“Dance with the one who brought you.” This phrase was attributed to an iconic college coach. There have been lots of interpretations of this comment, but the coach basically said that when the big game is on the line, when the championship is at stake, you do not tinker with your personnel and your coaching strategy.
Stick with the basics that brought you to this point in the season.
Throughout our careers, whether we are a butcher, baker, surgeon, or oncologist, we have transcendent experiences that we never forget. In our medical environment, medical students and interns rotate through subspecialties for several months throughout their training.
I recall one lesson learned on a bitterly cold Christmas Eve.
I was on the neurology service with a neurology professor who was revered for his clinical skills. He did not write many papers and was not an invited speaker at national meetings, but he was the go-to detective when there were tough diagnostic cases.
The call came from the emergency room late that day. I responded to the attending physician, who described what he believed to be a case of ALS—that devastating neurologic disease with an average survival of approximately one year. Patients essentially lose muscle functioning, and some develop difficulty swallowing and breathing.
The patient was promptly admitted to our internal medicine service. I observed this gentleman in his early fifties with muscle wasting of his shoulders, garbled speech, and weight loss since swallowing was difficult. I examined the patient with my primitive neurologic skills at that time, and indeed his upper extremity muscles were weakened. Indeed, he had lost several pounds, and his speech was barely intelligible.
Following our usual practice, the attending neurologist came on board, and I went over the case with him. He respectfully listened, went to the bedside, took a careful history, and performed a meticulous neurologic examination. I keenly followed his repertoire, and I was intrigued when he put on an examination glove and gently and respectfully palpated the patient’s tongue and gingerly pressed to the back of the tongue.
He then excused himself from the bedside, and we found a quiet room where he explained his findings. He politely said, “This is not ALS. This patient has a potentially curable cancer at the base of the tongue.”
I then asked the consultant about the upper extremity shoulder wasting, and he chided me, “If you had taken a careful history, you would’ve known that the patient was a carpenter, and for several weeks he was putting in a ceiling. He developed a kind of arthritis of his shoulders.”
The patient underwent a number of examinations and evaluations, and indeed a biopsy-proven cancer at the base of the tongue was excised. He was given hope.
What is the lesson?
We are now being battered, bludgeoned, and overwhelmed with a tsunami of information about artificial intelligence and the issue of medicine being replaced by bots. But at the end of the day, what each patient seeks is a compassionate, thorough health care professional who genuinely cares about us and goes back to the basics of a thorough, hands-on history and physical.
We danced with the one who had brought us when we went to the big dance. Her name is history, physical examination, and review of pertinent medical testing and imaging.
Edward T. Creagan is a hematology-oncology physician.
