The fog of expectation
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《英国医生杂志》
1 Dept of Medical Genetics, Sydney Children's Hospital, Randwick NSW 2031 kirked@sesahs.nsw.gov.au
The demented elderly man arrived in the emergency department with a note from his nursing home: "cough and shortness of breath worsening over the past 7 days." He had a low grade fever but did not seem too unwell, and my examination revealed only some crepitations at the base of the right lung. Chest infection, I thought, and the x ray did show some patchy opacification in the right lower lobe. I started some antibiotics and sent him to the ward. A couple of hours later, the medical registrar phoned me and gently informed me that the opacities I had seen were, in fact, the entire lung—collapsed as a result of the huge pneumothorax which ought to have been impossible to miss.
One Saturday night a few weeks later, I found myself the only doctor on an island, home to an Aboriginal community. A 14 year old girl, 32 weeks pregnant, a shy and diffident historian, attended the island's hospital complaining of lower abdominal pain. She too had a low grade fever. I suspected urinary tractinfection, and a very cloudy urine specimen was positive for blood and protein. I sent her away with antibiotics. Fortunately for us both, and very fortunately for her baby, she re-presented soon afterwards, giving me the chance to make the correct diagnosis (labour) in time for a helicopter to take her to someone more qualified than I to manage the footling breech delivery of a premature baby. The urine had been cloudy because it was full of vernix.
I was young, inexperienced, and overconfident. In each case, lacking a clear history, I made things harder for myself by doing an inadequate examination. But the biggest mistake, common to both of these stories, was of leaping to a conclusion early and then seeing what I expected to see. Expectations can fog your vision. It's best to wait until all the evidence is in before attempting a synthesis.
Competing interests: None declared.
True confessions
In October Minerva asked readers to submit their tales of clinical, career, or other mistakes, for publication in this issue. First to respond were Dave Sackett and Richard Smith, followed by others, some of whose confessions are printed below. You can see all the responses and add your own contribution on bmj.com (http://bmj.bmjjournals.com/cgi/content/full/329/7474/DC3)(Edwin P Kirk, staff speci)
The demented elderly man arrived in the emergency department with a note from his nursing home: "cough and shortness of breath worsening over the past 7 days." He had a low grade fever but did not seem too unwell, and my examination revealed only some crepitations at the base of the right lung. Chest infection, I thought, and the x ray did show some patchy opacification in the right lower lobe. I started some antibiotics and sent him to the ward. A couple of hours later, the medical registrar phoned me and gently informed me that the opacities I had seen were, in fact, the entire lung—collapsed as a result of the huge pneumothorax which ought to have been impossible to miss.
One Saturday night a few weeks later, I found myself the only doctor on an island, home to an Aboriginal community. A 14 year old girl, 32 weeks pregnant, a shy and diffident historian, attended the island's hospital complaining of lower abdominal pain. She too had a low grade fever. I suspected urinary tractinfection, and a very cloudy urine specimen was positive for blood and protein. I sent her away with antibiotics. Fortunately for us both, and very fortunately for her baby, she re-presented soon afterwards, giving me the chance to make the correct diagnosis (labour) in time for a helicopter to take her to someone more qualified than I to manage the footling breech delivery of a premature baby. The urine had been cloudy because it was full of vernix.
I was young, inexperienced, and overconfident. In each case, lacking a clear history, I made things harder for myself by doing an inadequate examination. But the biggest mistake, common to both of these stories, was of leaping to a conclusion early and then seeing what I expected to see. Expectations can fog your vision. It's best to wait until all the evidence is in before attempting a synthesis.
Competing interests: None declared.
True confessions
In October Minerva asked readers to submit their tales of clinical, career, or other mistakes, for publication in this issue. First to respond were Dave Sackett and Richard Smith, followed by others, some of whose confessions are printed below. You can see all the responses and add your own contribution on bmj.com (http://bmj.bmjjournals.com/cgi/content/full/329/7474/DC3)(Edwin P Kirk, staff speci)