“And who has sent you to me?”
Working as a private consulting pulmonologist in a healthcare system where referral letters are virtually nonexistent, I always ask new patients to tell me who sent them—a social engagement routine before we get into purely medical matters. It works as an informal survey of the people who visit my office, giving me an idea of how they get to know me and, occasionally, providing the encouraging message that someone had formed a favorable opinion about my work and had taken the trouble to pass this opinion to others.
The man facing me across the desk had not booked an appointment: he just turned up on my doorstep. “I picked your name from the Yellow Pages,” he said. “I have been getting breathless for quite a while now, and I smoke a lot, so I thought I’d better see a chest doctor.”
Varied are the ways in which we get to meet people in our trade. Why should he choose me out of a number of specialists listed in the book? Is there some reason behind such a choice? Anyway, here he was, and I would not be the one to question his motives. History, physical examination and spirometry disclosed moderate airways obstruction, so I gave him an appropriate inhaler (and the even more appropriate smoking cessation advice) and a further appointment to check on his response to treatment. There was nothing to suggest that he needed additional investigation; however, perhaps affected by his recurrent worried mention that he smoked too much, or maybe driven by clinical intuition or divine inspiration, I sent him for a chest film. Half an hour later, the mass at the top of the left lung came as a nasty shock for both of us.
Within moments, our “blind date” transformed into an intimate life-and-death relationship: I, a doctor picked randomly out of the Yellow Pages, had to become an angel of bad tidings and announce to this man I barely knew that his life horizon was critically restricted. The courtesy plural I had been using in our discussion was almost automatically replaced by a friendly singular and a first name. He had come unaccompanied. Within a brief clinical encounter, I had to take him by the hand, like a child, to find out whether he had a next of kin for support (he had none) and irrevocably relocate him from the land of the apparently healthy to the domain of cancer sufferers. I had to lead him through a medical maze in which various blood tests, computed scans, and a bronchoscopy lurked like so many beasts, each of them threatening to rob him of his chance of a cure. And I had to do all these things without losing valuable time.
Fortunately, my patient found the strength to run the gauntlet without difficulty—or so it appeared. He gave up smoking, and within a couple of weeks his lung function improved. His staging investigations were favorable, so he went on to have radical surgery. When I met him again a couple of months later, he was symptom free and in good general health. The postoperative pathology report was encouraging. His outlook remained positive: he continued with his inhalers, and he was soon due for a follow-up scan at the hospital. I wished him the very best, with all my heart.
However, lung cancer is a wily rogue. Three weeks later, the scan showed that his lungs and abdomen were full of metastases. He showed no panic, no hysteria, but a stoic acceptance—or was it shell shock from this new thunderbolt? Once again, I resumed my familiar role as the angel of doom. I took him through the remaining management options. Chemotherapy appeared like a one-way street, though in my experience it was more likely a blind alley for Stage IV disease. I could not bear to break this kind of information to him. The hospital he was attending had already arranged for the oncologists to take over his care.
I had no further news from my patient. Whenever I came across his file, I wondered how he was faring with his treatment. Time and workload constraints, a summer absence, some painful patient deaths, and a reluctance to get involved in yet another emotionally charged situation all conspired to prevent me from picking up the phone to find out. Finally, one day I rang up the hospital to check on another patient and asked my oncologist friend about this man. He did not know him, but as he echoed his name for confirmation over the line I heard another colleague in his office saying, “This man died in September.”
My patient passed away shortly before turning sixty, exactly six months after the day of his diagnosis: the day that he himself chose for his “blind date” with a strange doctor, to whom he unknowingly assigned the sad privilege to predict the likely cause of his death and tell him, with a chill in his own heart, that the sand in his hourglass was running out fast.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School in 1981. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, specializing in pulmonary medicine. He also holds a postgraduate diploma in palliative medicine from the University of Cardiff, Wales, United Kingdom. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece.