|Sunset in Halkidiki, Greece, Fall 2019. Photo by Anthony Papagiannis.|
Working in specialist medical practice one is familiar with the spectrum of clinical problems likely to appear in one’s regular professional menu. However, it is common knowledge that unexpected situations do occur: the human body and being is complex and unpredictable, organ systems work interdependently and not in isolation, and we must keep our wide-angle lens constantly open so that we will not miss something significant in the periphery of our main focus. Let me expand on that.
A previously healthy elderly man consulted me for a respiratory problem of recent onset and an abnormal lung scan. He was otherwise well, with no limitation to his daily routines. As I clipped the oximeter probe on his index finger I noticed a pulse rate of 38 with normal oxygen saturation. I palpated his arteries, listened to the heart, and counted his rates in the traditional way: all readings were below forty per minute, and a subsequent EKG confirmed the suspicion of complete heart block. I explained to the patient that the priorities had changed: insertion of a pacemaker was in order before further investigation of his lung problem could be pursued. He looked astonished. “I am quite well. Why should I have it?” was his not-so-unreasonable reaction.
Every so often we find ourselves in similar situations. A visit to the doctor for some other reason brings to light an unrelated and totally unsuspected problem, which may require urgent and possibly invasive action. Rarely if ever is the patient prepared for the “surprise gift” we have to spring upon him or her. The lack of relevant symptoms makes the patient incredulous, even suspicious of our motives. It takes time and adequate explanation for the fact to sink in, and communication skills may be put to the test during such an encounter. Denial may prevail, and the discussion may have to be repeated at a later time, if the circumstances allow it. A second opinion, if required, should be encouraged. Above all, the facts will have to be offered honestly, without undue and threatening enhancement or obfuscation: not for a moment must the patient feel that he or she is being cajoled or blackmailed to follow a specific course.
In the case described above things went well. The patient’s daughter was a doctor: she readily grasped the situation in its real dimensions, and her advocacy helped to consolidate the message. The patient himself checked his own pulses repeatedly, and realized that they tended to drop to quite low figures, so he turned up at the hospital the next day and had the pacemaker inserted.
Perhaps the best argument in such situations is that all of us, doctors included, have no idea what we may be carrying around in our bodies. It will befall somebody else to detect it someday, perhaps accidentally, and inform us about it. This universal reality should be explained to our patients as a reminder of our common vulnerable human nature. Diseases do not discriminate by profession or social class, and their limitations are only dictated by their own nature and epidemiology. In this light the Boy Scout motto “Be prepared” applies also to the practice of clinical medicine.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He graduated from the Aristotle University of Thessaloniki Medical School. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, and specialized 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. He also edits the journal of the Thessaloniki Medical Association, and blogs regularly.