Interesting

I pull up a test result for my patient, and the senior resident standing behind me lets out an excited squeal.

“I’ve never seen the imaging come back positive for this,” she says.  Our two-week-old infant, who already has a rare infection, also has a rare associated structural abnormality.  It’s not benign, but it is fixable.  The fix usually requires surgery.

As we walk over to the patient’s room to update her mother, my senior gushes about the zebra that was uncovered on the ultrasound.  She asks me if I’m excited.   “I dunno,” I mutter, which is somewhat more diplomatic than my discomfort that she is.  ”Her kid has to get surgery now.”

But in the room, the resident says all the right things to the patient’s mother, with the right amount of explanation, reassurance, clarity, and tone.  She shuts the door and looks at me, finally, in sad contemplation.  ”Let’s give her a bit.  I think she’s going to cry now.”

Since I work at a well-known teaching hospital, we get referred many cases you only hear about in textbooks.  Perhaps I’ve gotten spoiled: on my first day I picked up a teenage patient with a chronic disease with an incidence of 1 in 200,000.  Yet it wasn’t until my third week that I saw my first child with asthma–a condition that is 20,000 times more common.  A resident with four years of practice, meanwhile, has treated thousands of asthmatics, thousands of stomach viruses, and thousands of strep throats.  Seeing something for the first time in years must trigger that flurry of novelty that I still get on a nearly daily basis.

This rationalization does nothing to quell my unease that a doctor’s initial reaction to an unusual and undesirable test result was happiness.

Excitement about anomalies crops up in different ways.  Recently, a resident reported being “obsessed” with a patient’s cough.  He took a thorough history and physical exam, scoured the literature, wracked his brain.  He wanted the cough to be tuberculosis.  He tried to make the pieces fit the diagnosis, but they weren’t quite the right shape.

Why the desire for the cough to be more than just a cough?  Cinching an esoteric diagnosis is fulfilling.  If it is a dangerous but treatable disease like tuberculosis, then I imagine it is even more fulfilling.  In this case, perhaps obsession drives better patient care.  In fact, there is a school of thought that the best doctors are the most curious ones, and I don’t disagree.

But the conflict remains.  Do we wish an interesting tragedy on a patient over no tragedy at all?

“To be a doctor you have to be aroused by sickness,” my classmate told me.  I felt the unease creep up again.  ”I’m aroused by making sick people better, not by the sicknesses themselves,” I shot back, sounding a bit more confident than I felt.

My 1-in-200,000 patient had infected lungs.  With what, we weren’t sure.  We took his chest x-ray to a radiologist.  The diagnosis was inconclusive.  ”It’s an interesting case,” the radiologist said, looking thoughtful.  I thought about the interesting lungs belonging to the interesting patient.  He was upstairs playing Wii, unaware of just how darn interesting he was.

Can I simultaneously be fascinated by sickness and also wish it didn’t exist?

On one of my first days on surgery, I was stitching up a patient’s abdomen when I felt a sharp twinge in my finger.  I peeled off my gloves and saw a drop of blood that wasn’t the patient’s.   I uttered a few choice words under my breath, scrubbed my hands like Lady Macbeth, and went to the emergency room.

The chances of someone having HIV are 1 in 200.  The chances of contracting HIV via a needlestick are 1 in 300.  As of today, there is not a single documented case of HIV transmission using the particular needle I did.  If I get it, I would be really interesting.

I wonder if somewhere out there a doctor’s subconscious is rooting for the zebra that could kill me.

Note: Minor patient details have been changed to preserve anonymity.

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13 Responses to Interesting

  1. Jamie says:

    Have a chat with a policeman or two about this. I think you’ll find some common ground. A cop friend used to talk about “excitement” on the beat and the tendency for more cops to arrive on a scene than necessary just due to the “interesting” development.

  2. Kevin says:

    If it hasn’t started happening already, I’m guessing that the first crop of medical students that were inspired by the TV show “House” will be graduating soon. That show is is built around the idea of medical mysteries, and its hero embodies the questions you raise in this post. He cares only about the puzzle, and doesn’t give a crap about the patients.

    I wonder if any of these freshly minted MD’s will hold that character up as a role model, and will be disappointed when they come face to face with reality.

  3. Several years ago my Dad was the one patient in 200 who recovers from a perforated ulcer without surgery. (The doctor in charge waited until Dad was about to be released from the hospital to tell us.) It doesn’t hold a candle to 1 in 200,000 but it was interesting enough at the time.

    Last year, in order to repair severe blockage in the arteries of his left leg, Dad had a “bypass”–which, when we inquired a little more, turned out to be a tube of GoreTex running from near his heart to a few inches above his ankle. It’s outside his rib cage, so I can run my fingers along it.

    Thanks to that tube, Dad kept his leg and foot, but lost the three small toes. Gangrene had taken hold before the surgery. It led me to examine more closely how humans walk. (Aside: It’s very difficult for a person with a full complement of toes to try walking with only the two big ones.) Subsequent anecdotal evidence shows it’s not difficult to walk with only those two toes, but lateral movement can be a little unsteady.

    I’ve mostly kept this to myself until now. Sonogram technicians seem uncomfortable when I peek over their shoulders while they’re examining Dad’s leg. Even doctors were sometimes taken aback when I asked questions about Dad’s condition without (dare I say it?) the expected womanly tears.

    Yes, I was very worried at first. I was afraid Dad might lose a foot or part of his leg. I was afraid he might even die (he was 83 and this was an ordeal). Worst, I was afraid that whatever happened might not ease the terrible pain he was in before he was admitted to the hospital. We were lucky and got the best possible outcome I could have imagined.

    Knowing what was happening helped me (and Dad), but I’ll be the first to admit that not every patient or family member would feel the same. Some would rather not know. Maybe most. I’m geeky, though not a specialist of any sort. My parents encouraged my natural curiosity as a child and it paid off when Dad was hospitalized.

    Perhaps if I’d introduced myself to every hospital staffer I met by saying, “I’m his daughter, Karen. I used to work in the IT department for the American Red Cross Disaster Services,” it might have made more sense to them. I’ve had similar discussions with emergency responders: we’d be very happy if there were no more disasters but, knowing there will be, we want to be ready to do something when the need arises.

    I suspect that one of the key things any medical student needs to learn is how to “feel out” patients and their relatives to assess their comfort level in discussing details. Some of us are comforted by having as much information as possible; others not. That is the sweet spot, the difference between scaring a family out of their wits or leaving them to worry unnecessarily about all the things the doctors have already ruled out, the difference between understanding and fear.

  4. Knom says:

    I couldn’t blame you or any individual for queasiness under such circumstances. However, just because you or even a vast majority (myself included) would be similarly queasy, doesn’t mean there isn’t a greater purpose behind that apparently morbid fascination. I saw a documentary about the pioneers of heart surgery, where week after week, five patients per week, they were left with a single surviving patient after a good week. Was it a morbid curiosity that kept them going? Where would we be now without whatever drove them to continue? Human nature being what it is, let those with the morbid curiosities go where it takes them, if they are not committing any basic evil and are truly helping those they serve; directly, and indirectly for generations.

  5. Shara Yurkiewicz says:

    Thanks for the comments. Just fyi, I appreciate all input, including disagreement. I think there is a wide spectrum of opinion on this one.

  6. Nancy says:

    I’ve been a nurse for over 20 years, and I want the doctor who finds the zebras delightfully interesting, provided they take good care of the horses, too.

  7. JJ says:

    Speaking as the mother of a son with a fairly major 1 in 10,000 illness: I want the doctor who is incredibly interested in the zebras as I think it must help in their drive to understand and treat the illness. I love the way Nancy put it; it’s that exactly.

    But I completely understand your reaction to it, too. I’d actually be very interested to know if your reaction changes as you get more experience – if you’re more able to separate the illness from the patient, I suppose.

    I’d be happy that both of you were treating my son, you both sound lovely.

  8. John Burson MD says:

    Sounds like you might have been better suited to be, say, an accountant?

  9. Shara Yurkiewicz says:

    Thank you for the anecdotes; I appreciate reading and thinking about them. I’d like to reiterate that I do think there is a difference in being interested in someone already who has a very rare disease vs. waiting for test results in an otherwise healthy person and rooting for them to have something interesting (and being happy when they do). I currently do the former but not the latter. Perhaps my mindset will change as I gain more experience.

    @John Burson MD: I’m allowed to trash comments as I please, but I decided to leave yours up just to show that there are doctors out there who prefer snark to genuine conversation. It is particularly odd considering I’m a medical student who is open to having her mind changed, and you are an established doctor in a position to change it, yet you choose to insult me rather than engage me. I imagine that encountering this attitude in the hospital from superiors plays in a role in why doctors-in-training become burnt out and jaded.

  10. Elle says:

    I want the doctor that’s intensely curious about the zebras, knows to keep an eye out for them, and always hopes they turn out to be horses. You sound like that might be you. I appreciate the humility.

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  12. David S. Goldfarb MD says:

    Shara, I enjoy your posts and selection of entertaining quotes, and that video that explains homeopathy…that homeopathic lager…nice. Medicine is very repetitive…I’ve seen some of the zebras 100 times. But if you’re “curious” as you put it, then you’ll never actually understand anything you see and can actually think every “case” is interesting. What the hell is chronic kidney disease? Will this person’s CKD progress or not? Where in the kidneys do stones form and why do they only happen in a few of a few hundred thousand nephrons? What is chronic allograft rejection and is it happening today or it this something else? Why is this dialysis patient having an MI? If you squint, they’re all horses with stripes. And you can look that way for a really long time.

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