He did a double-take as we passed on our small town sidewalk the other day.
“Hey Doc, I didn’t recognize you dressed like that, without your …”, he gestured to where my tie or stethoscope would have been. I was wearing a cafe-au-lait colored T-shirt and faded Levis.
“Did you hear about the appointment with the cardiologist yet,” I asked.
“It’s in two weeks,” he answered. “Tell me, Doc, how serious is this murmur?”
“Right now, not very, but you could end up needing a valve job someday, so you’ll need to have another echo done through your esophagus so they can get a better look at that noisy valve and then regular follow-ups”, noting silently to myself and I’ll never know how you make out now that I’m handing over your care to one of my partners.
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He started thanking me for being his doctor for so many years, through so many illnesses, both life-threatening final diagnoses and mere scares we had worked our way through.
Two years ago, almost to the day, I had a hunch that he might have a malignant kidney tumor, based on some nonspecific symptoms and an extremely elevated sedimentation rate.
In the end, he had something a bit less serious, and I was more relieved at him not having cancer than embarrassed about my inaccurate clinical hunch.
This time, he had been in for a routine checkup, and as I listened to his heart, I heard something new. He had a distinct early diastolic murmur. Soft systolic murmurs, between the first and second heart sounds, are dime-a-dozen, but diastolic ones are fairly rare, and his was fairly loud – what I ballparked as a 2-3/6 (more than a third of the maximum volume imaginable).
Systolic murmurs sound like Bipzzzt-Bip; diastolic ones sound like Bip-Bipzzzt. The diastolic murmur I knew the most about but haven’t diagnosed very often is mitral stenosis, usually caused by rheumatic fever. My patient had never had that as far as I knew, and he had no symptoms of heart failure. I sent him for an echo, and I got a call from the cardiologist who read it, praising me for my “excellent pick-up” of the murmur, which on the transthoracic echo indeed looked like at least a moderate if not severe mitral stenosis.
Being praised for my auscultation skills was nice, but I wasn’t pleased that my patient could be facing heart surgery in just a few years.
Early in our careers, doctors have a tendency to triumph over serious or rare diagnoses we make as we marvel over our newfound skills and the logical complexity of the human body.
At this stage of mine, I often feel sadness when a patient I care for, and care about, develops a symptom that signals the possibility of a serious disease.
If the diagnosis I think they might have is easily treatable with a good prognosis, I can triumph over my clinical hunches and diagnostic acumen. But if it is not, how can I feel proud about my skill at recognizing the distant footsteps of the grim reaper?
Hans Duvefelt is a family physician who blogs at A Country Doctor Writes: and the author of A Country Doctor Writes: CONDITIONS: Diseases and Other Life Circumstances.
Image credit: Shutterstock.com
