That woman lived, but some mistakes are discovered only in the morgue: A few years ago, a 28-year-old woman arrived in a Halifax ER from an addiction centre complaining of chest pain. The ER staff were instantly on guard – they had plenty of experience with addicts feigning injuries, hoping to be prescribed drugs. While she was there, the women stepped outside for a smoke. The doctor on duty felt irritated that she was wasting his time: He diagnosed anxiety and discharged her. That night, she died from massive blood clots in her lungs.
Without a full medical history – and an open mind – the doctor never considered the risk of clotting caused by her smoking habit and birth-control pills.
Jerome Groopman, the author of How Doctors Think, explains that 80 per cent of most diagnoses can be made strictly from a patient's medical history and description of symptoms. And yet, he says, doctors typically interrupt a patient within 18 seconds – they are already floating several possible diagnoses within a few minutes of the encounter.
They have become increasingly reliant on technology to make the call (which assumes, of course, that patients get the right tests) and are less likely than in the past to physically examine patients.
In ERs especially, where doctors don't know patients personally and are often sleep-deprived and incredibly rushed, there is little time to take long patient histories. Patients themselves, after stewing in the waiting room for hours, also may be impatient about giving them.
It can be even harder for doctors to overcome confirmation bias when the accurate diagnosis is more unusual. Last February, Tara Jacklin went to her family doctor in St. Catharines, Ont., complaining of bloating, constipation and a lack of appetite.
An emergency nurse and a long-distance runner, she was, at 24, the picture of health. She was worried, however, and asked for an abdominal ultrasound to check for ovarian cancer. Her doctor told her that it wasn't necessary – she speculates he might have seen her as a rookie nurse with worst-case scenarios on her mind. She had no family history of ovarian cancer. The doctor diagnosed irritable bowel syndrome and told her to eat more fibre.
Ms. Jacklin convinced herself that he was right, though her symptoms persisted. When she went back a second and third time, the doctor maintained his diagnosis. “I felt stupid, like I was overreacting,” she says.
Finally, she visited a walk-in clinic for a second opinion: Was it unreasonable, she wanted to know, to insist on an ultrasound? That doctor directed her to emergency, where tests revealed a tumour in an ovary. She was eventually diagnosed with aggressive but early-stage ovarian cancer.
“Statistically, it didn't make sense to look into anything serious,” says Ms. Jacklin, who is now receiving chemotherapy. “I know that every time someone has an ache and pain, you can't just take 12 test tubes of blood.”
What she regrets, though, is not pressing her doctor harder to consider alternatives.
She will take that lesson back to work: “I will really give credit to the patient when they come in,” she says. “I will advocate for them.”
In Joel's case, once he was finally diagnosed, everything else fell into place and his care was excellent. He was a subject of study for residents, whose minds may some day pull up his unusual case should they ever see a patient with a drooping mouth and a strange insect bite.
But the young ER doctor who told Joel to go back to work, or the older physician who sent Ms. Thomas home to take Tums may never have discovered their errors. That's the truly tragic medical blunder, as Dr. Goldman and Dr. Croskerry would say – the failure to learn from a mistake, so it doesn't happen again.
HOW TO IMPROVE YOUR OWN DIAGNOSIS
The good news is that most of the time doctors get their diagnosis right: Your sniffles really are just a nasal infection. But about one-fifth of the time, something is missed or conclusions are reached too quickly. Here's how it can happen, and how a patient can help prevent it.