One Strike, You’re Out!

We buried my wife’s cousin Ruth last week. She had a strange mole on her arm a couple of years ago. The doctor told her it wasn’t anything to worry about, but he was wrong. By the time she got to the cancer clinic in Chicago, her melanoma had spread to her lungs, and in spite of chemotherapy and radiation, it continued to spread through her spine and, finally, her brain. The somewhat tired looking Ruth we saw at Christmas died last weekend in a nursing home, where, in the end, she had been unable to speak or feed herself. This seems such a horrible and unnecessary tragedy, and Ruth’s family is still in shock. As we sat around her parents’ living room the night after the funeral, some bitter thoughts were voiced about the doctor who misdiagnosed her melanoma. Someone said he should be sued, but Walter and Ellen said they wouldn’t consider it; that would not bring Ruth back. Someone else said he should be stopped from ever practicing medicine again, so he wouldn’t be able to make any more serious mistakes. That’s where I found myself having to defend him. Of course we need ways to monitor the quality of medical care, and to discipline negligent physicians, but “one strike, you’re out” is three times stricter than the controversial laws that impose life sentences on habitual offenders in California and some other states.

To watch over your fellow human beings’ health is a tremendous responsibility, especially on the front lines of Primary Care. Every bellyache is a possible appendicitis, every headache a possible brain tumor, every case of indigestion a fatal heart attack, and every mole a potential melanoma. We have the technology to correctly diagnose these conditions, but can we use all of it in every situation? Does every bellyache require an exposure to the high doses of radiation of a CT scan or the risks involved in an exploratory laparotomy? Does every headache justify an MRI, and does every case of indigestion warrant an admission to the cardiac intensive care unit to rule out a myocardial infarction?

Is it humanly possible to never ever be wrong? And if we punish mistakes by barring doctors from practicing medicine, will there be enough doctors left to treat us? Is it possible to learn and gain experience without ever making a mistake in judgement? I have 63 small “birth marks” on my upper body. They all look harmless, but think of all the spots on all the people out there.

The only way I can think about these questions, without wishing I were already retired, is in the context of a healthy doctor-patient relationship, where the doctor shares knowledge and information with the patient, and every clinical decision is explained in such a way that the patient knows what to expect if all goes well, signs of trouble to be on the lookout for, and when to come back for reevaluation. An authoritarian doctor who gives a categorical answer without explaining his or her diagnosis, and a patient who doesn’t question the doctor’s assessment when things seem to be getting worse are a dangerous combination. We need to communicate better with our patients, and that is where Ruth’s doctor failed her.

After talking about it some more, Ruth’s family agreed that the doctor deserved a chance to learn from his mistake. I hope he does.

3 Responses to “One Strike, You’re Out!”

  1. 1 drtombibey March 24, 2009 at 10:58 pm

    I’ve been at it a quarter century. I try as hard as I can on every patient encounter. By the grace of God I have stayed out of trouble.

    However, to ask us to get through a whole lifetime and never make an error is more than any human can do. I am sure Twain had a few typos. Tiger Woods is the best golfer I’ve ever seen, but even he hits a few out of bounds. As a society, we reward him, mistakes and all, far more in a year I could earn in several lifetimes.

    There is a golf book called ‘Golf is Not a Game of Perfect.’ Neither is medicine and it never will be. As we generate more paperwork and rules to try to make it what is can not be, perfection is made even more difficult to approach due to the distraction from patient care that process creates.

    And by the way, we also reward Health Insurance CEO millions for ‘managing’ patient care. At least from a regular Doc’s bedside perspective, they don’t do it very well, but it is strange that no one demands their heads. I guess it is because they are not on the patient’s radar. We are in the trenches, quite visible, and easier targets for wrath.

    If Docs work drunk, take advantage of patients, engage in inappropriate sexual relationships, develop dementia, or are impaired from substance abuse, they need to either get help and get right or retire.

    But, one time a patient told me they would only go to a surgeon who had not been sued. I told them I didn’t know one. If we fire them all for errors in judgement in short order there will be no Docs left.

    I always tell my patients the only Perfect One died on the Cross. The rest of us will just have to do the best we can.

    Dr. Tom Bibey

  1. 1 One Strike, You’re Out! Trackback on March 26, 2009 at 1:00 pm
  2. 2 One Strike, You’re Out! « Medicinski blog Trackback on November 23, 2009 at 12:07 pm

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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