MISSED CANCER DIAGNOSIS, new grad feeling terrible

[LAPA259]

hi all

im a new grad about 3 months into my job at a family medicine/urgent care clinic

I missed a diagnosis of cancer on a chest xray twice. we do our own in house xray imaging and if a patient is feeling SOB or has any warning signs we order and personally interpret an Xray in clinic.

Monday of this week a patient came in to ask for a copy of his xray because he was now seeing a specialist for lung cancer they had caught in the ER about a month after a visit with me where I treated it as pneumonia and asked him to follow up if he saw no clinical improvement (documented this). SP looked at the xray and commented it was definitely debatable and I hadnt made a poor decision. Obviously I still felt terrible about this and have vowed to over analyze any abnormality seen on chest xray for as long as i live etc etc. I picked myself up and decided it was a growing pain and to learn from this.

Thursday of the same week a different patient came in with a similar story, almost the exact same story. I had seen this patient my 16th day practicing as a PA and had noted an abnormality, began pneumonia treatment etc lost to follow up. However with this patient I did not document that I had asked him to follow up in order to cover my butt - needless to say my SP is now very unhappy and has decided he needs to review all chest xray I order. 

I understand I am new and fresh out of school and still have a lot to learn, but right now I just feel SO incompetent. Yes I noted abnormalities on the xray, but I treated poorly and now I cant stop thinking about the possibility of being sued for missing these things - i cant imagine having that on my record after only 3 months of working. Though it is kind of embarrassing, I am 100% on board with my SP reviewing all of my xrays as I do not want to harm any patients and I feel like I have done these two patients a horrible injustice. 

Any thoughts or words of encouragement/advice are appreciated.

 

[lkth487]

It happens.  Learn from it.  

 

I've missed some crazy things. A 6mo baby died because I was late in making a diagnosis. You have to live with those things and learn from them.   

You WILL make mistakes, whether you're brand new or have been practicing for 40 years. 

The question is what you are doing to get better at X-rays.  

[HMtoPA]

Again, it happens.

I had a patient that I saw a couple of times for a subacute cough. Treated as for bronchitis the first time (she had a concurrent, overlying URI). Second time I got the CXR, even the radiologist interpreted it as a pneumonia at first. Patient saw another provider at least a couple of times after me before the lung cancer diagnosis was finally made (primarily due to lack of response on abx), and underwent lobectomy. She did fairly well post-op, but died recently (about a year later), ironically of pneumonia complications (ARDS). Of course, I felt/feel terrible. I admit that malignancy was not far up enough on my differential - it's difficult sometimes when there is a constant parade of not-sick patients coming through during cold season with garden-variety post-infectious coughs, and even more difficult when you get imaging that is supposedly reassuring.

I will say that your practice needs to do something different regarding handling of imaging. No way should a new grad PA be responsible for the final read of anything. It's okay to do your own wet reads, but IMO every image should be seen and officially read by a radiologist. There's just too much liability otherwise.

[BruceBanner]

Chest xrays are often nebulous and difficult to read, IMO, and I look a lot of them.

There have been times I missed lesions or infiltrate and radiology caught it, and there have been times I caught infiltrate or opacity and radiology missed it. Quite a few actually. Same with fractures. I've been a PA for 6 years now. It makes you realize the burden of responsibility we do have. 

To reiterate it does happen, and you should always have some redundancy/failsafe system in reading your imaging and other semi-subjective interpretations. Hell you should (if you dont already) have someone reviewing every single chart for the better part of a year. 

A good mental tool I was once told is to always think of the top 3 things that could kill someone for a particular complaint/presentation. For cough and abnormal vitals I would think PNA, malignancy, PE. 

Add a follow-up note to all charts. "If symptoms worsen or do not improve in __ days, f/u or present to ER", something like that. "Patient understands/agrees."

[jmj11]

You are not a radiologist. My father was seen three times in the ER for consecutive pneumonia episodes. I raised the question of lung cancer (life long smoker) and he saw his PCP, who got a chest CT and did have lung cancer, but it was missed by three visits to the ER with radiologist readings. But with pneumonia, secondary to cancer, it is even more difficult to see the cancer and I don't blame the ER for that.

[EMEDPA]

2 hours ago, lkth487 said:

It happens.  Learn from it.  

 

I've missed some crazy things. A 6mo baby died because I was late in making a diagnosis. You have to live with those things and learn from them.   

You WILL make mistakes, whether you're brand new or have been practicing for 40 years. 

The question is what you are doing to get better at X-rays.  

yes, this. If you work long enough you will make a bad call and there will be a bad outcome. it happens. we are all human.

regarding chest xrays , do this for every single film. this is what I teach the med/pa students who rotate with me:

abcdef method (in this order)

Airway: fbs, deviation, etc

Bones: fxs, dislocations, etc. it's embarrassing to read a film as no infiltrate and the rads read is r shoulder dislocation...

Cardiac/mediastinum: heart size/location, widened mediastinum, etc

Diaphragms: free air, hiatal hernia, elevation, etc

Everything else: fbs, lines, tubes, ports, monitor leads, pacemakers, pumps, cervical fusions, hardware, etc

Fields: last , but not least look at the lung fields for infiltrate, effusion, masses, pneumothorax, etc

 

[GetMeOuttaThisMess]

And don’t forget the never to be seen unless by a radiologist, Kerley B lines. My dad had a nodule in his left lung (CA), I was told it was there, and never did see it until it was pointed out overlying his left clavicle.

 

[sk732]

I picked up a kid with early SVC Syndrome because of Hodgkin's - had a CXR about 4/12 before I saw them in the ER and I thought the mediastinum was wide on that one  - the rad called it (N)...CXR I did wasn't much different, just extra nodes...the (different) rad reported "in retrospect, the previous CXR also shows a widened mediastinum".  Frig, I just missed a subtle pneumo 2 weeks ago on someone...went back and revisited it because my neck hair was standing up when I was writing the chart and lo and behold, tiny pneumo and very subtle pleural line...got the dude back in for F/U.  We're all humanoid, we'll miss stuff - that's why rads get paid more money per second than most of us get per hour, and even they aren't infallible.

SK

[EMEDPA]

a pneumo less than 10% really isn't that big a deal...

[SedRate]

You are not a radiologist, and even radiologists with their fancy screens and dark rooms miss things.

Lots of good advice in the above comments. Like the others suggested, have someone review your films while you get through your first year. At three months out, it's silly to expect you to read your own films without a formal radiologist read or second set of eyes. Everyone makes mistakes. Learn from them and educate your patients on F/u measures if no improvement or worsening. And as always, DOCUMENT, DOCUMENT, DOCUMENT.

[Joelseff]

I saw a pt a few months ago with c/o otalgia. On exam he had ipsilateral turbinate edema and I saw an injected and retracted TM with a red streak that looked like a blood vessel. I thought it was a blood vessel. Certainly looked like a blood vessel... I gave him Flonase for ETD. Pt returns 2 days later with worsening pain. I looked in the ear again and saw that the "blood vessel" moved. I was able to extract it. It was a Thorn!

 

Don't worry about missing stuff. Yes my example was more benign than yours but still missed it. EVERY provider misses things. We are not all House MD.

 

Learn from it. I have had my share of face-palms over the years.

 

Sent from my SAMSUNG-SM-G891A using Tapatalk

 

 

 

 

[lkth487]

THis is a more specific recommendation but for radiology (pediatric specifically), my residency requires all interns to complete all of the Cleveland clinic radiology modules:  https://www.cchs.net/onlinelearning/cometvs10/pedrad/

Mignt be useful to you.  It's not just X-rays  and it's relatively comprehensive (it won't make you a pediatric radiologists but you can interpret basic head ultrasounds and X-rays and stuff like that).  I once missed a head bleed on head ultrasound and I made it my mission to be great at those from then on.  Don't wait on a consultant to do or say something - think about why and what they will want you to do when you get a consult (whether it's endocrinology or radiology) and understand the reasoning behind it.  It'll make you a better provider.

 

I think the key takeaway you should have from this is be constantly humble and be constantly learning. There's always stuff you don't know regardless of your previous knowledge, background and experience. 

[LT_Oneal_PAC]

I've absolutely made bad calls. I've been kept up nights. You are human. You are imperfect. Same as me and everyone else. Accept this will happen. Learn from it. Try to be better in the future. That's all we can do. I try to remember after I come out of my funk, that I am a force of positive good in the world. Sometimes I will cause harm, but I save many more lives than I hurt.

 Just as a side note, if your thoughts turn grim, please open up to a confidant (not someone you work with) about those. 

[sk732]

6 hours ago, EMEDPA said:

a pneumo less than 10% really isn't that big a deal...

Except to a nervous parent with deep pockets and access to a dickhead lawyer...

SK

[Cideous]

It's a terrible feeling and it never gets better.  It's happened to me prob half a dozen times after all these years.  Whether you get sued or not is not up to you so I would just say to try and put it out of your mind.  If it happens, it happens.  I pray a lot.

[ventana]

New grads (or even experienced) should never be sole read on X-rays.   

 

This is is an error in your employer.  Not you.  

 

[Hemmingway]

Several years ago a woman came to see me who had developed a "knot" at the lateral margin of her L quad femoris after moving a bunch of furniture. I decided it was a muscle injury, gave her the usual precautions and sent her home. She came back 4 months later and this thing was HUGE and clearly a mass of some sort. Testing ensues.... metastatic myosarcoma. She died about 4 months later.

Did I mention it was my wife's best friend? I gave her eulogy. I'd been a PA better than 20 years.

[ventana]

4 minutes ago, sas5814 said:

Several years ago a woman came to see me who had developed a "knot" at the lateral margin of her L quad femoris after moving a bunch of furniture. I decided it was a muscle injury, gave her the usual precautions and sent her home. She came back 4 months later and this thing was HUGE and clearly a mass of some sort. Testing ensues.... metastatic myosarcoma. She died about 4 months later.

Did I mention it was my wife's best friend? I gave her eulogy. I'd been a PA better than 20 years.

Ugh. Sorry.   

 

Came very very very close to missing a broken neck on friend.   Initially missed it.   Ugh

[Cideous]

A very good set of friends called me one night as his wife was acting a little forgetful and sleepy.  She was only around 40 and had recently started some new meds.  I told him it was prob the new meds and to keep an eye on her.  A few hours later she crashed. He rushed her to the ER and she was admitted for emergency surgery for bil blocked ureters and subsequent sepsis from a UTI.  They called him to the hospital and basically said she might not make it.  Thank God she did, but it was touch and go for a while.  Honestly, after that our relationship was never quite the same.  There was this underlying tension partially based on my guilt and their resentment.  You like to think that people can get past things like that, but in all honestly most don't.

Fast forward ....we have not spoken to them in about 6 years.

[GetMeOuttaThisMess]

I felt really bad when I missed this on my brother-in-law.  Well, almost.  This is what happened when he fell through a ceiling landing on his head on the kitchen counter with a Scott air pak on which he then hyperextended his neck over.  Up, walking around, and bitching as usual present day.

Oops, had to delete.  Darn HIPAA.

[TrekkieByDay]

16 hours ago, lkth487 said:

THis is a more specific recommendation but for radiology (pediatric specifically), my residency requires all interns to complete all of the Cleveland clinic radiology modules:  https://www.cchs.net/onlinelearning/cometvs10/pedrad/

Mignt be useful to you.  It's not just X-rays  and it's relatively comprehensive (it won't make you a pediatric radiologists but you can interpret basic head ultrasounds and X-rays and stuff like that).  I once missed a head bleed on head ultrasound and I made it my mission to be great at those from then on.  Don't wait on a consultant to do or say something - think about why and what they will want you to do when you get a consult (whether it's endocrinology or radiology) and understand the reasoning behind it.  It'll make you a better provider.

 

I think the key takeaway you should have from this is be constantly humble and be constantly learning. There's always stuff you don't know regardless of your previous knowledge, background and experience. 

Saved. 
Thank you. 

[rpackelly]

You know, even BC ED docs have their films over read.  I missed a lung CA early in practice, but it was caught that evening by the radiologist.  Coin lesion.  Patient did well and celebrated her anniversary of the event by going on a cruise to Alaska.  Thanks to the radiologist she could go.  That is why medicine is practiced optimally in teams.  I have also caught things radiologists have not because I had the benefit of examining the patient.  

Fast forward 30 years, working UCC.  Patient came in and wanted “pan xray” after rear ender MVA.  Michigan law encourages this for reimbursement reasons  ( the MAs were always taught to comply.)  No evident injury on PE.   I said I would do it only against my better judgment if the patient was fully warned of rad effect and if every film was over read by radiology.     Supervising md was called by MA and I was overruled.  Last per diem shift I ever worked there despite numerous requests.  Reading 15 films including spines both unnecessary and leads to enhanced liability.  Anyone can miss a tiny asymptomatic compression fx.    Let specialists earn their big bucks and give patients their money’s worth for their high monthly insurance payments.  When in doubt send it out.  

[dchampigny]

Mistakes happen constantly in health care. Some are of no consequence and never get noticed, others are front page headlines. Certainly after a mistake occurs, we become hyper-vigilant. We triple check the dose of every medication, ask for a "another set of eyes" on that baby with a fever, spend extra time reading our documentation. 

If you let it, this will consume you. This is unhealthy to your practice and overall wellness.  You will learn from it and move on. Medicine offers a lifetime of opportunities. Learn, reflect, adapt and become a better provider for it.

You should always have a back up x-ray read by radiology. In our practice, I am asked to give preliminary reads, but radiology always makes the final call. Shame on your SP for thinking you would be comfortable reading chest x-rays 16 days into practice. The blame is more on him than it is on you. If I were you, I would have a candid conversation with him and let him know your concern. 

 

Hang in there, medicine is a roller coaster. Every slope down is an opportunity to climb back up. 

[Reality Check 2]

I had a 65 yr old lady nonsmoker come into family practice with a cough. NO fever, O2 sats good, she wasn't in distress.  Her lungs didn't sound bad, cough, no wheeze, no rales. 

Viral illness most likely call. Supportive measures. 

Urgent Care came across the building and got me 5 days later. Cough not better, now a little distressed. Chest Xray shows HUGE infiltrate all over - almost like SARS or ARDS but her vitals were still not impressive. UC was even baffled and the radiologist read the films. Sent her to the hospital. 

She died 5 days later. Acute massive leukemia - the medical examiner called us all. None of us would likely have caught it unless we were looking for zebras. He called us because of how unusual the findings were. Her husband wanted to sue everyone in town but the medical examiner actually talked to him and told him it was odd, rare and untreatable at that point of aggressive progression. Her body shut down. 

I questioned myself for months and likely ordered more CBCs and CXRs than normal and then calmed down again. 

We will all make a mistake - we are human. Technology is not perfect.

My personal issue - ALL your films should be overread by radiology - I don't like the idea of a practice doing its own films without oversight. Don't walk in the swamp alone. 

Flipside - a mom yelled at me and complained to the private doc because I sent her and her 17 yr old son to the ER because he was clinically dehydrated and not quite right. He fell in the shower that morning AFTER Mom gave him her hydrocodone for a sore throat. I didn't know if he hit his head or passed out or what. He was also sicker than hell. Turns out to be mono, LFTs off the charts, dehydration and he was goofy - maybe from the hydrocodone.  She never quite caught on that giving a 17 yr old her pain meds was STUPID and that he was clinically ill. He got 2 liters, barely peed, has mono and got decadron for his swollen throat.  I can't fix her or her complaint but I did right by the patient.  

Win more than you lose and know you did the best you could at that time.

My crusty old 2 cents

[GetMeOuttaThisMess]

I must have attorneys waiting in line for me then because EVERYONE with a cough and snot nose with the duration of cough <1 month has bronchitis in the absence of abnormal vitals, apparent distress, rales, bronchial BS, fever, or consolidation (remember egophony?).  Just like the flu without fever, "If you go to a horse farm you're probably going to find horses, not unicorns".