St Mary's Maine Blog

As is the case with life, we as humans occasionally do something so phenomenally thick-skulled that it defies all previously-held notions of the limits of human stupidity.  What is even worse, we are sometimes even convinced that we’re doing something really smart, even as the ship slowly sinks.  I now refer to these moments (thank God they’re few in number) as ‘daisy duck’ moments.  There’s a good reason for that, as I’m about to explain. The original ‘daisy duck’ moment happened a few months ago, not long after I arrived at St. Mary’s.  I was so embarrassed after it happened that I couldn’t bring myself to share it in a blog, although after months of hearty laughs and good-natured badgering from Dr. B, one of my preceptors, I have decided to face the music.

On the aforementioned day, I was preparing for an afternoon of office visits by scanning through the list of upcoming patients and getting to know their medical histories and chief concerns.  Near the end of the schedule I came across the chart for ‘Duck, Daisy’, a patient tucked into the 4:30-5:00 PM slot. ‘Hmm… Odd name,’ I thought as I opened her chart.  ‘Daisy Duck… don’t hear that one often.’

Well, apparently you do if ever watched cartoons on the Disney Channel, or have ever been to Disney World, or have not been living beneath a rock for the past, oh, 60 years or so.  It is fair to say that, in my defense, we did not have television growing up AND I was raised in a town of about 50 residents in the woods of Maine, so it wasn’t entirely my fault.  Still, I should have recognized the first red flag warning me that a moment of great stupidity were about to transpire.

I started to browse through Ms. Duck’s chart, which had a long list of medications, a number of notes from prior office visits, some med requests, and some phone notes.  ‘Hmm…I see she has had a cholecystectomy, an aortic aneurysm, a lump in her breast, some anxiety, Type I diabetes (ugh- bad string of luck, Ms. Duck!)   Yep, got some high cholesterol and afib in the picture too, past screening for prostate cancer… wait a minute. What’s THIS?! They screened her for prostate cancer? But… women don’t even HAVE a prostate gland!’ I couldn’t believe my eyes.  Right there on the screen was glaring evidence of gross medical error- a female patient had been screened for prostate cancer!  What was even more amazing was that such an obvious error had not only been missed from the outset but had actually made it all the way into the patient’s chart. How could this happen? My God, at least they didn’t try to give her a TURP!

When Dr. B walked into the office from his lunch break, I was nearly coming off my seat waiting to point out this glaring error that everyone had missed but that I, the lowly medical student, by dutifully reading the charts of all the patients before their visits, had picked up.  I excitedly recounted my findings, observing that it was really an amazing thing that nobody had noticed this yet (it’s awful that she has experienced so many medical problems too!) and what would be the best way to proceed? Should we apologize to the patient for drawing an unnecessary blood test? How could such a thing every make it past all of the doctors, nursing staff, and lab technicians (you’d think SOMEBODY would have picked it up)? What sort of system could be put into place to ensure that such a thing did not happen in the future?

Looking very concerned, Dr. B asked me who the patient was. ‘Ms. Duck. Daisy Duck.’ I excitedly blurted out. ‘Odd name, I know.’ There was a moment of shocked silence as he weighed the ramifications of this great mistake. Then, to my great surprise Dr. B did not pull up her chart, brows furrowed as he scanned back through her labs and past visits to figure out where the system tell apart.  Rather, he laughed until he almost cried.

In the mirthful aftermath (his mirth, my aftermath), I found out that ‘Daisy Duck’ is a dummy chart used to help new office staff learn the electronic medical record system by adding medications, uploading new diagnoses, and creating complete notes for the record.  In addition to being the ‘practice chart’, Ms. Duck is also used as a space-filler in the schedule when appointment slots remain open.  In retrospect, I picked up on a few small things that might have tipped me off:

1)      Daisy is referred to as a ‘she’ in the chart but is listed as a 42 year old male- apparently they got her sex wrong too.

2)      She gave consent for her providers to speak with Daffy Duck in case of emergencies.

3)      Half of the notes are empty.

4)      Daisy quit after smoking 2 packs per day since the age of 12- but her quit date is April, 2012.

5)      Elsewhere under ‘Medical Problems’ is listed, ‘DEAF AS A DOORKNOB.’ (That should have been a giveaway).

Alas, what might have been a shining moment in my budding medical career turned into, well, a ‘Daisy Duck’ moment.  It may have not been the stupidest moment in human history but man, it sure felt like it.  After a long and hearty laugh that lasted for a few days and returned every time Daisy popped back up in the schedule, Dr. B suggested that maybe this would make a good blog story.  For obvious reasons, I would have been content to let this one fade away but Dr. B was persistent.

It would be easy to end this by quoting some moral drivel about ‘the folly of pride’ or ‘losing the forest for the trees.’  Really though, I don’t think we need to dwell on it.  Let’s say we’ll all just forget about this one?

(This blog is dedicated to Dr. B.)