didn’t yet have a diagnosis he seemed to be doing incrementally better each day.

On the fourth night I again saw the daughter and she asked: “You don’t think I should be planning the funeral for my father, do you? He’s not going to pass in the next few days?” I understood why she was asking the question — any child ought to be concerned for the well-being of a parent. But I was also surprised because her father was on the mend. I told her that if he continued to improve he would leave the hospital, and his primary care doctor would follow up the lab results and see him in clinic.

At around 2 a.m. that same night, a voice over the hospital loudspeaker echoed throughout the halls as I jumped out of my chair: “Code blue, 7th floor, code blue, 7th floor.” There was a patient in cardiac arrest. I ran out of the workroom and met up with another resident. Which patient was dying? On my way to the code I ran through the patients on the coverage list that evening; I did not expect anyone to pass away. As the other resident and I ran down the hall I saw the code cart containing all the medical resuscitation equipment necessary to treat cardiac arrest outside of the room I had visited every night for the past four nights. My heart leapt out of my chest; I pleaded with some higher power that it not be that patient. But it was.

The resident, nurses, and I immediately began CPR. The anesthesiologists burst into the room and stuck a tube down the patient’s throat and into his trachea to protect his airway as the respiratory therapist attached the tube to a ventilator to help the patient breathe on his own. After multiple rounds of CPR, his pulse returned. We wheeled the patient — attached to tubes, and poles filled with intravenous fluids — to the ICU for closer monitoring. He didn’t respond to our questions or poking and prodding, but he was alive.

Alas, as soon as we got to the ICU, his heart once again stopped beating and his IV line ceased working — his veins (which can happen as we age) were friable and brittle, and the small vein carrying the volume and force of the IV infusions burst. Without an IV we could not give medications. We turned, then, to an intraosseous (IO) line. This entails drilling a hole into the bone and infusing medications through that hole. It is a proven method of administering medications when physicians and nurses cannot obtain IV access. I opened the IO kit and attached the drill to the IO needle, placing it on the shinbone and drilling. It slid into the bone, I detached the drill, and hooked up the IV tubing to the IO line jutting out of the patient’s bone. At this point, the code had been going on for nearly 15 minutes and the patient’s family had arrived. They watched as we furiously attempted to revive their loved one. At some point a family member shouted “Stop, please, enough!” Time of death: 2:45 a.m.

I sheepishly held my head down, avoiding eye contact with the family as they sobbed. The medical team and nurses quietly left the room, leaving the patient in peace. As I passed by the daughter, I could only say “I’m so sorry” — little else would have sufficed. Not only did we not save him, but night in and night out I had given the daughter a false impression that he wouldn’t die. Perhaps, I wondered, I had been disingenuous in some way. Either way, I was wrong.
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Alas, physicians are wrong relatively often, and there is ample evidence for this. In a systematic review in the British Medical Journal in 2012, researchers found that each year up to 40,500 adult patients in American ICUs die with a misdiagnosis. The Journal of the American Medical Association published an analysis in 2009, concluding, among other things, that “while the exact prevalence of diagnostic error remains unknown, data from autopsy series spanning several decades conservatively and consistently reveal error rates of 10% to 15%.” The American Journal of Medicine published a separate analytic review article in 2008, concluding that diagnostic error occurs up to 15% of the time in most areas of medicine. The authors further theorized that overconfidence often accounts for at least some of the errors. These reports have reached a wide audience in the laymen’s press as well. In 2015, the Washington Post published an article indicating that diagnostic errors affect 12 million adults each year. The impacts of errors, as we see in the story above, don’t just involve the patient but the patient’s families, too.

Though these statistics are shocking, it is almost impossible, from the patient perspective, to look at them and subsequently be skeptical of everything a doctor says. After all, we are not only practically but also emotionally dependent on them: We want reassurance from our physicians and we want definitive answers. As a patient, it is frustrating to hear “It may or may not be cancer and we can’t be sure” or “I don’t know how much longer she has left.” Indeed, when the path ahead of us is no longer clear, we turn to physicians for answers because of their experience. We want them to be the kinds of people none of us can be — always right, always knowledgeable, always calm and composed. But they are fallible, despite the impossibly difficult and long road they’ve traversed.

And what can we as physicians take away from this? Doctors want to be the kinds of people their patients expect them to be. But the statistics of medical errors are the reminders of how impossible that is; how many years of studying and experience are necessary even in order to be competent; how difficult, despite the many exams we take and pass, it is to apply knowledge appropriately. Not only are we fallible, but the science we rely on is not always helpful either. Indeed, the best studies are useful merely for inferring what will probably happen — they do not tell us definitively what will happen to the patient in front of us. Moreover, scientific evidence does not exist for every treatment in every situation or every diagnosis in every situation. Once again in medicine, our ideal does not match with the real, and our preconceived notions are sometimes shattered in moments of frustration and uncertainty. Perfection is unattainable, but we must constantly seek it out, always aware of how out-of-reach it lies.

When patients and their families now ask me questions about prognosis or treatment I always preface what I say with: “Nothing is 100% in medicine.” Though I will be wrong again in my career and will, hopefully, learn from my mistakes, I never want to give a false impression. We often tend to ignore uncertainty or wish it away, but we must always remind ourselves, whether as patients or doctors, that no doctor and no science is perfect.