My Greatest Mistake

The fog of expectation

BMJ 2004; 329 doi: (Published 16 December 2004) Cite this as: BMJ 2004;329:1495
  1. Edwin P Kirk, staff specialist (kirked{at}
  1. 1 Dept of Medical Genetics, Sydney Children's Hospital, Randwick NSW 2031

    The demented elderly man arrived in the emergency department with a note from his nursing home: “cough and shortness of breath worsening over the past 7 days.” He had a low grade fever but did not seem too unwell, and my examination revealed only some crepitations at the base of the right lung. Chest infection, I thought, and the x ray did show some patchy opacification in the right lower lobe. I started some antibiotics and sent him to the ward. A couple of hours later, the medical registrar phoned me and gently informed me that the opacities I had seen were, in fact, the entire lung—collapsed as a result of the huge pneumothorax which ought to have been impossible to miss.

    One Saturday night a few weeks later, I found myself the only doctor on an island, home to an Aboriginal community. A 14 year old girl, 32 weeks pregnant, a shy and diffident historian, attended the island's hospital complaining of lower abdominal pain. She too had a low grade fever. I suspected urinary tractinfection, and a very cloudy urine specimen was positive for blood and protein. I sent her away with antibiotics. Fortunately for us both, and very fortunately for her baby, she re-presented soon afterwards, giving me the chance to make the correct diagnosis (labour) in time for a helicopter to take her to someone more qualified than I to manage the footling breech delivery of a premature baby. The urine had been cloudy because it was full of vernix.

    I was young, inexperienced, and overconfident. In each case, lacking a clear history, I made things harder for myself by doing an inadequate examination. But the biggest mistake, common to both of these stories, was of leaping to a conclusion early and then seeing what I expected to see. Expectations can fog your vision. It's best to wait until all the evidence is in before attempting a synthesis.


    • Competing interests None declared.

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