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I was intrigued recently by the reaction of one of my colleagues to a CT pulmonary angiogram report for one of her patients. She was delighted to find that he had a pulmonary embolism.
Of course, it’s not that she had wanted him to have a clot on his lung, but she had suspected it might be there, and she was pleased to be right.
When I pointed out how this could be misconstrued, she was immediately rather embarrassed. But we all do it.
As medical students and doctors we are selected and trained to be competitive and analytical, and we like to get things right. There is a reason for this, and although it might occasionally come across as callous or unempathetic, it can be a force for good.
This patient’s initial working diagnosis had been pneumonia, but the doctor had re-examined the pieces of the clinical picture and come up with a different theory.
The patient had been on the verge of a dismissal home with some inappropriate oral antibiotics. Now he would get worse news, but the right treatment.
I remember once finding myself gratified to find an abnormality on the CT brain of a man in his fifties who had presented to A&E with a first episode of psychosis and a recent seizure. I thought there could be an organic explanation, so I had stuck to my position and refused admission under psychiatry until the scan was done, and I felt vindicated.
I knew it was good that the patient would be looked after in the right place, and get the appropriate investigations and treatment, but if I’m honest, I was also pleased because I had got it right.
It was a slightly guilt-tinged feeling, because I knew for the patient there would probably be bad news. I had taken an extensive personal and social history and I could imagine the other members of his family, his workmates, his children, and how they might be affected too. But feeling sympathy for them didn’t stop me experiencing that modicum of satisfaction. It’s possible to feel both things at once.
Medicine is an intellectual pursuit. As well as being a human being in distress, to a doctor every patient is also a ‘case’, a clinical puzzle to be solved. Getting it right not only allows us to give the patient the appropriate treatment, it’s inherently satisfying. That’s just human psychology, and it provides positive reinforcement that’s a vital part of the learning process.
It is always salutary to remember that what may be a small intellectual victory for us can have profound and devastating consequences for the patient - for medical professionals, empathy is essential; but, I would argue, getting it right is important too.
It's natural to be pleased when you're right... but do you also have that guilty feeling when it's bad news for your patient?
Use the comments section below, and talk to and about the Secret Doctor on Twitter.
Being proved right, even when the diagnosis is not a good one, can be a source of satisfaction to both the doctor and patient if the journey towards that diagnosis has been a shared one; doctor has the intellectual kudos and patient has confirmation that they were correct all along "I knew there was something not right with me"
As a GP I can recall many cases where patients were investigated, referred and reassured but kept returning with symptoms which I agreed were genuine we persisted in a joint endeavour and with some repeated tests and further referrals (I do miss the General Physician who used to do this job of digging until diagnosis found - now it is GP who has to keep looking and try to identify which microspecialism to refer to next!) we would eventually reach the diagnosis - unfortunately in some cases this would be an occult carcinoma or Lupus.
The shared journey however did reinforce the doctor/patient relationship and also gave the patient an understanding of the 'grey' nature of much of medicine in primary care, where time, persistence and observation are significant tools in achieving the diagnosis.
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