Missed Calls

We all have tough days, but the past few weeks have been unbearable.

It's Thursday evening and it's been almost 3 weeks since my father passed away due to complications from surgery. Looking for a mindless distraction, I switched on the Bengals-Ravens game. Although I am not routing for either team, the game turned out to be great matchup, up until the final moments, where several potentially outcome-changing calls were missed, but without the calls, the game continued, benefiting the Ravens.

In my consulting work, I’ve always followed a simple mantra: 'We are not operating on babies, and no one is going to die because of our work.' It’s a grounding philosophy that reminds me of the relative low stakes in my own field. But that got me thinking, in some fields the stakes are so much higher than in others. Like in medicine, a missed call isn’t just a shift in the score or who wins; it can mean the difference between life and loss.

Despite Missed Calls, the game goes on

During the game, the Bengals fought hard to secure a win, only to have two critical officiating decisions go uncalled at the final moments. In a crucial play, Bengals quarterback Joe Burrow targeted one of his tight ends, however, the other tight end Mike Gesicki was clearly being held in the end zone by a Ravens defender—a clear penalty to many watching (well non-Raven’s fans that is).

The other penalty that was not called on the Ravens, occurred when Burrow was hit square in the face by another Ravens defender, a textbook personal foul (again if you are not a Raven’s fan), yet no penalty was called – even though the defensive lineman clearly made forcible contact with Joe Burrow’s face mask.

The flags never came, the pass went incomplete, denying the Bengals a game-winning two-point conversion. The Ravens held on to their one-point lead, and the game ended.

Referees of Our Health

Going back to what got my mind going in this topic; doctors and referees share a similar role. Both operate under enormous pressure, tasked with making high-stakes calls based on the information available at that moment. Refs and doctors must provide a safe and balanced environment, whether it’s on the field or in the emergency room.

This was where I thought of one critical difference: While a referee’s error may change the course of a game, a doctor’s misjudgment or delay can irreversibly change—or end—a life.

There’s no replay review, no final whistle to signal a reset, no possibility of playing in next week’s game or of starting fresh in a new season.

And when the stakes are life and death, every decision, every moment matters.

When Medicine’s Referees Make the Call

As I reflect on my father’s recent medical journey, I’m struck by how the actions and decisions of each doctor impacted his care and ultimately, his life. My father required a series of quick, expert judgments as his condition deteriorated, particularly involving his heart. Each biomarker, each diagnostic result, and every dosage change were like points on a scoreboard, indicating how his body was responding and whether his team of doctors was winning or losing.

Unfortunately, in his case, there were times when critical signs were missed, or treatment decisions fell short of what he needed. This wasn’t the first time I’d seen doctors challenged by complex cases or by the limitations of available data, but it was the first time I saw, firsthand, the irreversible consequence of these decisions. Watching his care unfold felt like being on the sidelines of a game where each decision was more important than the last.

In one of his final days, doctors weighed the necessity of invasive interventions and carefully monitored his heart and organ functions. In these moments, their expertise, speed, and precision could have saved his life. But a single oversight—an unobserved biomarker or a momentary delay in adjusting his treatment—proved to be a turning point.

Just like the countless replays of those missed calls in the game, I found myself replaying every treatment step taken for my father, examining each moment. These medical oversights left a lasting void in my family - a season[life] ending loss.

A Call for Accountability and Precision in All High-Stakes Fields

There’s a lesson to be drawn here for both professions. In sports, there are increasingly stringent reviews and protocols to minimize the effect of human error. The medical field, too, has begun to implement checks and balances, technology, and team-based decision-making to reduce the risk of critical oversights. But just as fans will always argue over missed calls in a game, we know that the human element in medicine will never be perfect.

My father’s treatment reminded me that, in both fields, accountability and the drive for continuous improvement are essential. Every missed signal or error should become an opportunity to learn and prevent similar outcomes for the next patient—or the next team. In a world where precision can save lives, we owe it to each other to make every decision count.

Coaches often say, “That’s just part of the game.” For the Bengals, there will always be another game, another season to make up for a loss. But in medicine, there’s no next season or second chance.

The impact is profoundly final.

As someone who is always looking for a better process, a more effective way to reach a goal, I am left with a hope that someday, the field of medicine can refine its systems to the point where we can simulate and test treatments quickly (LLM's that double as your virtual self), much like video assist in sports. Because while a game can always go on, a life cannot be replayed. In medicine, the stakes are immeasurably higher, and with each decision, the difference between winning and losing carries the weight of life itself.