In Pro Per

By Dr. Jack Hasson
     
      An Imperfect Practice
      After more than 50 years practicing medicine, I have come to believe that it is society's expectation of infallible medical practice that fuels medical litigation. But errors in diagnosis are inevitable. The delusion of medical infallibility must end before litigation reform is possible. Many years ago I was called to the operating room to see a problematic frozen-section biopsy from a patient undergoing surgery for a cancer of the lung. The patient was a woman in her 60s who had smoked for more than 40 years. A chest X-ray showed a possible lung cancer. A biopsy was done by passing a long needle on a syringe through her chest wall into the tumor and aspirating tissue to be examined microscopically. The biopsy contained cancer cells. The surgeon decided to surgically excise the tumor. He first explored the inner surface of the chest cavity surrounding the lung, looking for any evidence that the cancer had spread, which would have meant a surgical cure was impossible, thus ending the operation. He submitted a suspicious-looking nodule for a frozen section.
     
      I was helping diagnose whether this was, indeed, a cancerous nodule or a benign reaction to some sort of injury. The tissues lining the inside of the chest cavity can respond to injury, such as an infection, by rapidly multiplying its cells, which can resemble cancer cells microscopically. But I saw no evidence of inflammation: This was a sharply demarcated nodule surrounded by a normal lining, and the cells looked like cancer cells. I made a diagnosis of a cancer that was inoperable; the surgeon ended the operation.
     
      I was deeply upset the following day to learn that the nodule was not a cancer at all but a wild-looking benign change due to injury. I then learned that the nodule was located where the aspiration biopsy needle had pierced the inner surface of the chest cavity before
      it entered the lung tumor. The injured surface reacted by forming cells that mimicked malignant features. The good news was that the lung cancer was still operable for a possible surgical cure; a second operation was needed.
     
      The error devastated me because I held myself to the standard of infallible medical practice. I felt disgraced. I was overwhelmed by guilt and remorse for causing pain to both the patient
      and her family. Several days later, the patient's internist told me that the error was probably a blessing in disguise. He noted that the patient had serious difficulties breathing after the first operation because of retained mucous secretions in her lungs. Lifelong smokers commonly develop chronic emphysema and bronchitis, which cause excessive mucous secretions into the airways. This interval was an opportunity for the patient to clear her lungs and improve function so she could be better prepared for the second operation. Unfortunately, she died several months after that surgery-the cancer had spread to other organs, a common outcome with lung cancer.
     
      Years later, when I was 64 years old, at a talk on diagnostic errors revealed at autopsy, a well-known pathologist presented the idea that unavoidable errors without negligence were inevitable, and indeed necessary; the only way to avoid them was by ending medical practice. He cited a dual theory of the causes of medical fallibility. The first cause was the vast void in our medical knowledge-what we don't know can hurt us. The other factor, nature, delights in the unpredictable, doing as she pleases. The reality is that patients are as unique as hurricanes, snowflakes, mountain ranges, and the shapes of clouds. We can't anticipate every one of the infinite possibilities of disease behavior. When I heard these ideas, I sensed sunshine breaking through clouds and a heavy burden of guilt being lifted off my back. But my remorse was unaffected because of the nagging question, "What if?" The answer to that question is unknowable, but even asking it suggests possible fault. It would be ideal if nature were responsible for every bad outcome that was really the result of either negligent malpractice or unavoidable factors. But there are endless shades of gray between those black-and-white extremes, and doctors live within that uncertain world all their professional lives.
      Jack Hasson (jmkphasson@netzero.com), a pathologist since 1951, recently retired as an associate professor of pathology from the University of Connecticut Health Center. He is the author, with Razi Sharafieh, of Why Even Good Doctors Make Mistakes (iUniverse, 2005).
     

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