Wednesday, February 15, 2017

How Not To Be A Shit Doctor #1. Never Assume. And Actually Act on the Red Flags.



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They slumped down in their seats, as crestfallen as anyone who’d just lost someone would be. I count them as my best friends, yet I had no words to tell them. 

They’d just lost their 27-year-old cousin, no, their elder sister, to a blood clot in her brain that appeared suddenly. I’d talked to many who’d lost loved ones too often before, but when I finally found some words that could comfort them, all I felt was shame.

Shame that I, as a medical student, was part of the establishment that had let them and their family, down. 

Because even as I heard her symptoms mere days ago; severe headaches, nausea and vomiting and numbness and weakness in her arms - even as a second year medical student, I knew she needed a CT scan. Hell, I’d even asked if she’d had one done yet!

Supreet Kaur hadn’t. Not after her GP sent her to emergency, urging her and her doctors to get a CT scan done (she was sent home with pain medications instead). Not 7 days later, as her symptoms worsened, and she admitted herself to the same hospital. Not until 3 days after that, and a fall in the bathroom did they finally find the clot that would end up taking her life.

Supreet on her wedding day.

At that point, after transferring her to another hospital, it was too late.

Investigations are ongoing. Hopefully the hospital will learn, and the next Supreet to come through those doors won’t be failed so miserably.

But I fear that they will. Because Supreet Kaur was too young to get sick. Even her doctors would have thought that. And that may have been what doomed her.

Just as it had almost doomed me.

In my final year of high-school, at the age of 17, I started feeling sick. Really sick. I’d been to my GP, telling him I was feeling bone tired, that I was pale, that I’d had long nose bleeds - that I felt like I was dying. I was sent away, with him mumbling about HSC stress into his beard. When I came back months later with a chesty cough that wouldn’t subside, I was given a course of antibiotics and sent away. Not once, but twice. It wasn’t ‘til 6 weeks after and a change of GP that I was finally given the blood test that would lead me to being diagnosed with leukaemia. At that stage, my marrow was filled to the brim with leukaemic blasts my chances were down to 10 or 20%.

Somehow, I’m still here. But I often wonder whether my family would have been as devastated as the Singhs, the Basras are now, if I hadn’t been as lucky as I was. I wonder if my disease may have been controlled easily, earlier, and without the soul breaking side effects that I still bear today if I’d only been given that tiny investigation by my doctor.

We’re not just outliers though, Supreet and I. Young people are routinely let down by a system which often prematurely rules out diagnoses because of age alone. Young cancer patients often face significant delays in diagnoses[2-4]; sometimes up to and even over a year in length, [1], which most papers agree contributes to worsened outcomes [5-10]. Latent autoimmune conditions such as type 1 diabetes are often ruled out prematurely in this age bracket too[11]; women are particularly vulnerable[12] and mental illnesses such as depression, which affect young people more than any other demographic, are oft missed too.

And I can kind of see why. In medical school, we're taught the typical characteristics of disease. The examples we’re shown are designed to be the classic, uncomplicated, yet unrealistically perfect case. We’re expected, in practical exams, to drill a mock patient for the correct diagnosis, displaying our knowledge of pathological processes, proper examination techniques and the nuances of patient interaction, all in a seven-minute window. In the real world, doctors are expected to do the same, but then also consider the risks of investigations, the costs and capability of the patient to undergo certain tests and then spend the same amount of time writing it all up. It’s nearly impossible to not make mistakes.

But something like this, in a system designed to encourage team-work and one with built with fail-safes, should never happen. There are papers highlighting the problem of stroke misdiagnoses in youth, whose signs Supreet was exhibiting[13,14], one even mentioning the need for “young stroke awareness among emergency department personnel”[15]. 

Why is it that someone needs to die for these lessons to be learned?

Well, it’s happened now. As my friend had to say to Supreet’s heartbroken husband of only 1 year, no matter how much we want, we can’t go back in time and change that.

What we can do is learn. 

To the doctors out there reading this, I know it’s hard, nearly impossible to do what you do and do it well. I’ve only had glimpses into it thus far, and I still can’t fathom how we somehow get from where I am right now to full-time practice. But though it’s impossible to be perfect, and though age can still confound, if only because it’s so much more unexpected, I urge you to at least consider ordering that test when red flags or persistent concerns come up. The one question I'd ask is what side do you want to err on? Though journals correctly emphasise the undue stress that these tests can bring, they forget the MUCH higher cost of missing something vital. 

To the medical students, please, in the midst of all that study, just make sure you know those red flags, if nothing else, backwards and forwards, and remember that age isn’t a tickbox that needs to be checked for certain diseases to exist.

Never. Ever. Assume. 

To the patients, indeed, to anyone out there, understand and acknowledge that doctors often know things we don’t; though a CT scan could have saved Supreet, each one exposes you to 100 times more radiation than an X-Ray, and can increase your risk of diseases like cancer. 

But at the same time, you know your body best. If symptoms persist, keep seeing your doctor, and don’t be afraid of getting second opinions. You’re well within your rights to do both, and in Queensland, Australia you also have Ryan’s Rule on your side – a system that reinforces these rights through referrals to shift managers and a hotline, just in case.

And to the policy makers and hospital directors and heads of staff still here, it’s up to you to bring these rights to everyone, and to also relieve the pressure that brings these mistakes to the fore. Because in a system where there just aren’t enough specialists, where the threats and realities of hospital cuts are coming way too often, where the number of training positions for interns lags so far behind new medical school places, and where nurses routinely work double shifts to barely meet safe nurse:patient ratios, you’re as much to blame as anything else the investigations into Supreet’s death bring up.

I for one, know I will be working even harder. Not just to be the best doctor I can be for those I’ll end up caring for, but to stop any biases or misperceptions I may have from harming them. 

I hope we all will.

For them.
Supreet and her cousin.


Nikhil Autar is an ex acute myeloid leukaemia patient, and current medical student and researcher in Sydney, Australia. He also heads a start-up attempting to make money for charities through what we do in our spare time called PlayWell. You can find his blog – Musings of a Med Student Patient – at www.nikhilthegrizzlybear.blogspot.com



1. Docker MA. Cancer survival gap: Progress stalls for young adults. Wall Street Journal 2005 July 5; Sect. D:1.
24. Eaton G. Article main page [Realtime Cancer portal]. St John’s, Nfld: Realtime Cancer; 2006. [cited 2006 September 29]. Available at: http://www.realtimecancer.org/articles.asp.
2. Young CJ, Sweeney JL, Hunter A. Implications of delayed diagnosis in colorectal cancer. Aust N Z J Surg. 2000;70(9):635–638. [PubMed]
3. Rohrer TR, Fahlbusch R, Buchfelder M, Dorr HG. Craniopharyngioma in a female adolescent presenting with symptoms of anorexia nervosa. Klin Padiatr. 2006;218(2):67–71. [PubMed]
4. Yu CK, Chiu C, McCormack M, Olaitan A. Delayed diagnosis of cervical cancer in young women. J Obstet Gynaecol. 2005;25(4):367–370. [PubMed]
Delay causes worse outcomes;
5. West Midlands Urological Research Group. Wallace DM, Bryan RT, Dunn JA, Begum G, Bathers S. Delay and survival in bladder cancer. BJU Int. 2002;89(9):868–878. [PubMed]
6. Christensen ED, Harvald T, Jendresen M, Aggestrup S, Petterson G. The impact of delayed diagnosis of lung cancer on the stage at the time of operation. Eur J Cardiothorac Surg. 1997;12(6):880–884. [PubMed]
7. Burgess C, Hunter MS, Ramirez AJ. A qualitative study of delay among women reporting symptoms of breast cancer. Br J Gen Pract. 2001;51(473):967–971. [PMC free article] [PubMed]
8. Richards MA, Smith P, Ramirez AJ, Fentiman IS, Rubens RD. The influence on survival of delay in the presentation and treatment of symptomatic breast cancer. Br J Cancer. 1999;79(5-6):858–864. [PMC free article] [PubMed]
9. Tjemsland L, Soreide JA. Operable breast cancer patients with diagnostic delay—oncological and emotional characteristics. Eur J Surg Oncol. 2004;30(7):721–727. [PubMed]
10. Forbes LJL, Warburton F, Richards MA, Ramirez
11. E Laugesen,1,2,3,* J A Ƙstergaard,1,2,3,* and R D G Leslie, Latent autoimmune diabetes of the adult: current knowledge and uncertainty, Feb 2015, Diabet Med. 2015 Jul; 32(7): 843–852. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676295/
12. Shawna B Christensen, MS,1 Mary Helen Black, MS, PhD,1 Ning Smith, MS, PhD,1 Mayra M. Martinez, MPH,1 Steve J Jacobsen, MD, PhD,1 Amy H Porter, MD,2 and Corinna Koebnick, MS, PhD1, The prevalence of polycystic ovary syndrome in adolescents, Fertil Steril. 2013 Aug; 100(2): 10.1016/j.fertnstert.2013.04.001., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3813299/ 
13.  Kuruvilla A1, Bhattacharya P, Rajamani K, Chaturvedi S., Factors associated with misdiagnosis of acute stroke in young adults., J Stroke Cerebrovasc Dis. 2011 Nov;20(6):523-7 Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/20719534
14. Luciana Leon8, Fatima Pantiu, Julieta Quiroga, Pablo Bonardo2, Claudia Uribe, Julieta Mazziotti9, Alberto Zinnerman3, Alejandra Martinez, Andrea Sotelo10, Lorena Jure11, Pedro Nofal1, Eduardo Bendersky5, Luciano Alberto Sposato4, Patricia Riccio6, Ricardo Reisin7 and Manuel Fernandez Pardal2, Misdiagnosis in Young Patients with Ischemic Stroke, April 2015, Neurology April 6, 2015 vol. 84 no. 14 Supplement P7.122 Available at; http://www.neurology.org/content/84/14_Supplement/P7.122


5 comments:

  1. I for one.. hope there will be more doctors and medicals professionals like you coming up the ranks sooner rather than later... it's a profession in my opinion that needs a shift in how it's done/thought... it's not as easy as tick a box... but what I see is doctors that would have been better suited to academics auditing or accounting rather than doctor dealing with real life and peoole.. coz they didn't think out side the box...

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  2. Thank u, I needed it

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  3. This comment has been removed by a blog administrator.

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  5. W also have a Ryan's rule equivalent in NSW, it's called REACH
    http://www.eih.health.nsw.gov.au/initiatives/reach-patient-and-family-activated-escalation

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