The fact that unexpected outcomes and rare events occur is one of the realities of medicine that is difficult to comprehend until you have personally experienced it. There are over 130 million emergency department visits annually, over 16 million of which require admission to a hospital. With that many encounters, even the rarest of events becomes possible. However, practicing medicine is impossible if you are constantly looking for the 0.0001 percent or the 1 in a million case.

Evidence-based medicine (EBM) is based on researched outcomes and proven interventions that are utilized to prevent and treat illness. In today’s EBM world, diagnostic testing that attains sensitivity or specificity in the 99-person range is superior and exceedingly difficult to attain. However, we rarely acknowledge that fact, and we must base decisions on something or suffer crippling indecision.

So how do we deal with situations where seemingly impossible events occur? A child dies from a heart attack, a healthy young man dies from a life-threatening infection caused by a strep strain found in the throats of most people, or a patient has a cancer missed despite numerous tests. There are so many stories of patients who should have had an unremarkable course but instead die. It is the lightning strike of medicine. It may be rare, but it’s occurrence opens our eyes to the possibility of these events and reminds us of how much uncertainty there is in medicine.

What do we do with these events? Is it possible to learn from them? Is it possible to adjust our practice without becoming completely useless physicians unable to reach decisions because we are always seeking more diagnostic certainty? We have seen physicians of this kind, and we often make whispered comments regarding their inability to practice like “the rest of us.” Patients also misunderstand the quantity and complexity of diagnostic testing and procedures believing that we have attained certainty in medicine. The truth, which we come to understand completely only after one of these rare events, is that medicine is not black and white. Testing is imperfect, decisions are based on the “most likely,” and bad outcomes can and will occur despite our best efforts. This is not a reflection on our clinical skills, our decision making, our training or our competency as physicians. It is also not a reflection of our attitude toward our patients or family.

If you are a physician, physician assistant or any provider and have found yourself asking the questions: “How did this happen?”, “What else could I have done?” or “How am I supposed to face my next patient and make a decision next time?” — know that many have faced these same questions. Lightning strikes, and the experienced physician reviews cases such as these and often says, “This outcome would have been the same on any other day with any other physician.” Some outcomes are not preventable or foreseeable despite all of the medical care at our disposal.

Lift your head up and move forward. What you do is essential, and we all need you.

• Discuss the case and convince yourself that your care was appropriate.
• Believe that what we do is not perfect but it is the best that we can do with what we have.
• Know that you did not cause this illness and that people die despite best treatment.

There are some occurrences we are not able to explain in medicine. Though the legal system may seek a cause to identify a source of revenue for the victim or family, the field of medicine does not support this in all cases. Our hearts break and emotions run wild in anguish for our patients. And there’s the belief that we are responsible, but this is not the case.

Know that time heals, and the hardest thing to do is to return to work and keep moving forward. If you should find yourself in a dark place, unable to see the light at the end of the tunnel — seek help. You are not alone. Many others have been in this situation, and we are here to help.

Sam Ashoo is an emergency physician who blogs at Admin EM.

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