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?
When I read the first sentence of your post, I thought "well, that sounds like any number of idiots I know". Then I figured you'd explain it and I'd feel foolish. Then you explained it. I don't feel a bit foolish.ReplyDelete
Do you think perhaps the chairman meant that as a surgeon you should always project confidence? When I was a junior resident, my senior always seemed to know what to do, and I asked him how he knew everything. He said, "I don't, I just act confident. Fake it till you make it." And I have to say, as a surgeon something I'm not sure of the right answer, or whether I can reduce that fracture. But patients need someone to be strong when everything (and everyone) around them is going haywire---seems to happen a lot when bones are sticking outside the skin. And during that time, I have to be the island of certainty, I have to say "I will put the bone back in its place." Even if I'm not sure I can achieve the reduction without anesthesia. More often than not, I succeed...perhaps it's a self fulfilling prophecy. Not that I am saying we should lie...there have been plenty of times when I said "I don't know the answer but I will find out after consulting with my colleagues."....it's more of how you present yourself to bring the patient comfort.ReplyDelete
Helen S., MD
This. I can testify from the other side - as the parent of a patient when things were going haywire - that when the surgeon walked in my one-year-old's room with the aura of a demigod and calmly declared they were taking him to surgery, my panic was almost instantly assuaged by his manner alone. Even though he admitted he did not know exactly what they were going to find - only that they knew for certain he needed surgery fast.Delete
24 hours later when he was feverish and miserably recovering from surgery (strangulated bowel by Meckel's Diverticulum) the same surgeon sailed into the room where I was crying because the nurses were about to catheterize him, and ordered them to put that rubbish away and get his NG tube out so he could start feeling better. We left the hospital six hours later.
I wanted to kiss that man's feet. Now obviously he DID know what he was doing, but even if he hadn't...his confidence was what I needed both times. Turned me from a basket case to a calm and rational human being in seconds.
(Also, hi Doc, found your blog many months ago and have now stumbled on it again; love it. Satisfies both my latent science nerd and my snark appetite at once.)
Doc, thanks as always for sharing some important insight. Personally, I don't mind *at all* if any doctor treating me, or any of my family or friends, lets a bit of doubt lead to further evaluation and investigation. That's what ultimately leads to the best *outcome* possible...knowing what's *really* happening.ReplyDelete
On a related note, this is what I found so disappointing when I read the report from that second team of doctors who examined Israel Stinson to verify whether or not he is brain dead. It seemed that they weren't really sure *what* was happening, but still dismissed the need for any further testing.
In Ruby's case, your further investigation ended up resulting in a positive outcome. But even when the accurate and complete diagnosis *doesn't* end up to be a good one, I truly believe doctors do the best service to their patients when the facts are there for all parties to consider.
I could be wrong but I thought the report you read was about the lady not found to be brain dead - not Israel. His report was pretty thorough.Delete
Thanks for the correction, you're right! :) I meant Anahitra (the young woman) not Israel. Can you tell I've been reading too much about brain-death-or-not in recent times?Delete
No problem, I wasn't even sure I was right! And I think we have all read too much about brain death recently. Sometimes it seems like the brain dead loved one is smarter.Delete
on that note, Israel is apparently now in Cuba, undergoing coma reversal procedure, digesting food just fine, and signed up for little league.Delete
I think this example also speaks to the professional regard you and Dr. Bob must hold for each other and your experience that when something niggles at you about not being quite right, it is indeed not quite right. You went to Dr. Bob as someone whom you respected for his expertise, and though he initially said he saw nothing, he undoubtedly got that feeling moments later that 'hmm, Doc Bastard had a funny feeling about this and he usually knows what he's talking about, I should take another look.'ReplyDelete
I think the most generous interpretation of the chairman's comment is that a surgeon has to be ready to make a decision, even if that decision is wrong. It seems to be increasingly the case these days that nobody is prepared to make a decision on anything even if failing to decide means that the opportunity for action is missed.ReplyDelete
One thing that I perceive as an essential skill in a surgeon (and you know I'm not a medic so this is only assumption) is the ability to make a decision and act upon it even at risk of making things worse or of having to defend that decision if it turns out to have been wrong. More harm will be caused by inaction and indecision than by the occasional wrong call.
Just a thought - and thanks for an entertaining story, as always.
my first thought on reading the opening line was of our favorite brain dead troll. except it's not quite accurate, he is nearly always wrong, but never in doubt.ReplyDelete
more on topic, I've known a Dr. Bob. (his real name) he typifies the better interpretation of the slogan. it is more of a "we don't know, yet, but we will figure it out" mindset.
I actually didn't mind the quote; I see what you mean but when in first read it I interpreted it as, 'You're going to be wrong sometimes but as a trauma surgeon you have to think fast, make the best decision, and go with it instead of waffling around.' Something like that :)ReplyDelete
The first lines of this post certainly evoked negative emotion (to the point that I felt the need to wait until there were no minors present to continue reading), as I am not unfamiliar with this attitude.ReplyDelete
However, I agree that doubt plays an important role in the practice of any strong physician; I see it as serving as a type of internal system of checks and balances, reigning in the hubris that threatens to develop with the donning of the white coat. It only becomes debilitating when excessive.
Interesting story, and a valuable lesson. Certainty is the privilege of the ignorant.ReplyDelete
A late addition to the dark side of "often wrong but never in doubt"ReplyDelete
a recent customer had a procedure undone at the end of an unrelated procedure, despite the patient specifically telling the doctors they needed to call the specialist and double check, because the patient was absolutely certain that the procedure needed to NOT be undone. - this left us, with the patient, in significant discomfort, waiting for the reserve ambulance to come pick him up to return to the hospital, via the ER, to redo the procedure which should not have been undone in the first place; and would not have if the doctor who undid the procedure had experienced enough doubt to actually listen to the patient.
I don't think it's doubt that compels me to listen - it's common sense.Delete
that, too. just another example for your long list of cases of doctors not listening.Delete
I'm catching up on your posts, so I hope you see this and it doesn't disappear into the void.ReplyDelete
For some patients, expressing your doubt can be very important. You want to show confidence in the things you do know, and one of these things is the amount of uncertainty in any diagnosis.
I know this first-hand, from when my dentist told me I needed to have my wisdom teeth removed. I asked him why, and his response was basically "because that's what people do". My next dentist appointment was more than 2 years later (you can guess that I didn't have much trust in my dentist), and he was unhappy to see my wisdom teeth sitting exactly where I left them. This time, though, we didnt stop with a half-assed explanation. I kept questioning him until he explained that there's only about a 50% chance that the wisdom teeth would cause a problem. But, by the time I start to notice such a problem, there would be a lot of damage and the teeth would be much harder to remove. I had the wisdom teeth removed about 2 months later.
I could sense his original false certainty, and that's what held me back. I'm the type who insists on knowing the facts and options before making a decision.
If the doctor is uncertain, I want to know it. Whether he expresses that or not, he's still making the same recommendations. But if he explains his uncertainty, that could prompt me to provide any extra info that may be helpful, and it prepares me better for the possibility that his best diagnosis was wrong.
I'm glad you went back and listened to your gut! One of the worst doctor experiences I've ever had was with a surgical resident. I have CF, and I'd been in the ICU for two weeks. I was on the regular unit but I still had two chest tubes in me from pneumothorai that had happened.ReplyDelete
I was watching TV, minding my own business, when this guy sweeps in at 8 p.m., tells me that I'm having surgery tomorrow to fix the pnuemothorai, that we're going to basically crack my chest to do it, and then leaves.
I FREAK OUT. My dad came down to the hospital (I was 19 at the time) and tore this guy a new one. The nurses on the floor applauded. I didn't need surgery at ALL, the chest wall healed itself (as it is wont to do), and this guy got us all upset for NOTHING.
Just this morning I read a very thought-provoking article about the disturbing trend of "teleradiology." The rise of better technology is (at least in the U.S.) leading to a dangerously growing divide between radiologists and treating physicians, as radiology gets outsourced more and more. Your blog post could be Exhibit A for why this is a bad idea -- it's an outstanding example of the importance of good communication between medical professionals. See: https://ww2.kqed.org/futureofyou/2016/10/25/technology-radiology/ReplyDelete
Also -- thank you so much for your excellent, witty, well-written, and informative blog... it never fails to enlighten, amuse, entertain, and (it must be said) occasionally dismay. There's apparently no limit to the degree of human folly.