I once had a patient present with a perforated duodenal ulcer.
Nine days after over sew, he had a minor melenotic stool. The surgeon preferred to do nothing, suggesting the blood was likely old and working its way through the small bowel. It sounded like a very plausable explanation and watchful waiting could safely be employed. The gastroenterologist preferred instead to recommend a colonoscopy. To the surprise of everyone, a large right fungating colonic mass was discovered, leading to a hemicolectomy on post op day ten.
I once had a patient, a young healthy functional patient present with substernal chest pain, minimal risk factors for coronary artery disease, a normal looking ECG, negative cardiac enzymes a normal looking echo and a negative cardiac stress test. The patient was the antithesis of underlying cardiac disease. I made a decision to ignore all the negative clinical data and get a cardiology opinion regarding the utility of cardiac cath. To the surprise of everyone was the multivessel disease on catheterization resulting in the recommendation for bypass surgery.
I once had a patient, a young healthy functional patient present with atypical chest pain, minimal cardiac risk factors, a normal ECG, negative cardiac enzymes, a normal looking echo, a negative cardiac stress test, a heart rate of 74 a normal blood pressure and an oxygen saturation of 98% on RA. Despite all the negative data, I ordered a CT angiogram and to my surprise was a massive saddle embolism.
Three patients. Three three complaints. Three conditions. Three surprises. Big surprises. Big surprises.
Not in a million years would I have thought the patient with the duodenal ulcer would have had a colon cancer too. Not in a million years would I have thought the low probability chest pain would need bypass surgery. Not in a million years would I have thought the no probability chest pain would need anticoagulation for a massive PE.
Not in a million years would I have predicted the science of disease could have been so wrong.
So what am I supposed to do now? Do I walk through my life as a hospitalist, thinking every patient with chest pain needs a heart cath? Do I walk through my life as a hospitalist thinking every patient with atypical chest pain needs a CT angiogram of their chest? Do I walk through my life as a hospitalist thinking every post operative ulcer surgery who bleeds needs a colonoscopy?
I suppose I could. And I suppose I could practice fearing the unexpected. Fearing that a missed diagnosis was some how my fault. Fearing that some how a patient would blame me, or worse, sue me for missing a diagnosis that fell outside the realm of sound clinical practice. I suppose I could treat every patient as that patient I once had. I could recommend cath to everyone with chest pain. I could order a CT on everyone with atypical chest pain. I could recommend a colonoscopy in every post GI surgical bleed.
And I would be failing my duties as a physician.
I know dang well that I will miss a major diagnosis, probably many times in my career. By sheer numbers alone, in a career of 30 years or more, at 2500 encounters or more a year, to expect perfection in 75,000 patient encounters would be irrational.
All I can do is hope I use sound clinical principles, evidence based medicine and a touch of luck to find those patients who fall way outside the normal presentation of common diseases. Every day I hear physicians talk about the patient they once had. Some physicians use the patient they once had as a justification for pretending to practice good medicine justifying every lab, every procedure and every expensive evaluation in the search for another example of a patient they once had.
It should be our goal as physicians to practice good medicine. Our goal is not perfection. Perfection is irrational. It drives irrational standards of care. If we strive for perfection, we will always be disappointed. And our country will be broke. Good medicine will not guarantee against a bad outcome. It will guarantee a reduced probability of a bad outcome.
If we as physicians strive to practice medicine by expanding our list of patients we once had, we will have no money left to treat the patients we currently have.
It's time we stopped treating patients we once had and start treating patients we currently have.
