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Teaching and Learning Moments

My First Terrible Diagnosis

Kittleson, Michelle MD, PhD

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doi: 10.1097/ACM.0000000000002851
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From the first day of medical school, I couldn’t wait to graduate. I would practice phrases like postganglionic neuron and supraventricular tachycardia like an actor memorizing lines. I collected trivia: Currant-jelly sputum indicated Klebsiella pneumonia; a bobbing uvula was a sign of severe aortic regurgitation; yellow skin that spared the sclera was carotenemia, not jaundice.

I loved the certainty of the first few years, where pathophysiology so easily translated into etiology, which flowed into treatment. I spent my summers in the lab, carefully setting up gel electrophoresis trays for Southern blots. When the film developed, I always felt a thrill of discovery: For just a few moments, I knew something that no one else knew.

I was smug in the way that only a novice can be when I started my clinical rotations. When a surgical intern ordered haloperidol for a delirious patient with Parkinson disease, I educated him on the finer points of dopamine receptors. When I admitted a patient with tingling across the bridge of her nose and the labs revealed hypocalcemia, I worked through parathyroid hormone and vitamin D metabolism and ultimately diagnosed malabsorption from celiac sprue. Jumping from rotation to rotation, I was secure in the knowledge that diligence and the right textbooks would never let me down.

That changed during my fourth year, on a rotation in the urgent care clinic. A woman in her mid-60s noticed a lump in her breast and mentioned it to her daughter, who drove her straight to the clinic.

I knew as soon as I opened her gown and looked down at her left breast. The skin was angry and dimpled, the classic peau d’orange. The egg-shaped mass beneath was hot and stuck fast to her chest. Her future flashed before me: biopsies, surgeries, radiation, chemotherapy, metastases. I saw her weight loss, hair loss, vomiting, and despair. As I tied the patient’s gown and left the room, I couldn’t look her, or her daughter, in the eye.

My attending physician examined the patient and told her that the mass could be an infection or something else and that more tests needed to be done. The patient left with a printout of appointment dates and times. My attending and I both knew the lump was cancer, but I never asked him why he wasn’t honest with her.

After that visit, I replayed these cases in my head, filled with shame and guilt. Shame because I’d always relished getting the right answer instead of thinking about the patient behind the answer—how scary it must have been for that confused and agitated patient with Parkinson disease, but all I had felt was satisfaction that I knew more than my surgical intern. And guilt because I had let this latest patient down. She left urgent care with no answers, no plan, and no comfort.

The shame and guilt over my inept handling of that first terrible diagnosis have stayed with me. When I make an awful discovery, the dread is still there, but I confront it. I offer patients an honest differential diagnosis and ask what they are most afraid of. I go through the best-case and the worst-case scenarios. I acknowledge that we both may have more questions than answers but promise that we’ll make a plan to get the answers.

I still relish the wonder of medicine, but now I see both sides of a diagnosis. I never saw that patient with cancer again, but whenever I deliver bad news, I remember her. I use my expertise to provide comfort, and that comfort assuages some of the shame and guilt from that encounter 2 decades ago.

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