Occasionally wrong, but never in doubt.
The above quote was said by my chairman during my surgical training more than once. While at first glance it may sound somewhat tongue-in-cheek, trust me, he most assuredly didn't mean it that way. Surgeons, he explained, must always be sure of their diagnosis, even if it's wrong. As long as we never wavered in our diagnosis, we would never be criticised. Or so he would have us believe.
It made no sense then, and it makes even less now, and the more I think about it, the crazier it makes me. When I'm seeing a patient, whether for the first time or for follow-up, I'm constantly thinking and revising and double checking and self-regulating. In fact, I'm doing it right now. I revised and rewrote that last sentence 6 times before I got it right. There's a slight chance that's an exaggeration, but you get the idea. The point is that I'm always in doubt, and it is that very doubt that keeps me thinking, keeps me honest, and prevents me from becoming lazy and complacent.
My experience with Ruby (not her real name™) demonstrated this rather convincingly.
Ruby was minding her own business playing Scrabble in the back seat of a car, when (in her words) "all of a sudden . . . BOOM." Her car rear-ended another car, her seat belt tightened, and the sudden deceleration constricted her 80-year old abdomen between the belt and her spine.
When she got to me her blood pressure was normal but her heart rate was high, around 110. She had a rather impressive abrasion on her neck from the shoulder belt and an even-more impressive abrasion across her entire lower abdomen. I gave a little push on her belly and she winced.
In the vast majority of cases, this is nothing more than an abdominal wall contusion, and further testing confirms it. Ruby's high heart rate was somewhat worrying, but it also isn't abnormal right after a huge scare.
The rest of her examination was fairly benign. I palpated her chest, but she only said her abdomen hurt. I lifted both arms, and her abdomen hurt. I palpated down both legs, and her abdomen hurt. I palpated her spine, and her abdomen hurt.
After a touch of pain medicine her heart rate improved to the 90's, so off we went to the CT scanner. I watched the pictures come up, and something immediately struck me in the right lower abdomen. There wasn't free fluid (ie blood), the bowel didn't look thickened, but something just looked wrong. There was fat stranding (which denotes inflammation) in the area, though nothing else looked distinctly abnormal.
I sat right down at the adjacent computer and looked through the pictures carefully. I couldn't see a specific problem with the bowel itself, but it still was just . . . different. Abnormal. Wrong. And then I saw what looked like three little black dots in the middle of her abdomen where they didn't belong. Black on a CT scan is air. And air outside the bowel means there's a hole somewhere. And holes in the bowel are bad.
I'm not a radiologist, but it looked bad.
Since I wasn't sure I was seeing what I thought I was seeing, I walked across the hall to the radiologists' reading room and found Dr. Bob (not his real name™), a radiologist I know as someone who could see anything on a scan as long as it's there. When Dr. Bob is looking at a scan, it appears to me that he's looking into the Matrix. He sees everything. And Dr. Bob saw nothing. Don't misunderstand - he saw the stranding, but he didn't see the little black dots. No free air. WHEW. My eyes had apparently deceived me, and I went back to Ruby to tell her the good news.
Her abdomen was still hurting. A lot. I explained to her that though the scan was essentially normal, I was going to keep her for observation just to be on the safe side. I was still concerned about her abdomen, and bowel injuries can be very difficult to diagnose until patients start to deteriorate.
Satisfied that she was ok for the moment (though not letting my guard down), I went to the lounge to get a coffee (decaf . . . grrr). As I was stirring in the sugar, one of Dr. Bob's colleagues came up to me.
Dr. E: Hey Doc, Dr. Bob was just looking for you.
Me: I know, I talked to him.
Dr. E: No, he was just looking for you, like 10 seconds ago.
Me: This can't be good . . .
Dr. E: He showed me that scan you were looking at.
Me: (under my breath): Shit.
Dr. E: He thinks he sees some free air, and I agree.
I went back to Dr. Bob, and he pointed out those three little black dots that I had thought I had seen but then had not seen and was now seeing again. The hole in her bowel that I suspected she had but then was mostly convinced she didn't have was now probably there.
I thought about my chairman's stupid little adage as I told Ruby I wasn't 100% convinced that my diagnosis was correct, and I was most definitely in doubt. She wasn't thrilled about her impending surgery, but with the amount of pain she was having she didn't argue one bit.
Despite the five other "emergency" cases pending in the operating theatre, Ruby was under anaesthesia about 45 minutes later and waking up 45 minutes after that with her small bowel laceration, which was about 1 cm in length about midway through her ileum, repaired.
Thinking back on Ruby's case, my initial impression had been that something was wrong. My doubt made me consult the radiologist, and his doubt caused him to look at Ruby's scan a second time. That's how good science works - evaluate, evaluate your evaluation, then re-evaluate everything until you're damned sure you're right. This is a pretty important concept in medicine, but it's vitally important in surgery when the difference between "pretty sure" and "positive" is a major operation.
Which leads me to one conclusion: What the hell was my chairman thinking?