Good Doctoring Is in the Details
Some people think practicing medicine requires brilliance. Doctors know better. Good doctors are smart, yes, but most of all they are dogged and detail oriented. This truth hit me full force not long ago when an attorney asked me to review the case of a man with chickenpox. From charts and depositions, these were the facts I gleaned.
A few years back, the patient--in his 30s--came to an emergency room covered in spots. He knew he had chickenpox because he caught it from his daughter. What he couldn’t figure were his pains. One day into his rash, his chest and abdomen hurt so bad he could barely walk. His wife finally brought him to the hospital late that night.
In the emergency room, the patient was seen by several nurses and an emergency doctor. The diagnosis of chickenpox was obvious to all. However, at least in the doctors’ written entries, no one connected his pain with his chickenpox. Nor did anyone note another chronic illness: emphysema.
Instead, the patient left with a painkiller and a tentative diagnosis of gallstones, to be confirmed by an ultrasound scheduled the following morning. The ultrasound result was normal and ruled out gallstones. But at that point there was no new diagnosis or plan. A second emergency doctor simply renewed his pills and once again sent him home.
Finally, 36 hours later, severely short of breath, the patient showed up at a new hospital. By now, his chest X-ray was a blizzard and his diagnosis unequivocal: chickenpox pneumonia. In adults, it’s the most dreaded complication of a usually benign childhood infection. Despite admission to the intensive care unit, artificial ventilation and antiviral treatment, within hours he was dead.
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What if he had received aggressive care two days earlier? No one knows for sure, but odds are he would have made it.
A story like this is a doctor’s worst nightmare. An incomplete history, missed diagnosis, delayed treatment ending in death. In most hospitals, this case would find its way to the “M&M; conference.” That’s hospital-speak for “Morbidity and Mortality,” a monthly closed-door meeting where doctors scrutinize one another’s errors of judgment, process and technique.
As a doctor in training, attending M&M; was mandatory. Now, as a middle-aged physician, I still go once or twice a year. No matter what case is discussed, one lesson always emerges: If you want to avoid bad medical outcomes, thoroughness counts more than brilliance. Among other things, that means stalking clues over and again, contemplating worst-case scenarios and, if necessary, calling for help.
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Back to the two emergency doctors. Their depositions revealed that neither had ever seen or treated complicated chickenpox. Nor did they know the likelihood of death due to chickenpox: 15 times higher in adults than in children. And that’s before factoring in severely damaged lungs due to emphysema, which greatly increased this patient’s risk. Of course, just a phone call away was a specialist with knowledge of all these things. What a tragedy that call was never made.
No one likes reading about mistakes, doctors or patients. So what, if any, are the positive lessons of this story?
In recent decades, medicine has come far. So far, in fact, that certain syndromes like chickenpox pneumonia are rare. Now and in the future, doctors need to be extra vigilant not to miss unusual presentations of once garden-variety ailments that can still kill.
Another lesson of the story is for people with elusive diagnoses. Although you should never diagnose yourself, when consulting a doctor, don’t be afraid to collaborate and volunteer information that may be helpful.
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One way to collaborate with your doctor is to know a little about the standardized history drilled into every medical student. It’s an ordered inventory of symptoms and underlying diseases that, combined with physical exam and lab tests, guides medical professionals to working hypotheses. The list includes: the patient’s chief complaint, history of present illness, medications and medication allergies; past medical and surgical history; family history; social history; and something called a “review of systems.”
A review of systems may be the last item on the list, but since it covers the body from head to toe, it’s well worth a doctor’s time. After a full review, it’s not likely emergency doctors in this case would have missed emphysema and budding viral pneumonia.
Finally, never hesitate to ask whether a physician has seen a certain condition before. If not, ask him or her to call a specialist.
Somewhere far away lives a widow and three children. I understand she drives a bus, that her son is smart as a whip, and all the kids miss Dad. For them, one doctor dogging the details might have made all the difference in the world.
Claire Panosian Dunavan is an internist and infectious diseases specialist practicing in Los Angeles. She can be reached at drclairep@aol.com. The Doctor Files runs the fourth Monday of every month in Health.
