|Photo by Anthony Papagiannis
Physicians learn about chronic disease by watching its natural history and attempting to modify it with therapies. Cardiologists record episodes of ischemic disease, oncologists follow the progression of malignancies, and pulmonologists note changes in respiratory function over time. When patients are first seen, the disease is often already established. It is less common to document a condition from its first onset.
I had an opportunity to do this recently, when I received a phone call from a woman who wanted an appointment. Her name was familiar; in the distant past I had looked after her father and uncle, both long dead, and her husband, a colleague in another specialty, sometimes refers patients to me. I did have an old record for the woman herself: it was one of the oldest entries in my practice registry, dating back more than twenty years. She had been a medical resident then and consulted me for an episode of chest infection. She was a forty-a-day smoker, and I had given her the usual strong advice to quit. She had come back five years later with another infection, the pack of cigarettes still in her handbag. I offered the same treatment and strong advice, as she now had spirometric evidence of early airway obstruction. Now, eighteen years later, she wanted to see me again.
The next day she called in with her husband. She had been increasingly breathless with daily activities, and had required antibiotics for frequent bouts of bronchitis. She had used an inhaler with no obvious benefit, and was concerned about a recent chest film that mentioned bronchiectasis. She still smoked, had a prominent expiratory wheeze, and her spirometry now showed severe obstruction, a significant progression from years ago. I had to tell her in no uncertain terms that she now had established COPD.
Some physicians believe in browbeating patients in an attempt to convey the gravity of their predicament. I try to take them into my confidence, explain their condition, and suggest things that can be done to improve their health. I do not want them to feel that the situation is desperate; they must understand that there is (usually) a margin for improvement, but they will have to help themselves in order to achieve it. This woman, a doctor herself, understood airflow obstruction and flow-volume curves and the course of this disease with and without treatment. I gave her a short refresher lecture, pointing out the marked decline in her lung function over the years. Not for the first time my old hand-written clinical notes proved invaluable: a visual comparison of the two loops spoke for itself. We tackled the question of management: I reassured her that all was not lost, and that we would have to see the effect of treatment before assigning her to a severity class. I again stressed the importance of quitting smoking for good, adding that all this could have been avoided if she had taken that decisive step twenty years ago.
A few days later she was back with the results of her tests. She told me she was already feeling better. It may have been that her inhaler technique had not been good before, but smokers also frequently report an immediate subjective improvement when they first quit cigarettes. I encouraged and reassured her, but kept repeat spirometry in reserve for a couple of weeks: better to give her some time to fully digest her situation, and also allow the medicines to work adequately before assessing a maximum response. That would be the real morale booster, and it is one worth waiting for. It may also reduce the risk of relapse.
It is an unfortunate fact that people rarely seem to understand the natural history of a disease until it is almost too late for them. Perhaps that natural history should be used as an educational tool more frequently in the early stages of disease, when the prospect for primary prevention is much better. Such cases would be excellent teaching material, even for some of our colleagues.
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 at the University of Thessaly, Larissa, Greece. He also edits the journal of the Thessaloniki Medical Association, and blogs regularly.