A 300-lb white man comes in for a physical. His BP is elevated, but he doesn’t have time to get an EKG. The patient returns 1 week later, complaining of a rash. We do an EKG and find upside down T waves in 2, 3, aVL, aVF, and the lateral leads. The patient denies any chest pain or other symptoms, but I send him to the hospital, thinking he has coronary disease and will end up with a stent. At the hospital, he is diagnosed with bilateral pulmonary emboli.
This story, sent to me by a reader, is evidence of a dirty little secret of clinical practice—the importance of luck.
In the lexicon of luck, there are times when a prepared mind puts disparate information together to arrive at a diagnosis. A case in point: While filling in for a colleague, I saw a patient with anasarca. He had a minimally elevated transaminase and, in leafing through his chart, I spotted an ultrasound suggesting intrinsic liver disease. Lo and behold, his hepatitis B and C panels were positive. My suspicion immediately turned to chronic hepatitis. Perhaps this comes under the heading of educated luck.
Consider, too, the dumb luck of the incidental finding—when you order an imaging test for pneumonia and find the treatable (but unrelated) cancer or aneurysm.
But what I’m struck by most is when physicians experience plain old good luck. I had a long-time patient with mental health issues and a long history of arthralgias. After an unrevealing initial work-up, I sent her to a rheumatologist, who quickly diagnosed clubbing and a non-small cell cancer. All of a sudden I was a hero for making a referral for a diagnosis I had missed!
On the flip side are the patients who seem to be dogged by bad luck. The incidental puncture wound that leads to fulminate meningitis; the 22-year-old who has a stroke out of the blue. I see such cases occasionally as a potential expert witness and just shake my head: “What awful luck. No one could have been expected to prevent that!”
I doubt that many of our patients would want to hear their doctors talk about the role of luck in medicine. That’s our dirty little secret.