Authors: Jerome Groopman
Croskerry's prototypical error illustrates the opposite pole of emotion from disgust. Croskerry embodies many of Evan McKinley's characteristics himself: both are energetic, passionate men who love their work and for whom outdoor exercise is a major part of life. Powerful positive feelings about a patient are generally held to be good, the cornerstone of humanistic medicine. We all want to feel that our physician really likes us, sees us as special, and is emotionally moved by our plight, attracted not so much by the fascinating biology of our disease but by who we are as people. Usually such positive feelings enhance our relationship with our doctor and the quality of care we receive. But not always.
Doctors must be wary of "going with your gut" when what's in your gut is a strong emotion about a patient, even a positive one. Physicians understandably care deeply about their patients and want a good outcome, which can cause them to underinvestigate problems. Doctors may make decisions that stack the deck so that they draw what seems to be a winning hand for a patient they especially like, admire, or identify with. Croskerry chose to rely on the very first set of data—the normal EKG, chest x-ray, and blood tests—all of which indicated a favorable diagnosis for McKinley. He didn't arrange for follow-up testing.
We all tend to prefer what we hope will happen to the less appealing alternatives; this natural tendency is termed "affective error." We also lull ourselves into thinking that what we wish for will occur when we get the first inkling, however fragmentary, that our wish may come true. In short, we value too highly information that fulfills our desires. This kind of error can affect even a consummate clinician like Pat Croskerry.
The case of Evan McKinley brought me back to my conversation with Dr. Myron Falchuk. After Falchuk told me about Anne Dodge, I asked him if he had misdiagnosed a patient recently. His face fell for a moment. Then he told me about an elderly Jewish man he had seen earlier that year. "He was a wonderful, delightful character from the old country," Falchuk said. Joe Stern was in his late eighties but still spry, driving himself around Brookline and taking adult education classes. Stern complained of indigestion, specifically heartburn, for several weeks. Such symptoms are common; a general practitioner or internist usually treats them. But Falchuk knew the Stern family, and so took Joe on as his own patient. Over the course of four months, he treated him with antacids and other medications. The treatments gave him only slight relief.
Falchuk found himself enjoying Joe Stern's company so much that he ran over the allotted time at each visit. "He had a great sense of humor, and we kibitzed together in Yiddish," Falchuk recalled. "We really connected. I said to myself, Do I really have to put him through invasive tests? So I just kept adjusting his medications over four months." Falchuk paused. "Then he came in saying he felt faint and exhausted, and it was clear that something was different. He had become anemic." Falchuk performed an upper endoscopy, the same procedure he had done on Anne Dodge, snaking a fiberoptic instrument down Stern's throat and into his esophagus and stomach. What he saw was not subtle: large growths with the characteristic pleated appearance of gastric lymphoma. A biopsy confirmed the diagnosis. The cancer clearly had been there all the time, and accounted for Stern's persistent indigestion and acid reflux.
"It's a treatable cancer," Falchuk said, "but I kicked myself over and over again. I just didn't want to subject someone of this age, whom I liked so much, to the discomfort and the strain of the procedure. And because of that, I missed the diagnosis." Fortunately, as with Evan McKinley, the ultimate outcome was good. The delay in diagnosis did not harm Joe; he went into remission. After Falchuk finished, I told him of a case of my own from many years ago: the case of Brad Miller.
Ever since he was a little boy, Brad Miller loved to run. His mother joked that it didn't matter when or where, even if he didn't have sneakers on. Growing up in Southern California, he would jog three miles to school, and on weekends he'd take the bus from Culver City west to the beach and sprint in the warm sand. Brad went east for college. He was undeterred by the sleet and broken sidewalks of New Haven, running each day in a wide arc from the university to the train station and back. Brad never joined the college track team, and doubted that his speed was sufficient to compete at the varsity level. But that didn't matter, because running just seemed to be a part of him. All through the stresses of college and graduate school, Brad used running as his tonic. He returned to Los Angeles with his doctorate in hand, his dissertation a meticulously footnoted study of ancient and contemporary female archetypes that influenced James Joyce's work. As a new English professor at a local college, he felt his life had taken a strong start out of the blocks.
"You look familiar," Brad said to me the first day I entered his hospital room at the UCLA Medical Center. It was the early winter of 1979, and I was in my fellowship training in hematology and oncology. I studied Brad, but his face did not register.
"I see you running with two or three friends around the university," he said. "I'm a runner too—or at least was."
Nearly every evening, a pack of young doctors ran the hills of Westwood. The incline along Highland Avenue was particularly steep, from the hospital to the apex of the campus. It tested my stamina. "I must have been the one gasping for breath," I said. "Perhaps that's why I stuck in your mind."
Brad's smile was brief.
"We'll do everything possible to get you back running," I said. "The chemotherapy is difficult, I won't minimize that, but it can make all the difference."
About six weeks earlier, Brad had noted an ache in his left knee. At first he thought it was simply due to his intense training schedule for an upcoming marathon. But the ache did not go away with rest and anti-inflammatory medication. He saw a sports medicine physician, who examined the leg and recommended stretching and wearing a knee brace when he ran. Brad dutifully followed this advice, but the ache only seemed to get worse, the leg stiffer. The physician ordered an x-ray. He told Brad that it showed some kind of growth around the end of the femur, just above the knee. He said the problem was outside his area and that Brad should see a specialist. The doctor couldn't hide the gravity of what he saw with euphemisms.
The growth in Brad's leg was an osteosarcoma, a bone cancer. The surgical oncology department at UCLA, among the best in the country, had pioneered an experimental program for these types of sarcomas. In the past, people like Brad would have had the leg amputated, but a new chemotherapy drug, Adriamycin, had been developed that often shrank the tumor. Oncologists had nicknamed it "the red death" because of its cranberry color and its terrible toxicity. Not only did it cause severe nausea, vomiting, blistering of the mouth, and reduced blood counts, but repeated doses could injure cardiac muscle, resulting in heart failure. Patients had to be monitored closely, since once the heart was damaged, there was no good way to restore its pumping capacity. The experimental strategy at UCLA involved treating patients with multiple doses of Adriamycin in the hope that the cancer would shrink enough to be surgically removed without amputation.
We began the treatment that afternoon. Despite medication to stave off vomiting, Brad spent several hours retching uncontrollably. Within a week, his white blood cell count had fallen precipitously. Because of this decline in his immune defenses, Brad was at great risk for an infection. To try to prevent this, we isolated him; he was visited only by people wearing a mask, gown, and gloves. His diet was changed to reduce exposure to bacteria in raw foods.
"Not to your taste," I observed, eyeing the untouched meal on his tray.
"My mouth hurts," Brad whispered. He had multiple oral ulcers from the chemotherapy. "And even if I could chew, it looks pretty tasteless."
We were giving Brad a special anesthetic mouthwash to try to alleviate the pain, but it clearly was not helping much. I agreed that the food looked dismal.
"What is to your taste? Fried kidney?"
Brad looked knowingly at me.
"Nothing like Joyce to lift the spirit."
I had told him when we met that I'd studied
Ulysses
in a freshman seminar. The professor had explained the relevant Irish history, especially Parnell and the Easter Rebellion; the subtle references to Catholic liturgy; and a host of other allusions that otherwise would have passed most of the class by. In the book, Leopold Bloom savors fried kidneys.
Brad was my favorite patient on the ward. Each morning when I made rounds with the residents and students, I would take an inventory of his symptoms, examining him to check on the medical team's findings and reviewing his laboratory results. Then I would linger, trying to raise his spirits and distract him from the misery of the therapy.
The protocol called for a CT scan after the third cycle of Adriamycin. If the cancer had shrunk sufficiently, the surgery would proceed. If it hadn't, or if the cancer had grown despite the chemotherapy, then there was little to be done short of amputation. And even after amputation, patients still live under a cloud, since the cancer can metastasize to the lungs or other organs.
Three cycles of chemotherapy took their toll on Brad. He became listless, difficult to engage in conversation. Then, one morning, he developed a low-grade fever of 100.2° F. The residents told me on morning rounds that they had already gotten blood and urine cultures, and that his physical examination was "nonfocal," medical jargon meaning that they had found no clear origin for an infection. People undergoing chemotherapy often get low-grade fevers after their white blood cell count falls; if the fever has no identifiable cause, a physician must use his judgment about when to begin a course of antibiotics.
"So you feel even more wiped out?" I asked Brad.
He nodded. I reviewed again a list of symptoms that might identify a source of infection: Did he have a headache, difficulty with vision, pressure in his sinuses, a sore throat, problems breathing? He answered no to each. Was he bringing up any sputum? No again. Any pain in his abdomen, diarrhea, burning on urination? None at all.
Brad said he was too exhausted to sit up on his own, so a resident took one shoulder and a student another and propped him up in bed. Brad had the body of a long-distance runner, tall and lean. Adriamycin dosages are based on body surface area rather than weight, so with the large surface area of a person of his physique, Brad had been getting high doses. His remaining wisps of black hair were matted with sweat, and he was ashen.
I examined his eyes, ears, nose, and throat, and found nothing of note except some small ulcers on his inner cheeks and under his tongue, side effects of his treatment. Brad worked hard to take deep breaths when I examined his lungs—they were clear—and his heart sounds were strong, without a "gallop" indicating heart failure. His abdomen was soft, and there was no tenderness over his bladder.
"Enough for today," I said. Brad looked so peaked that it seemed wise to let him rest. He nodded his thanks.
Later that day, I was in the hematology lab, looking at the bone marrow biopsy of a patient with leukemia, when my beeper went off with a stat page. "Brad Miller has no blood pressure," the resident reported when I called. "His temperature is up to 104, and we're moving him to the ICU."
Septic shock. When bacteria spread through the bloodstream, they can shut down the circulation. This can be fatal even in people who are otherwise healthy, but patients with impaired immunity, like Brad, whose white blood cell count has been lowered by chemotherapy, often die.
"Do we have a source?" I asked.
"He has what looks like an abscess in his left buttock," the resident said.
Patients who lack the white cells to fight bacteria are prone to infections at sites that are routinely soiled, like the area between the buttocks.
I fell silent as I replayed in my mind the scene on rounds with Brad that morning. The abscess had certainly been there a few hours before. "Enough for today," I had said.
Not enough at all.
I had failed to ask him to roll over so I could examine his buttocks and rectum.
"We repeated his cultures and began broad-spectrum antibiotics," the resident said. "The ICU team will take over."
"Okay. Good job." As I hung up the phone, I berated myself further.
Bad job. Sloppy job.
My heart had ached for Brad, and that deep feeling had caused me to break discipline. Normally, I had a system that I followed with every immune-deficient patient every day, beginning at the crown of their head and working down to the tip of their toes, examining every cleft and fold and orifice and organ. I had not wanted to add further to Brad's discomfort. I left the bedsheets on him. That could prove to be a fatal mistake.
I attended to the day's remaining tasks and rushed to the ICU as soon as I was free. Brad was on a respirator and opened his eyes wide to signal "hello." In addition to saline, he was receiving pressors, drugs that increase the contraction of the heart and the tone of the vessels to try to sustain the blood pressure. His heart was holding up now despite all the Adriamycin. His platelet count had fallen, as often happens in septic shock, and he was receiving platelet transfusions. The senior doctor in the ICU had already told Brad's parents how serious his situation was. I saw them sitting in a room next to the ICU, their heads bowed. At first I considered walking by, since they had not seen me, but I forced myself to go in and offer a few words of encouragement. They thanked me for my care of their son.
After a restless night, I arrived early the next morning before the residents on the ward to review all the charts of my patients. Rounds lasted an hour longer than usual, as I checked and double-checked every bit of information the team offered. I could see them growing restless, but I needed to reclaim my balance and this was the only way I knew how.
Brad Miller survived. Slowly his white blood cell count increased, and the infection was resolved. After he left the ICU, I told him that I should have examined him more thoroughly that morning, but I did not explain why I failed to. His CT scan showed that the sarcoma had shrunk enough for him to undergo surgery without amputation. But a large portion of his thigh muscle had to be removed along with the tumor. After his surgery, running was too demanding. Occasionally I would see Brad riding his bicycle on campus, and I gave silent thanks each time I did.