Tales from the office

Murray and Esther

For a 73-year-old retired man, Murray looked great. The first time I met him, I noted a thin and spry graying man on my exam room table who waiting excitedly for his yearly physical. And his attentive wife sat on a chair right beside him.

That was the norm for my practice. My patient population contained a large contingent of retired Jewish couples who had lived in the same apartment for most of their lives. They seemed to do everything together, including accompanying each other to doctor visits. They usually had cute behaviors and communication styles that expressed complete intimacy and shared understanding. And they tended to be very healthy. In general, studies show that married people typically have better health than singles. In this case, it was because of a doting and demanding wife who dragged her husband to my office for routine check-ups.

At the time of this appointment, I had only been at the clinic for six months. I was the young, new doctor replacing the old, retiring physician. As a new doctor, I could be perceived as an asset or a liability. I may know all the latest guidelines for diagnosing and treating illness, but I lacked any sort of experience or wisdom that accrues with time.

Murray and Esther chose to believe that I was an asset. Esther brought Murray to my office for a fresh look at his health. She was sure I could find problems that the previous doctor, in his haste, had overlooked.

Most non-medical people don’t realize, however, that routine physical exams are very low-yield instruments. As doctors, we rarely find any new or important diseases with a “screening” exam. In fact, statistically it’s essentially useless. Almost all patient problems are “symptom based,” meaning that the patient notices a new problem and comes in to have it evaluated. In that case, a doctor can frequently find something. But the reality is, in an asymptomatic person, the most important part of the visit is ordering a handful of age-appropriate screening tests (blood pressure check, pap smears, mammograms, colonoscopies, blood tests for cholesterol and sugar) and asking some relevant screening questions (smoking, alcohol, drug use, depression). Truth be told, as a screening test for disease, a physical exam is unhelpful. It’s sometimes even damaging. But it’s a show that patients want us to perform.

Imagine this scenario: You feel well and go to your doctor’s office for your yearly physical. The nurse takes your blood pressure. The doctor asks you many relevant questions about your health, your family history, your personal history of disease, and your lifestyle. Then your doctor counsels you on how you can live better. Your doctor subsequently leaves without even touching you. The nurse returns to the room, maybe draws some blood, gives you referrals for appropriate screening tests, then tells you that you’re done. How would you feel about the experience? You would probably think your doctor is lazy, a quack, or uncaring. You would probably never return to her office. In all reality, however, if you have no medical symptoms, that’s all you need from the visit.

But, as doctors, we play the role that people expect. We end up performing a fruitless exam on the patient simply to make the person feel better. That’s what people want. And it’s no use talking a patient out of it. “The more the better” is the sad, thoughtless adage of our age.

So, after I asked Murray extensive questions about his health history, I performed the expected exam. To my surprise, I actually found something. While examining his abdomen, I palpated a throbbing mass. It was an abdominal aneurism. And it was big. An aneurism refers to a blood vessel that develops weakness in its wall. And, over the course of years, that blood vessel wall starts ballooning outward. The stretching of the wall makes it thin and pressured. Under the wrong circumstances, the blood vessel wall finally pops, and blood starts leaking into the surrounding tissue. If the blood vessel is large enough, a person can bleed to death internally and die in a matter of minutes.

I was a hero. On my exam I found a problem that put Murray’s life at risk. And the problem could be fixed. The aneurism I discovered in Murray had certainly been there for years and Murray’s previous doctors had never found it. Murray and Esther were understandably concerned when I told them what I found. But they thanked me profusely for having discovered a potentially life-threatening problem that had a solution.

The next week was a blur. I sent Murray to have the aneurism measured by ultrasound. It was large and had a substantial risk of rupture. He quickly saw a vascular surgeon who recommended an operation to correct it. Murray and Esther consented to the immediate surgery. During the operation Murray died of a known, but rare, complication.

The situation was tragic. Murray was dead. Esther was a widow.

I realized that I had played a major role in this tragedy. I started to ask myself the obvious questions: What if Murray had never come to me? Does his wife regret bringing him to my office? Would another doctor have found the aneurysm? If I hadn’t discovered the aneurism, would Murray have lived another twenty years anyway? Should patients really have physical exams when they’re asymptomatic? Did I directly cause a patient’s death? Did I live up to the oath of “do no harm”?

After Murray’s death, Esther continued to come to me as a patient. I treated her during her bereavement. The years passed and the grief slowly faded. She has her own host of medical problems. When I see her now, we rarely speak about Murray. But during each visit I sense that we share a connecting bond of unspoken second guesses and what ifs.

9 responses to “Tales from the office”

  1. aw says:

    You write so sensitively about your patients and so self-reflectively about your own practice. I wish more physicians did this. I have too many colleagues who would not think twice about the experience you describe. They would figure the guy would have eventually died anyway–and probably quote the statistic that ruptured aortic aneurysms have a 50% mortality rate when they make it to surgery so the aneurysm would likely have killed him, eventually, anyway.

    I empathize with the burden of wondering “what if?” In medicine you have this weird experience of intervening at a key moment in someone’s life and then wondering–or knowing–what happened because of your intervention. It is very humbling. At least Esther has a physician who acknowledges this. I suspect this has something to do with why she still sees you. Thanks for the post.

  2. Lane says:

    Incredible, moving, interesting, very sad and strange.

    Oddly I went for an exam two weeks ago. “The ‘annual’ check up” thing, which hadn’t been done for years. It is odd to have a doctor look for something when you don’t think there’s anything wrong.

    Very interesting post.

  3. bryan says:

    ditto, cedric. i love these posts. they stick to my brain for the rest of the week. i’ve missed them while you’ve been away.

  4. Rachel says:

    Hi, Cedric! I, too, love your posts, and your compassion and expertise make me want you for my own doctor.

    Still, Murray’s fate is one of my worst fears, and it makes me terrified of doctors in general. What could be worse than feeling great, going in for a checkup, and learning you have a terrible disease/need immediate surgery/will probably die soon? Even though it’s irrational, most people would rather stay ignorant and eventually drop dead none the wiser.

  5. Marleyfan says:

    Just Monday, I was wondering when ole’ “Doc” would be posting again. You should think about collectingl your stories, eventually compiling them into a book, it would work! Anyway, I turn the 40 in a couple weeks. With an extensive family history of prostate cancer, my doctor has told that I need to schedule my P.S.A. and “the” finger exam now (most men start getting them at 50); I can’t wait.

    Thanks for providing an ardent post.

  6. Scott says:

    It must be so difficult to have such a direct influence on lives the way you do.

    My non-medical opinion is that you did the right thing for Murry. It is incredibly sad that things worked out for him the way they did, but as any professional, you only have the tools available to you with which to work. You saw a real problem and dealt with it the way you were trained. You did the best you could.

    Your afterthoughts and questions are what make you so darn special. You would be an asset to any profession.

  7. MCL says:

    I always enjoy your posts, Cedric, and this one was particularly well-written, fascinating, and moving. Thank you.

  8. Stephanie Wells says:

    Everybody has said it already, but I must echo and re-echo how incredibly poignant your columns are, Every Single Time. Again I urge you to publish them in a book (you listening, Mr. LIterary Agent Wager?). The ethical wrestling you do in every column–maybe even every day–is riveting, and always so sensitively told. Thanks, again.

  9. Jeremy Zitter says:

    Me too. As sad as this scenario is, I’m so heartened by your compassion and insight. And I feel fortunate to know such a person as you, Cedric.

    (And I agree with everyone else. See above. Ditto.)