The doctor and patient talked and then began an involved workup, “yet no diagnosis was made.” Later, the doctor discussed the case with a colleague, who suggested getting blood cultures to test for an infected heart valve. For reasons beyond explaining, the doctor did not follow up and with his patient slowly deteriorating referred him to an oncologist whose blood cultures were positive. “Profoundly embarrassed and ashamed for missing something obvious, simply and inexpensively tested for and relatively easy to treat,” the referring doctor was nonetheless extremely relieved and told his patient he had “goofed.” Even though not feeling “ethically obligated” to do so, the doctor felt that he had “a close enough relationship with them so that there wasn’t even a question of not telling them.” He further added,
I also felt it important to be forgiven by them, not to be absolved of negligence, but so that I could continue to work with people and not feel I was being dishonest or covering up. At first, the patient was going to see another doctor in the [clinic] I worked at, but he changed his mind and continued to see me until I left a year and half later.
I also told colleagues about this mistake, something I have done in other instances because I feel the need for others to acknowledge my errors and tell me that it’s okay to be human and make mistakes. Often, they then share their mistakes and I can then go on, though almost humbled by the experience. Sharing mistakes, especially when they can have profound effects on people’s lives, is essential. If one cannot do it on any level, I think burnout, depression, substance abuse, and suicide are potential hazards.