Humble pie 

By Kittane Vishnupriya, MBBS, Johns Hopkins Medicine 

“Just let me go home, I already feel much better,” my patient insisted. An older man who had presented with generalized weakness and a fall, he just insisted on leaving. He had metastatic prostate cancer but was managing ok. He was down with flu about four days prior to the presentation. He also had recurrent SVT which was transient, mild volume overload, and low back pain. I examined him and there were no focal neurological findings or weakness. I’d seen him walk the hospital hallways with a physical therapist, and he did well and was recommended home therapy. I treated his volume overload, ensured stability of heart rhythm and even obtained an MRI of the L spine which didn’t show any new concerning problems although he did have widespread bone mets from his prostate cancer which was well known. He was seen by consultants from cardiology and oncology. After reviewing all data and relying on my clinical judgment, I discharged the patient with plans for multiple follow ups including his oncologist. 

Unfortunately, he presented a couple of days later with worsening weakness and yet another fall. This prompted additional testing including a lumbar puncture, and he was diagnosed with probable Guillain-Barré Syndrome. 

When I learned about this, I felt multiple emotions at the same time. I felt disbelief and then guilt. “How could I have missed that?” I asked myself. I used to be proud of my diagnostic reasoning skills and taught medical students how various kinds of biases can lead to diagnostic errors, and here I stand humbled by this encounter. I went over the whole thing repeatedly, wondering how I could have made the correct diagnosis. I kept telling myself, “The history had too many confounders,” “There were no signs of focal weakness,” “I wish I had gotten more details of the fall from the family too.” 

The patient eventually was discharged to rehabilitation after treatment. Here are a few teaching points after this experience:

1. Diagnostic errors, including delays, lead to significant harm in our patients. Studies estimate about a 15% diagnostic error rate in current practice. 

2. Studies also show that one-third of physicians remain confident even after making the wrong diagnosis! 

3. While system-based approaches, including frequent testing for maintaining board certification, appropriate use of clinical pathways, and technologies including AI tools are helpful, a crucial factor that’s still lacking is individualized feedback on doctors’ diagnostic accuracy. 

5. Many clinicians likely believe that they’re better than their peers and may be unaware of their true diagnostic accuracy. It’s important to always be aware of one’s limitations and blind spots.  

6. It’s indeed paramount to cultivate“diagnostic humility.” 

7. Some personal habits that can provide a crucial feedback loop include always asking “What am I missing here?”, following up on patients even after discharge or specialist consultations, and finding a coach or a mentor to help identify personal blind spots that might be contributing to our diagnostic decision making. 

I might be in a teaching role with medical students, but I continue to learn every day. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.