I look sheepishly around at the rest of the students in our supervision group and pray that our clinical tutor isn’t going to go into any more detail. We all think he’s great, but, you know, there are limits.
“Everyone remembers the first time that they suggest a diagnosis that no-one else has thought about and it turns out to be right.”
Well, thank Christ for that.
Sweet Cherry Pie
My supervisor continued. “I remember seeing a patient in clinic for months with abdominal pain and no-one could work out why. One of my junior clinical fellows suggested we investigate for a parasitic worm infection in the gut, and you know what? She was right!”
I was told that several years ago now and despite now having passed my finals, I still wouldn’t say I’ve Popped my Diagnosis Cherry. I suppose the closest came during my foundation GP rotation.
Unlike rotations during your foundation training which take place in a hospital, you get to see patients all by yourself when you’re on GP. You run your own clinics, make your own plans and arrange to see them again to make sure that things are on the right track. On the wards, it’s rare that you make a suggestion that hasn’t already been considered by someone with much more experience than you.
Get It off Your Chest
So, I’m in my GP clinic and the next patient is a delightful middle-aged woman, who’s come in with her husband. She’s here because the chest infection she’s had for the past six weeks still hasn’t shifted despite the antibiotics she’s been prescribed and she’s wondering if she could try some more.
I’m sure there are plenty of people who would have heard her hacking cough and obliged without further ado, but being the diligent junior doctor that I am, I asked a few more questions. She’s been a smoker all her life and her mother died of lung cancer. I also manage to tease out the fact that she’s been losing a bit of weight over the past few months without even trying.
There are enough alarm bells ringing now that I think it sensible to arrange a chest X-ray. I explain to her that, in all likelihood, it won’t show anything exciting – but in all honesty, I’m not sure I believe that myself.
We have to debrief every patient that we see with one of the senior GPs, to make sure we haven’t ballsed anything up. Like referring someone to a skin specialist for an itchy arse (you can make referrals for itchy arses, but not straight away. But that’s a different story.) So, I tell him about my chest X-ray request and he’s ambivalent – it probably won’t show anything, you may have stoked the patient’s anxieties, if we sent every patient like that for a chest X-ray, and so on. He’s happy to keep the request though.
Good News / Bad News
The following week, I’m sitting at my computer. A pop-up message appears from the duty doctor, who is tasked with looking through all the results from the blood tests and scans ordered by the practice, to make sure that none of them need urgent actioning.
“Do you remember that woman you sent for a chest X-ray the other week?”, the message reads. “Well, she had it today and it’s come up as a cancer alert. She’ll need a CT scan and a two-week wait referral to the chest team. Good spot!”
I slump back in my overly-squeaky chair and put my hands behind my head. Huh. I guess that was sort of my “first time”. I mean, not really, because I’m sure most people would have made the same call as I did and I hardly spotted a curveball diagnosis. But nevertheless, it felt bizarrely satisfying.
I notice that I’ve only read half the message. The second part reads: “She’s also booked in to see you again once she’s had the CT scan.”
Ah. My moment of glory is short-lived. I’m not afraid of seeing her again, far from it. We got on really well and I imagine she’ll be very grateful to me for what I did. It’s just that I’ve had a sudden realisation about a fundamental part of what it means to be a doctor.
When we go through the process of applying for medical school, we’re all told the one thing not to say if asked why we want to become a doctor: “Because I want to help people.” I think part of the reason is because it’s true for everyone, and also because if it was the sole reason, then why not become a nurse or a social worker?
The real reason most want to do medicine is because, at the heart of it, it’s interesting. And healthy people aren’t interesting. In fact, the more serious or complex the illness, the more interesting we tend to find it. The problem is, the more serious or complex the illness is, the more devastating it is likely to be for the patient.
So I am struck by a dichotomy. It is impossible to truly, deeply wish the absolute best for our patients without sacrificing the interesting cases and the sense of personal triumph whenever we are proved right. If everyone in the world remained entirely, impossibly healthy throughout their lives before dying suddenly in their sleep, then we would all be out of a job.
I am looking forward to seeing this woman again. But part of me wants to thrust my hands in the air and exclaim “I was right!”, even though what I will say to her is that “I wish I wasn’t.” Is it possible to believe both?
So near, and yet…
I see her again the following week. Before she comes in, I have a look at the CT report: “Negative for lung cancer. Likely infective cause.”
She’s feeling much better and has already been told the results of the scan by the hospital. She thanks me and I wish her all the best for the future.
I guess I’ll to wait a little bit longer before I get the answer that I’m looking for.