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Haunted by a mistake made 30 years ago

Thirty years ago, as a newly minted pathologist, I made a bad mistake.

I had joined a group of doctors who, in addition to serving as medical examiners, ran a private laboratory where we examined surgical specimens from three small hospitals and biopsies done at local doctors’ offices. On a given day, somebody covered the hospitals, somebody did medical examiner autopsies and somebody worked in the laboratory.

On a day that will always haunt me, one of the other doctors came to my office carrying a microscopic slide prepared from a tiny biopsy of a man’s prostate gland. The man had cancer, the doctor said. He wanted me to review the slide and confirm that cancer cells hadn’t invaded along a nerve.

I looked at the slide carefully, I thought. I saw no invasive cells, but I didn’t pay sufficient attention to the “cancer cells.”

Those cells were normal cells of a type not usually picked up in a little biopsy. They resembled prostate cancer cells, but only superficially. I should have known better. The other doctor should have known better. To this day, I can’t imagine why I didn’t realize what those cells were.

My colleague issued a report that said the patient had cancer. His prostate gland was removed at a larger hospital. When the gland was examined, no cancer was found. Pathologists at the big hospital asked to review the biopsy my colleague and I had said contained cancer. They correctly reported that it didn’t.

Not only had the patient undergone needless surgery, but as a complication of that surgery, he was impotent. He sued. Our insurance company settled the case for a sizeable sum.

I was devastated. I lost my confidence. When it was again my turn to examine slides, I asked one of my colleagues to re-check most of them. I seriously considered quitting my job and leaving the field.

The most senior doctor and head of the group sat me down and told me a story. During his first job, on the very first day he was assigned to examine microscopic slides, he thought he saw cancer in a woman’s cervix. He said so, the woman had a hysterectomy, and no cancer was found.

He said he’d felt just as I did. He said he’d gotten over it, and so would I. He said I should tough it out, and I did. But I haven’t forgotten. I’ve made other mistakes, but that’s the one that, after all these years, bothers me the most. It bothers me so much that as I type this column, I’m wiping away tears.

That mistake played a role, I’m not sure how large, in my eventual decision to leave clinical pathology and become a full-time forensic pathologist. I know I’ve made other mistakes – fewer than some, I like to think, and no more than most.

All people make mistakes, no matter how intelligent or educated, how well-meaning or well-trained. All become distracted. All fail to think of things they should have considered. All are, on occasion, lazy or careless. All are sometimes just inexplicably wrong. Some are better than others at forgetting, ignoring or justifying their shortcomings.

Doctors make faulty diagnoses. Lawyers provide ineffective counsel. Military commanders lead troops to disaster. NASA engineers decided to accept the risk that the space shuttle Challenger’s O-ring seals could fail after exposure to freezing temperatures.

People don’t easily forgive experts who make mistakes, and most experts don’t easily forgive themselves.

Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland. Reach her at chuser@durangoherald.com.