Doctors Make Mistakes: Can We Talk About That?

Many years ago, much earlier in my career, an 18 year-old by the name of Stephanie was referred to me by a colleague for management of convergence insufficiency.  She had previously seen an ophthalmologist who prescribed +1.00 reading glasses to help her with close work.  My optometric colleague recognized that she had CI, and she experienced what we thought was a successful outcome at the time.  Except a few months after she completed therapy she seemed to regress.  She had previously shown normal eye health and visual fields, but when her eye began to turn inward instead of outward, we knew something was seriously wrong and immediately referred her to a neuro-ophthalmologist to coordinate care.  This MRI is not Stephanie’s, but shows the same type of massive brain cancer that was silently doing damage over the course of her young years.  A beautiful soul with an extraordinary singing voice, Stephanie was married in a bedside ceremony at the hospital several months later, in the wee hours of morning just before she died.

Her parents knew how much I cared, and as much as I beat myself up in retrospect for any signs or symptoms that I might have missed, it was little consolation to me that both an ophthamlologist and an optometrist who preceded me in her care had no suspicion of the tumor that was to overcome her.  Her mother had only one request of me:  that I share her case with other doctors, and that would be part of Stephanie’s legacy.  I have done so, many times, in a continuing education lecture that I give on binocular vision disorders masquerading as disease, and vice-versa.  In this way I continue to remember Stephanie, and honor her memory.

Though the implications of a virulent tumor escaping detection are obvious, and certainly not all tumors that are detected can be treated successfully by the time there is sufficient index of suspicion for brain imaging, the converse happens all too often as well.  Patients with significant functional vision problems are written off dismissively as “psychosomatic ” because they don’t have a “real disease” to contend with.

Physicians need to be re-defined, and this re-definition begins one physician at a time until it coalesces into a culture.  Re-defined physicians are those who acknowledge that they are human beings, and that human beings make mistakes.   We need places where everybody who’s observing in the health care field can point out potential mistakes, and is rewarded for doing so.  Not the circling of wagons to attack those who point out the poison of insularity, of the “good ol’ boys network”, and the myth of medical perfectionism. This is not me talking.  It is Brian Goldman, M.D., and he is a re-defined physician.  His message will resonate deeply for you:  “I do remember”.

 - Leonard J. Press, O.D., FCOVD, FAAO