Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”
I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.
Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”
You would think that, after 30 years, I would recognize a basal cell.
Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.
In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?
The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.
Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?
We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”
We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.
Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.
Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”
Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”
I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.
As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.
Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.