The Miss – Episodes

The Miss, episode 7/7 – Doctor and patient

Patrick collected Elizabeth from the waiting room, opened the door to the clinic room and beckoned for her to take a seat.

“Thank you for coming Mrs Valtrey.”

She was thinner and appeared to have aged five years, though only three months had passed since the chemo started. But she was doing well, nevertheless. Patrick had seen the latest CT scan result. The tumours had not shrunk much. The decision of the multi-disciplinary team was documented in the notes – not for surgery. More chemo, for as long as she could take it.

“I didn’t expect to be sent an appointment Dr Elliot. I thought I was under the cancer team now.”

“Yes, we don’t usually have much to offer at this stage, but it’s good to see how you are getting on.” A pause. Elizabeth let the silence reign. He had asked her to come, after all.

“Actually, I have something I want to talk you about Elizabeth. Concerning the tests you had when you first came to see me.”

She let him continue.

“You had a blood test after you saw me, and it showed that you were anaemic. Mildly anaemic, but anaemic nevertheless…”

“Yes doctor. My GP Dr Atwal mentioned that.”

“Did she? Did she?” Patrick looked past Elizabeth towards to the blinded window. He wished he was on the other side. “Well you were anaemic at that time, but… I didn’t see the result of the blood test. I didn’t know you were anaemic.”

“And was that important?”

“It was. If I had seen that you were anaemic I would have, I’m pretty sure I would have, arranged a colonoscopy for you.”

Elizabeth understood immediately. In fact, Patrick’s confession did not surprise her. She had worked it out in her own mind, from scraps, looks, evasions. But larger concerns had pushed the need to hear it explained openly and honestly to one side. And now, here it was. The truth. The doctor continued,

“Elizabeth. It was my responsibility to see that result. I made a mistake. It’s very likely that if we had found the cancer when you first came to see me, it would have been smaller… and curable. We can never be sure, but it’s possible. I’m sorry.”

Elizabeth saw, briefly, an alternative future. But she banished it. It was useless. Harmful. Fantasy.

And anger. What of anger? No, it was too late for anger. Too late.

“Well I don’t know what to say Dr Elliot.”

And neither did he, now. How to close a conversation such as this? Like every other medical conversation. Constructively. With hope.

“I have made some recommendations, so that this does not happen again. From now on we are going to print out all the blood results on the letters automatically, with abnormal one highlighted, so that we, and a patient’s GP, are made more aware. It doesn’t help you, I know, but others… I hope.”

“Thank you doctor Elliot. That is good to hear.”

Her tone was rather automatic. He feared Elizabeth was just being polite. Making him feel better.

As he drove home that evening, he realised that he did feel better. It had cost him, yes. Saying sorry always costs something. But it was the only way forward. Elizabeth might well go home and report the conversation back to family, sons, daughters, and who knew what would come of that? For Patrick this meeting was the only way.

Even now, it was about him.

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The Miss, episode 6/7 – Doctor and conscience

Dr Ellliot had much time to think, to rationalise, to excuplate, to self-criticise.

Face it – her cancer wouldn’t be incurable if I had arranged an earlier colonoscopy. That’s the basic fact. If I had looked up the blood test I would have seen the result, and I would have requested the colonoscopy. I can’t get away from that. She’s going to die and it was avoidable.

Why didn’t I look it up? Why? Because in my mind, when I saw that letter, I had an image of the patient… and I remembered, I thought, there’s nothing wrong with you. Belly ache. One of the hundreds I see every year with belly ache. Cancer wasn’t even on my radar. I had no concern. I was lulled into… I had closed my mind to the possibility. Stupid. I sent the test. I must have sent it for a reason, surely. Why send it otherwise? Why do something and fail to check it? It was my responsibility, wholly mine.

Why cut myself up about this? This one oversight is nothing compared to the thousands of patients I have looked after well. All the cancers I have caught early. Other conditions that I have diagnosed through careful assessment, perseverance. Knowledge. I know I’m not bad at this. I am not a bad doctor.

But for Elizabeth Valtrey, I was bad. I dropped the ball.

Should I tell her?

Will it help her? Not materially. But surely she is owed it. That blood result was sitting on the system for nine months and no one saw it. It’s got my name on it, the one who ordered it. It was for me to see it…

Here I am, killing myself with guilt, but Daisy was right, the system did not help me. Nor did the GP. She knew Elizabeth was anaemic, but she didn’t tell me. I suppose she assumed I’d look at everything, leave no stone unturned etc etc… does she even know what the clinics are like? The pressure to turn patients around. It’s all my fault. And if I front up to her, it will look like it’s all my fault. Oh yes it will. And if there’s an interested son or daughter, some lawyer type, if they get to hear about it… dread to think what they will do. Years of stress. It will make me a less good doctor. Is that what anyone wants, really?

Is this about me, or her?

Well this is my mind. My fear. My future. Her life, her blood… her trust that I would do a proper job.

It’s gnawing away at me. It’s time to move on. Confront it, or turn away and leave it to sink under the sands of time. Will it sink? Or will it remain, a dark monolith on the plain, blotting the view, drawing my attention?

Shall I tell her?

 

 

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The Miss, episode 5/7 – Doctor and partner

“What do you think I should do?” asked Patrick, of his partner Daisy (who was not a doctor). He had told her everything.

“Oh Patrick, this has really got to you, hasn’t it? Is this why you’ve been moody recently.”

“I guess so, yes. I’ve kept it to myself, apart from telling Monica in the office, and I could tell she thought I’d messed up.”

“Well that’s the question, I suppose. Does it count as a mistake, not acting on that blood test.”

“A blood test I didn’t even see.”

“Was it your responsibility to look it up?”

“Anyone looking in from the outside would probably say yes, it was. Anybody with anaemia and low iron levels should be investigated properly. It’s basic medicine.”

“Do you normally look up results?”

“Yes! I check them when I sign off the clinic letters to the GP. Every time.”

“So why not this one?”

“I think it’s because they were discharged, and when the letter came I saw that the endoscopy had been done and it was all done and dusted. I overlooked it.”

“The system didn’t really help you, did it?”

“No. But I’m not sure any system could have made me check it.”

“The doctor who did the endoscopy could have checked the blood test.”

“There isn’t time. That’s not expected.”

“It sounds like a bloody dangerous system to me.”

“It usually works.”

Patrick twirled his pasta round the fork. Daisy looked at him with concern over the rim of her wine glass. Neither were enjoying it. Patrick sighed deeply, and said,

“System aside, I have to make a decision. Whether to tell the patient.”

“Will it do any good?”

“No. But there’s a duty, to be honest, if mistakes are made. Duty of candour they call it.”

“Legally?”

“If it’s agreed that it’s an error resulting in harm.”

“Well, do you think it is?”

“Probably. But I’m the only one who knows about it.”

“Oh. I see.”

“Nobody has made a complaint, or raised an issue you see. If I report it, report myself… it’s all a bit circular. It’s up to me to apologise, write to her…”

“Could she sue you?”

“Not me, personally. The hospital. But it’s unlikely.”

Daisy couldn’t help any more. Patrick was her partner, she loved him, but she could not make the decision for him. She did not fully understand the medical details. But she could tell, by the look of concern, by his sombre mood, that some sort of resolution was required.

“If nothing else,” she said, “fix that system so it doesn’t happen again.”

 

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The Miss, episode 4/7 – Patient and nurse

Elizabeth developed a good relationship with her clinical nurse specialist, Ademola Oni, a male nurse who had trained in Nigeria. She called him after the second round of chemotherapy, to ask, out of interest, how long she had been anaemic. Ademola was organising an iron infusion for her, because the anaemia had become more profound. Ademola clicked an tapped into the results system.

“Since last March, when you were referred. Why?”

“When I was referred first time you mean?”

“Let’s see. Oh yes, when your doctor wrote in about the abdominal pain. Yes you were a bit anaemic. What happened after that? It was eight months until you had the colonoscopy I see.”

“Nothing happened.”

“Ah…”

“Should I have, do you think Ady?”

“I can’t say Elizabeth. They often do request colonoscopies to look into anaemia, but it was very mild. Perhaps the doctor didn’t think it was necessary. Did you ask him?”

“I haven’t seen him again, since he told me the diagnosis. I don’t think I’m under him any more anyway.”

Ademola had nothing more to add. He knew Patrick Elliot was sound, conscientious, not lazy. But he knew also that something didn’t quite add up here. But what was he to do here? What was his duty? The sequence of events was too vague. Ademola recognised an ‘incident’ when he saw one, a mistake, and was quite capable of notifying someone about it, but this wasn’t one such error. So many people involved now. He might ask Dr Elliot at some point… but would not make a mission of it.

They rang off. Elizabeth was fatiguing very quickly now. She could just about keep cooking for her husband, but the personal care had been transferred to a visiting carers who came twice a day. She was mainly focussed on the next CT scan, which was due in 6-weeks. This would show whether the cancer was shrinking or not.

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The Miss, episode 3/7 – Doctor and colleague

Dr Patrick Elliot leaned back in his chair, distracted. Next to him, in the shared office, sat a colleague, another bowel specialist – Monica Byrne.

“Monica… advice please.”

“Shoot.”

“I saw a patient nine months ago. Routine referral from the GP, belly ache, no weight loss, couldn’t see any recent blood tests. Got an upper endoscopy, discharged. I’ve had another look at the letter, it didn’t mention anaemia.”

“Was she anaemic?”

“Well, yes. Mildly. A full blood count was done after the clinic appointment, but the patient was discharged from endoscopy and I never saw the result.”

“Was it sent to you, the blood result?”

Patrick paused. He didn’t enjoy the direction of Monica’s question. “I err… don’t know. It’s on the system. Paper results stopped years ago. I don’t remember reviewing it. I suppose, if I’d seen it, I’d have arranged…”

“Don’t tell me. She’s got cancer?”

“Yes. Sigmoid, advanced. And a metastasis.”

“Oh.”

Monica’s tone confirmed to Patrick what he already knew, what he now had to accept. He carried blame here. The defensive instinct rose quickly; “But if the GP was worried about anaemia she should have mentioned it in the letter. It was such a short referral, look – Please see this lady who has a three month history of upper abdominal discomfort… – She didn’t mention anaemia!”

Monica said nothing. The things she wanted to say could not be said right now, like: if you order a blood test it’s your responsibility to check it, and, if a GP refers a patient they expect a full assessment, not just an answer to the narrow question in the letter. But to offer these opinions, right now, would have been too cruel. Patrick was clearly cutting himself up over this.

“What will you do?” asked Monica.

“I don’t know.”

“Does the patient… does she have any concerns?”

“I don’t think so. Should I tell her? What would you do?”

“Think on it for a bit. Apologising isn’t going to help her right now. The main thing is, she’s getting treatment.”

Thanks Monica. I’ll… keep an eye…”

But Patrick was not reassurred; he was not comfortable.

 

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The Miss, episode 2/7 – Patient and husband

“I wish I’d been there with you love,” said Mr Valtrey, when his wife returned from the oncology clinic. He rarely left the house, due to Parkinson’s disease. But Elizabeth, who largely cared for him, was strong enough. They spoke about the coming weeks and months. The oncologist was actually quite positive about the chance of a response. If the tumours in the bowel and the liver shrank well, there was even a chance for an operation to clear everything out. A chance.

“Funny thing though,” said Elizabeth. “She looked at my records on the screen and asked me how long I’d been anaemic. I said I don’t know, a year, more. She raised an eyebrow.”

“What did that mean?”

“I got the impression something was amiss. In the blood tests.”

“Amiss how?”

“Well, anaemia, which I had, is a sign of bowel cancer. And I remember our GP, Dr Atwal, saying that I was mildly anaemic she sent me to see Dr Elliot in the first place. But Dr Elliot didn’t mention any anaemia. I’m wondering if I should have had a colonoscopy back then, basically.”

“What do you want to do?”

“I’ll go and see Dr Atwal, see what she says.”

“You think that doctor missed something?”

”I doubt it. I mean, it’s all on the system, isn’t it?”

 

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The Miss, episode 1/7 – Doctor and Patient

A new experiment for this blog. In 7 short daily episodes follow the thoughts and feelings of Dr Patrick Elliot and his patient Elizabeth Valtrey. Patrick has made a mistake; Elizabeth’s bowel cancer went undetected, despite an obvious clue, and is now inoperable.

The scenario is entirely fictional, but it allows an exploration of the reflections and evolving rationale behind a doctor’s decision to be transparent, or to let error go unremarked. We will hear conversations between doctor and patient, patient and husband, doctor and partner, patient and specialist nurse, doctor and conscience, and finally doctor and patient once again. This format owes much to that literary cubist, William Faulkner, who described the death of Addie Bundren through 15 characters.

A new episode will appear at midday for the next 7 days.

Welcome to ‘The Miss.’

***

Dr Patrick Elliot flipped through the notes on his next clinic patient – Elizabeth Valtrey, recent colonoscopy done to investigate rectal bleeding, large polyp found, biopsies taken. He keyed in her details on the results system – Biopsy: Adenocarcinoma. Had she had a scan yet? Yes; the endoscopist was suspicious enough about possible cancer to have requested one straight away. CT scan result: tumour spreading from wall of the large bowel to adjacent structures. A spot on the liver, query metastasis. Oh.

He called Elizabeth in. She was 64 years old. She took her seat. Patrick used his years of experience to address the diagnosis, mixing clarity with kindness, hope with realism. This was incurable disease.

Toward the end Elizabeth surprised him; “Actually doctor, I think I saw you last year… my GP referred me with tummy pain. You recommended a camera test into the stomach… but it was fine.”

Patrick leafed back through the notes. A sweat had risen on his skin. He found his clinic note, and the corresponding letter. ‘Dyspepsia, no red flag/suspicious features. Plan: Bloods, endoscopy, if normal –> discharge.’ Now he looked back to the result screen. The bloods. Haemoglobin 10.1 g/dl. She was anaemic 9 months ago! She should have been referred for a colonoscopy then. The tumour would have been found, smaller, operable.

He had overlooked the result.

“What is it, doctor?”

“I err… I was just looking at some old results…”

“And?”

“Nothing. Nothing Mrs Valtrey. Right… we need to make some arrangements for you. Your case will need to be discussed in something called a multi-disciplinary meeting…” and he laid out the near future for her. As she left he reflected that he might not see her again. Her care would now be taken on by surgeons and oncologists.

 

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