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The diagnosis

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The diagnosis
Ben Jamin MD
Dermatology Online Journal 15 (7): 11

I was sitting in traffic, a sea of slowly rolling cars, going nowhere. The tears welled up; there was nothing I could do but stare into space. How could I do that? I was always told that it would eventually happen to me, but I didn't think it would. When the old professor missed one, I thought I would be different, more careful, would avoid the traps, not be so arrogant. But it happened to me, too.

It was the danger of false pride and, despite my easy self-effacing manner, I was defiant; it had finally caught up to me. I was so stupid. But for some reason, I think he will be all right. It won't matter. He will live forever. But who can really know? The tumor's behavior is completely unpredictable, notoriously relentless.

The patient's doctor thought I was an idiot and I can't blame her. Yeah, I should've gotten it right. But she shouldn't have curetted it. She should have followed up. After all, wasn't I really just a consultant? She can blame me, it's OK. But it's her patient and she is also responsible.

My colleagues were nice about it, but their attempts to be helpful had the opposite effect. They said we were in this together, but I knew I was alone. When the lab director took me aside, all I remember were the tears. I don't know what he said. It doesn't really matter. One of my other co-workers had pronounced that the clinician did everything perfectly and I could only think, "Who are you to say that?"

The shrink thought my mistake was a manifestation of my dislike of the company I worked for and was trying to leave. Management was too greedy. We were offered egregious contracts that were probably illegal. I hated the sense of constantly being taken advantage of, signing out too many cases. I was not being treated like a physician but as an employee interpreting widgets. Well, this was certainly one way to get a new job. She called it acting out.

I hope he will be OK. I hope he lives forever. He and his wife took the news well, I heard. I wanted to say to him (like Humphrey Bogart), "Welcome back to the fight, this time I know our side is going to win." But will he win? I always thought, despite all of the statistics, that a good doctor could break the odds. I certainly didn't help his chance for long life. The tumor was thick and went to the base. But didn't he have a better shot one year ago?

I realize I'm going the wrong way, South. I wake up from my trance, switch to the right hand lane and think, "Don't get yourself into an accident now." What am I doing? It's passed and there is nothing I can do. Learn the hard way. I did it. It is the trial by fire, the rite of passage that we all hope to escape. I get on the North side and race to get to work faster so that I'm not late. Why am I racing? Isn't that what led to my current predicament? I have to learn to slow down. For me, it may be the hardest thing to learn.

I arrive at work, sit down, turn on the light, and begin. Slow down I tell myself. Order more levels. Show the case around. A few trays pass. I stop and think, "Boy, you really did it this time." I'm in a daydream. What am I going to do? The lab director looks at me knowingly. He says he missed one in a fourteen-year-old. Yeah, but that one was probably hard and who would have expected it in a fourteen-year-old? Mine was plain as vanilla. Maybe not, though. Where was the in situ component? Maybe it was a met and I caused no harm. Maybe the fact that I missed it bespoke that it wasn't so straightforward. I don't know. How can I?

When I first heard about it, it didn't really hit me. The next day I was in a fog. I wasn't concerned about being sued, at first. I just wondered what was going on in my head when I signed that case out. Where was I? Did I pick up the right slide? Why hadn't the clinician excised the damned thing after I said it was malignant. I checked the calendar. It seems I had just come back from vacation that day. I suppose there's a lesson in that, too.

As days passed I became more concerned about being sued. Sometimes, in private places, the tears came. But I was never good at crying. How could I have done this to a nice man? Maybe he isn't nice. I'd heard he was nice.

I tried to tell my wife. She asked many questions. I told her she could discuss it with no one. She understood. I had always told her it would eventually happen, but I never really believed it would happen to me. You see, what I do, really, is hard. I told her about how the clinician didn't take the news well. I wondered whether the clinician would be able to effectively communicate to the patient. I told her that I heard that the patient understood these things can happen. But, who knows, the family could convince him to sue. I told her that I had seen these things play out before; what would happen was completely unpredictable.

They should have taught humility in medical school. But there were too many big egos there. They would never admit to making a mistake. Each doctor thought that what he did was the hardest thing in medicine. But I knew that what I did was. We all have our secrets and I guess this one is mine. I suppose this may be the tempering needed for my formal graduation from the school of the naïve and inexperienced. I am going to make sure this will never happen again.

I have come to learn that it happens to all physicians who are really engaged and not afraid of taking on the hard cases, the high volumes. It is the kind of unfortunate experience that hopefully leads to good judgement. I walked away a sadder and wiser man.

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