Hard Cases: What Happens When a Medical Mistake Has an Unthinkable Outcome

Mr. H. went on to say, “If only you’d checked my stool, you probably would have found blood. And I could’ve been diagnosed and treated sooner.”

My heart sank. I had not performed the most basic of tests that are done when someone has a new anemia and now my patient had colon cancer. I thought he was calling to tell me to expect a malpractice suit, but before I could respond he said, “You probably think I’m going to sue you. I won’t. I wanted to let you know so you’ll be sure to check your patients in the future.”

My overwhelming relief was dueling with shame and guilt. I wasn’t going to be sued. But I had failed Mr. H. Failed him. He could die from a disease that I might have caught earlier.

Mr. H. Was My Lesson

One of my fellow residents recently told me that when she started medical school she knew she would inadvertently kill someone. After it happened, she said she was relieved because she could move on with becoming a doctor.

I had made a terrible mistake, one that could cost Mr. H his life. The acceptance and generosity of spirit he showed me was my lesson. I will never forget this Hard Case and the lesson I learned.

We physicians live in a blame and shame world, a rigid hierarchy, one where Mistakes. Are. Not. Allowed.