What I learnt this week: Missed diagnosis – do we fear for ourselves or our patients? #WILTW

This is the 74th #WILTW

Do you remember that patient you saw last night…?

Is quite possibly the most terrifying thing anyone can say to a doctor.

The fear is that it’s followed with, “…they have’t done so well” and an implication you have missed something in your investigations or management. It is testament to the generally humble nature of health care professionals that the initial reaction is one of negativity. No one expects, or remembers being told,  “Good job!” as the following reprise. Instead there is an expectation of failure or inadequacy.

Simon Judkins is an Emergency Doctor from Australia. This week he published an extract from his book in an newspaper. The short piece was entitled “What did I miss?”. It is powerful narrative in which he is candid about sending home a child at night who returned the next morning with meningococcal septicaemia and needed intensive care treatment. The pain he experienced is obvious from the way he tells the story.

Risk Dice

Those who work in acute specialities, especially those in which patients are discharged at all hours of the day, must learn stratagem for dealing with risk. You can not admit and treat all patients who present with a fever. The system would crash and furthermore those most in need of care would no longer receive it. You must make judgement calls. Those who are clearly well or unwell are, generally, easy. But many snotty, slightly miserable children, are brought to Emergency Departments by parents who are concerned about them. Following thorough examination, observation, and investigation (when required), with the important addition of ensuring parental concern has been addressed, many of these children will go home. They are no different to the 11month old Simon Judkins saw.

But you can’t end your shift and worry about all the patients you have sent home. It would not be possible to have a reasonable work-life balance if you did. In fact, I have learnt over time, when I come home uncomfortable about having discharged a child that is a sure sign I shouldn’t have done so. Gut Feeling is a funny thing.

But there is a deeper issue at stake here. I read Simon Judkin’s article and thought – poor guy.

I didn’t think – poor kid.

At least not immediately. It was quite an uncomfortable train of thought. I have written previously about a small aspect of emergency practice that is narcissistic. Not always in a “Look at me!” type way, but a pride in performance, a belief that in some patients you can make a difference. This balances the risks of the job, the possibility that at some stage you will bare the brunt of a poor decision. This I think is an aspect of self preservation. As I become more experienced the total number of patients I see with whom I could make a mistake becomes bigger. I hope the rate of my learning matches the ever increasing level of risk. But I wonder if I have adopted a strategy of risk management that is not primarily aimed at protecting patients but more aimed at protecting me from the ordeal that Simon went through…

What have you learnt this week? #WILTW



One thought on “What I learnt this week: Missed diagnosis – do we fear for ourselves or our patients? #WILTW”

  1. I read his extract also Damian. It was indeed a harrowing read. I completely understand your feelings of sympathy/empathy towards him as I felt that also when I first read it! It was a thought provoking piece indeed.

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