On Making the Wrong Diagnosis

To any medical student, no task is more daunting than having to come up with a diagnosis for a patient who comes to him or her for medical opinion. I am not referring to patients seen in the wards or in the outpatient clinic, but to family members or friends of family members complaining of headache, difficulty breathing, abdominal pain, or some skin lesion, among other things. Being the first doctor in the family (and my mother being the friendly village pancit vendor), I have had my share of such patients when I was in medical school.

Back then, I shared with three classmates a rented apartment that was three blocks from UP Med. Although home was only an hour and a half away (two hours max during Friday night rush hour), I had neither the stamina nor the patience to withstand the daily bus ride to and from med school. The three-hour total travel time easily translated to three hours that could have been spent sleeping or studying, so my parents did all they could to be able to pay for my monthly rent and provide a weekly allowance.

Because of this living arrangement, I was home only one or two days a week, usually a Friday, Saturday, or Sunday, depending on my duty schedule.

“O, pupunta mamaya si (Name), masakit daw ang (Body Part). Ano ba ‘yun?”

That was how my mother would welcome me upon arriving. Before even asking how my week went or whether I was tired from the bus ride home, she would greet me with her lineup of patients.

“O, masakit daw ang (Body Part) ni (Name 1), yung (Family Relationship) ni (Name 2). Anong oras ko papupuntahin?”

Although admittedly grumpy at times, I entertained these patients, most of whom where acquaintances of my mother (“Yung anak niyan nagdodoktor sa UP”). I considered them an extension of my hospital charity work, because as my mother would always say, “Tignan mo na anak, kawawa naman. Hindi naman magpapatingin sa iyo ang mga iyan kung meron ‘yang pambayad sa doktor.”

Similarly, during family gatherings, I would come prepared to listen to heart and breath sounds of relatives. I then offered them my best medical advice. Being unlicensed, I could not prescribe medications, so I just urged them when I thought they needed to consult a physician to seek appropriate medical or surgical treatment.

I only had one policy: no physical examination, no medical advice. From the start, I made it clear to my mother that I would not accept phone or SMS consults.

One of my patients was Ofelia Reyes, a neighbor who consulted for difficulty of breathing. She could not tolerate walking long distances, so my mother requested that I give her a house call, and I obliged.

I will not forget Ofelia because in her case, I made a wrong diagnosis, and I only learned of my mistake after she had died. I was in fourth year then, which meant that I had with me a little over a year of clinical experience in a public hospital, and an additional three years or so acting doktor-doktoran under the supervision of licensed physicians during medical missions in urban poor communities and nearby provinces.

Ofelia lived with her husband and three children. Her husband did manual labor for the water refilling station next door and she assisted her husband in cleaning the water containers. Speaking in sentences interrupted by periodic deep breaths, she told me that she had been coughing for three months already. She wanted my opinion because her difficulty of breathing could no longer be alleviated by regular nebulization.

Ofelia looked frail; I estimated her to be no more than 90 pounds. When I asked about this, she said that she had lost considerable weight (and with it, her appetite) in the last couple of months. Listening to her chest, I heard harsh breath sounds from both lungs. Otherwise, my examination was unremarkable.

“Umuubo po kayo ng dugo?”

“Paminsan-minsan, Dok.”

Though fully aware that I was just a medical student, my patients then, with no exception, addressed me with the title. It was always pleasant to hear so I never bothered to correct them. Consuelo de bobo, you could say.

“Nasa inyo po ang mga x-ray ninyo?”

She called her daughter, who retrieved the films from a cabinet and handed them to me. I knew what I was looking for and I was not surprised with what I saw.

What else would you think of when you have chronic cough + hemoptysis + weight loss in a Filipino?

It was advanced tuberculosis, I was convinced. The internist treating her at that time thought so, too. Ofelia showed me the four drugs that were prescribed to her. I advised her to take the drugs daily, to nebulize more frequently, and to have her children gently tap her back every morning. She should expect improvement after two weeks of taking medications regularly, I told her.

Two more times I visited her, still with the same complaint. I wondered why she was not feeling any better. In fact, she was getting worse. She kept losing weight, her breathing was becoming more and more laborious, and she now had multiple, gradually enlarging masses on both sides of her neck. The disease had spread to her lymph nodes, I remember thinking.

Could it be because she was not taking her medications as instructed? (I asked her children repeatedly to confirm that she was.) Could she be harboring the multi-drug resistant form of tuberculosis? (I asked her to go to the clinic of one of my consultants, who specialized in TB and could provide assistance in procuring second-line drugs for the infectious disease.) My three and a half years in medical school could not give me a reasonable answer.

“Mag-follow up po kasi kayo dun sa Pulmo ninyo,” I said with a hint of reprimand.

“Mahal po kasi ang checkup, Dok.”

“Para po malaman ng doktor ni’yo na hindi tumatalab ‘yung gamot na inireseta niya sa inyo.”

“Sige po, Dok. Salamat ha?”

I left, but only after instructing her children to bring Ofelia to the nearest emergency room if they noticed her turning blue or gasping for breath.

A month later, my mother called to tell me that Ofelia had died in a nearby government hospital. She was admitted for respiratory failure, and her doctors decided to repeat her laboratory examinations. Her husband and children were surprised at what the work up revealed, as I was.

“Kanser daw, anak.”

“A ganun ba.”

I could not think of anything sensible to say to my mother.

Lung cancer.

Of course.

Antibiotics would not cure cancer.

The haziness on her x-rays were not fibronodular infiltrates from TB. They were multiple cancerous masses.

The nodules on her neck were not scrofulas. They were metastatic lymph nodes.

Why didn’t I think of that from the start?

I was too fixated on TB, that was why. Something was amiss, but I chose to dismiss that nagging feeling that things didn’t quite fit.

Before Ofelia Reyes died, thinking of a differential diagnosis was an academic exercise, a form of intellectual masturbation so that I could have something to impress my resident or consultant in my clinical history or case presentation.

Ofelia taught me an invaluable lesson in my medical career, perhaps one that had saved and would save more lives in the years to come:

Always ask, “What else could this be?”

At the cost of a life, doctors learn more, not when we get the right answer, but when we unwittingly choose the wrong one.

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4 comments

  1. If you made the right diagnosis, would she have lived longer? Or would you have improved her quality of life? Sometimes I concede to the futility of it all – this desire to save lives which is at the core of our profession, when we are probably right just half of the time. I could only hope that we are nearest as possible to right for the rest.

    • She would have died, still. But at least, she would have known. She and her family could have prepared for the terminal course of her illness. Sayang lang, Ma’am Jean. I’m trying to remember all the things I said during the times I was seeing her. It didn’t even occur to me that she was already dying.

  2. We must always ask ourselves, “Is the obvious the only possibility?”

  3. We always have to weigh the risks and benefits when choosing the right diagnosis.

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Names, dates, and events may have been changed to protect the identity of patients. The stories are not meant to provide medical advice for specific illnesses. The author neither accepts online consults nor gives medical advice online. Please consult your trusted physician.