Harold Pollack, director of the University of Chicago Center for Health Administration Studies, is a health care expert who has served on national panels. In his article, “Lessons from an Emergency Room Nightmare” he writes, “Several people made mistakes in my wife’s care. The worst and most deadly mistake was ours.” His article tells the story of what happens when his wife developed chest pain in the middle of the night.

When someone presents with worsening chest pain and elevated cardiac enzymes, an ER doctor has to make some pretty quick decisions in an often chaotic environment. Fear of missing a deadly diagnosis, physicians generally begin their decision making process by starting with the worst case scenario – in this case a heart attack – and working backwards from that.

Given that time is of the essence in diagnosing a heart attack, the luxury of taking a detailed history is often abbreviated in light of worsening symptoms as was the case with Mr. Pollack’s wife. This article shows what happens when a bad decision snowballs and leads to a missed diagnosis. It’s easy to blame physicians but as this article points out, our health care policies can be equally at fault.

Why no one picked up on the error illustrates how we see what we want to see and disregard those facts that don’t quite fit. This is even more so when the diagnosis continues to be confirmed by other specialists. That’s why it takes someone with fresh eyes and the time to study the chart to see the error.

And it’s why the practice of medicine is both an art and a science.