By Dr. Jane Smith, Surgical Oncologist
I remember the case like it happened yesterday. A middle-aged man, active and otherwise healthy, came into clinic for excision of a presumed seborrheic keratosis on his upper back. It had been biopsied by his primary dermatologist — benign. I reviewed the note, glanced at the pathology report, examined the lesion, and agreed it looked innocuous. The patient wanted it removed mostly for cosmetic reasons. Simple enough.
I performed the excision, closed the site, and sent the tissue for routine histopathology. A few days later, I received the call every surgeon dreads:
“Dr. Smith, this came back as a melanoma.”
It was a thin lesion — 0.7 mm — but it was melanoma, unequivocally. And here’s the truth: I hadn’t suspected it. Not even a little.
A Lesson in Cognitive Bias
I’ve spent years training myself to recognize patterns, to rely on data, on experience, on gut. But that day, I fell into a cognitive trap. The prior biopsy said benign. The lesion didn’t scream “malignancy.” I anchored to the diagnosis already handed to me, and confirmation bias kicked in — I saw what I expected to see.
It wasn’t until the pathology came back that I realized how much I had relied on the narrative, rather than re-evaluating the lesion with a clean slate. That one moment taught me how insidious and invisible cognitive bias can be — even in the most straightforward clinical encounters.
The Power of a Second Look
What would I have done differently? I would have paused. I would have asked myself the questions I ask my trainees:
- Does this make sense in the context of the patient’s age, skin type, and sun exposure history?
- Are we letting the prior pathology prevent us from reassessing the lesion objectively?
It’s easy to move quickly in clinic, especially when the calendar is full and the procedure seems routine. But taking 30 seconds to challenge our assumptions can be practice-changing — even life-saving.
Vulnerability in the White Coat
It’s not easy to admit you missed something. We are surgeons — trained to be precise, decisive, competent. But being human means that sometimes we fall short. And acknowledging that is not weakness — it’s growth.
When I called the patient to explain the diagnosis, I didn’t hide behind jargon or pass the blame. I told him honestly what we’d found, what it meant, and how we would move forward. He appreciated the transparency. And together, we proceeded with wide local excision and sentinel node biopsy — which, thankfully, was negative.
What It Taught Me
That melanoma taught me more than any lecture, conference, or textbook ever could.
It reminded me that no lesion is too routine to deserve full attention.
It reminded me that our brains will trick us if we’re not vigilant.
It reminded me that humility is not optional in medicine — it’s essential.
Now, when I teach residents, I tell them this story. I want them to know that being a good surgeon isn’t about being perfect — it’s about being honest, curious, and willing to reflect.
That melanoma may have been small, but its impact on my practice was profound.
And I won’t miss that lesson again.
Dr. Jane Smith is a board-certified surgical oncologist with a special interest in skin and soft tissue malignancies. She practices at [Hospital/Institution] and mentors residents and fellows in surgical decision-making and cognitive awareness in clinical care.
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