If You Ever Missed A Diagnosis And Felt Terrible, Read This Article

Cancer?!? What?!?

I kept telling the young construction worker and his wife that his resting tremor was just anxiety and his anemia.

How wrong I was.

So was the neurologist he paid over $300 in cash to see, who sent him home with a pep talk and a benzo. I resisted refilling the benzo because I felt like we were treating the wrong problem.

How right I was.

I couldn’t figure out why his Hgb was so low (<6). I convinced him to go to the ED once, after he fainted several times. The ultrasound and CT were inconclusive, and transfusion got his Hgb to >7, but then they discharged him. I pleaded them to admit him and do a colonoscopy, but they declined because he didn’t have insurance. His Hgb started slowly dropping again as soon as he left the hospital, but he didn’t have the money for the colonoscopy.

Not knowing what else to do, I kept harping on him about his diet and exercise, thinking maybe he was getting hypoglycemic, too. He kept saying: “I feel so tired all the time.” No kidding. I knew he just wanted to work so he could feed his family, but all I could offer was: “take another gajillion iron pills and think about getting that colonoscopy.”

After months of wrangling, we found a GI willing to do the colonoscopy for $500, and the patient was able to get the money together and have it done. That’s when we found out. Cancer.

I felt like an idiot, a jerk, and clinically useless. I felt worthless as a person and nurse practitioner. Talk about missing the big diagnosis! I convinced him to go to the oncologist, who deemed his cancer marginally operable. He started radiation but soon after that he was “lost to follow up.

So how did I handle my feelings?

How To Flourish Through Frustration or: “Wat’s” With All The Proverbs?

I recently traveled to Thailand to learn about their perspectives on meditation, mindfulness, stress and burnout. My favorite “wat” (Thai Buddhist temple) had a walkway filled with Buddhist proverbs in Thai and English, which I use as a framework to delineate five ways to deal with feelings of failure and frustration.

Proverb #1: It Is Flooded Water That Makes Mud; It Is Clean Water That Wipes Away Mud

Sign on tree in Thai and English: It Is Flooded Water That Makes Mud; It Is Clean Water That Washes Away Mud

 

You are human and are going to make mistakes, but you have responsibilities as a nurse practitioner. You feel weighed down by an intense pressure to be perfect from yourself, society, patients, insurers and employers. However, on the days when you make the best call, and days when you totally miss the call, you are the same person, the same clinician.

Given the above, you absolutely must Always Give Your Best. However, realize that your best is going to be different from day to day, sometimes radically. Be honest with yourself and be okay with your best effort changing from day to day. When you have a bad cold, or are going through personal troubles, you won’t be at the top of your game. That’s Okay. Just be at the top of whatever game you have every day.

That said, when you gave your best, don’t judge yourself harshly. Even if you screwed up badly, if you honestly gave your best, then there is no reason for anyone else to judge you either. If you didn’t give your best, I recommend you start doing so immediately. It is much easier to live with yourself and your mistakes if you know you gave your full effort.

Proverb #2: Everyone May Be A Fool, But No One Is A Fool Forever

Sign on tree in Thai and English: Everyone May Be A Fool, But No One Is A Fool Forever

Come clean with yourself before you come clean with the patient. When you deal with your own feelings first, it becomes easier to be present for the patient when you explain the bad news to them.

Ask yourself questions such as: what happened? Why didn’t I think of that? Did I give my best? What happens now? As part of this process, you will often realize that yes, you may have missed something important, but you did give your best effort, and it was probably an honest miss, or obscured by circumstances. Knowing this will help you judge yourself less harshly.

Obviously, in emergency situations this point is moot, but the truth is that we often (especially in primary care) do have a couple hours or even days to think about things before we have to talk to the patients about them, and we should use that time to take care of ourselves and come to terms with the fact that we screwed up and that we need to explain it to the patient.

When you talk to the patient, be simple, direct and honest. Let them know what you thought, why you thought it, how you were wrong, and what is actually happening. They will almost always appreciate it, and your honesty will often strengthen the relationship, rather than damage it.

In my first few months of practice, I had an elderly patient with abdominal pain come see me five times, but I kept telling him it was a viral gastroenteritis, or his autonomic peripheral neuropathy. His a1c was well over 15% and he refused all diabetes meds, after all, so I felt justified in blaming his diabetes. He refused all scanning and testing due to cost. It took me five visits to think of doing blood work, specifically a CBC… I had forgotten that he wouldn’t refuse these; they were included in his visit because I was seeing him at a Federally Qualified Health Center. The CBC promptly came back with a white count of 17. He felt better within 24 hours of starting the metronidazole and cipro, and of the profuse apologies from yours truly for missing such a basic piece of lab work.

But you sure bet I started doing blood tests earlier in abdominal pain workups after that.

Proverb #3: With Mindfulness, A Person Always Prospers

Sign on tree in Thai and English: With Mindfulness, A Person Always Prospers

Mindfulness can ALWAYS help. Sit for a minute with your feelings about yourself and a mistake you made in the past. Pay attention to your emotions and your thoughts. Do you still judge yourself? Sit with the judgment. Be okay with being uncomfortable. Embrace it if you can. If not, squirm around and try to stay on task of being comfortable with being uncomfortable.

Honesty point: Occasionally I can accomplish the first, but usually I am still on the second. This is hard stuff. Be gentle with yourself and just notice where you are right now. Wherever you are is okay.

Proverb #4: Living Without Hope Is Like Burying Oneself

Sign on tree in Thai and English: Living Without Hope Is Like Burying Yourself

Now that you’ve had some time thinking and being mindful about the mistake you made, it’s time to start getting ready to move on. If you wallow too long in guilt, shame or frustration, you dig yourself a deeper and deeper hole that becomes difficult to get out of. As with most things in life, moderation is the key.

Do things to rekindle your hope in your potential. Recall past successes. Talk about the situation with supportive colleagues. Go outside and play. Listen to Music. Engage in a spiritual practice. Have a date night. Do whatever recharges your spiritual batteries.

The bottom line here is to do what brings you hope, and stop doing what brings you despair, so you can move forward with your life and practice.

Proverb #5: Failure Teaches A (Hu)man To Succeed

Sign on tree in Thai and English: Failure Teaches A (Hu)man To Succeed

This little gem helps tremendously, but only when you’re ready for it. If you try to apply this principle too early, you end up feeling more inadequate, angry and frustrated than when you started. Use it thoughtfully.

I prescribed an NSAID (indomethacin) to a patient with an acute gout attack… who also had renal failure. He ended up in the hospital with severe dependent edema, and the ED physician told the patient at length how stupid I (his PCP) was, and to get a new PCP immediately. The patient told the physician off and  demanded a new ED provider. When the patient came back to me the following week, I confirmed for him that I had indeed done something monumentally stupid, and I should have known better, and that I was really sorry I missed it. He said “that’s okay. We all make mistakes, and she had no right to talk about you that way. I’m okay now; you’re my doctor and that’s that.” I promised him I would never make that mistake again, with him or anyone else under my care.

And I never have.

Take Care of You,

Samantha

Note: The above stories are 100% true, except where patient information has been altered to protect their identities. 

2 Comments

  1. gregmercer601 says:

    Great piece! Personally, I didn’t see your first example as showing error on your part as much as persistance in confronting severe systems issues that prevented diagnostic testing. Most providers would have given up; you did not.

    • Samantha says:

      Thanks for the vote of confidence, Greg! It’s true: sometimes good patient care is sheer bloodymindedness in the face of willful systemic stupidity.