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06/27/2013

"Looking Back": Clinical Review and Reconsideration


It is only natural, if one has a memory,  to look back with the remembrance of the event and think to oneself whether the decisions made and the outcome of the event could have turned out better if the issue was thought out and acted upon in a different way.  And it is only natural but also part of the professional learning experience for a physician to look back, reconsider and contemplate  a different approach to the diagnosing the illness, explaining the findings to the patient, presenting to the patient professional advice and then different decisions made with the patient.  Looking back may expose to the physician mistakes made, mistakes which can be prevented in future experiences.

 Mistakes can involve errors of knowledge or related to assumptions regarding the clinical condition but also about the patients themselves.  Mistaken conclusions by the doctor about the his or her patient may arise because of insufficient time taken with the patient to obtain, beyond the biologic aspects of the patient’s illness, knowledge of the psychologic and social aspects of the patient’s life and the impact of the illness on it.  The patient who is described as “non-compliant” toward diagnostic procedures or treatments, after the fact, may have had issues, which could be considered and attended to earlier, but unknown to the physician because of inadequate history taking and earlier discussion with the patient.

Errors or delays in making proper diagnoses can often, on looking back, be related to assumptions based on the medical literature or the physician’s experience with patients bearing similar patchwork of symptoms.  It is much easier to base a conclusion on similarities to other cases than to start out with the approach that the diagnosis of the present patient will be unique and require more special and intensive intellectual attention.  Consultation of cases with specialists or others with assumed “more experience”, especially informal “curb-side” consultations though often helpful to the physician, may provide inappropriate conclusions since the specialist has not had the opportunity to talk with or examine the patient of the case.

Treatment of the patient’s disorder may be misguided by erroneous “it has always worked before” assumptions but also by paternalistic “this approach is the best for the patient” with some alternate treatments not presented to the patient for the patient’s consideration. 

Failure of correct diagnosis or failure of treatment or frank “medical/surgical mistakes” is always an underlying consideration by all physicians but, at times physicians may have become unreasonably “optimistic” regarding diagnosis and treatment.  When this optimism fails in results, as it can, there follows much personal soul-searching and “looking back”.  Yet, “looking back” really should be the final professional act in cases that “go well”  as those that don’t since every case should be a professional learning experience and, without “looking back”, looking forward may be missing something important for the physician  to know and, in fact, leave the physician misguided.   ..Maurice.

Graphic: Two Deer Looking Back–photograph taken by me at Red Rock State Park, Sedona, Arizona, June 2013.

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