A gut feeling

November 14, 2018
Ingrid A. Carlson, MD

Medical Economics Journal, November 25, 2018 edition , Volume 95, Issue 22

2018 Physician Writing Contest Runner-up

Good morning. Listen up!” All eyes focus on the stocky chief resident as he balances a paper coffee cup on a towering stack of charts. He scans his fresh crop of third-year medical students and quickly targets the weakest among us.

“Sheppard!” Adam Sheppard is a gentle giant who wants to become a pediatrician.

“Yes?”

“Bed 309 is a regular customer. He’s a 70-year-old alcoholic who was re-admitted last night. What do you see?” Overhead we gaze at an X-ray of the abdomen.

Adam answers, “Bowel obstruction?”

“Good guess.” Student, one point. Resident, zero. Game on. General surgery in 1989 is all about toughing it out, proving yourself, and when abruptly called upon, spewing out the right answers. I made sure like everyone else to spew out the right answers.

We stop in front of the next room. “Engel!”

“Yes?”

“This lovely lady in bed 311 was sent to us this morning from our friends downstairs,” he adopts a falsetto, “in Psychiatry.” Then he slaps a chest X-ray up on the light board. “Diagnosis, please.” I have never seen anything like it. Neither has my fellow student, Marvin Engel.

Meticulous, punctual, and always in the front row, Marvin is enthusiastic about forensic pathology. This should be right up his alley. He carefully crafts each word.

“There appear to be multiple radio-opaque foreign ­bodies…”

“Yes, and?”

“They are located in sub-dermal fat.”

“And?”

Marvin has no clue. Resident one point. Student zero.

“Today you will have the opportunity to assist in surgery to remove the sewing needles our patient has imbedded into herself.” We march on.
 
“Carlson!”

“Here.”

“We know you are here, Carlson. Bed 313 is a young woman with ITP. What is ITP?”

“Idiopathic thrombotic pur…”

“Idiopathic thrombocytopenic purpura. Cytopenia. It means not enough cells, specifically platelets. She has been unresponsive to medication. She needs surgery. Can you tell us what surgery?” Everyone in the room feels the scoreboard is about to light up in favor of our resident. My throat clenches. Think.

“Something to do with her spleen?”

“Correct. Please consent her for surgery. You will be assisting in splenectomy tomorrow.”

That afternoon I enter her dimly lit room. An acrid odor of disinfectant hangs in the air. Glancing at the chart, I take in her name, Annabelle Sanders. She is 29. She’s my age? The short dark hair on the back of her neck is already starting to mat against a flat pillow. Her rounded face from chronic steroid use obscures once-delicate features. She stares blankly at the television.

“Hello Miss Sanders, I’m a medical student on your surgical team. We need to go over some paperwork.”

She replies to the television. “I don’t want surgery.”

“It’s OK.” I inch toward her. “Removing your spleen will stabilize your condition.”

“Removing my spleen will kill me.”

For a moment or two neither of us speak.

Stay upbeat. “Oh, I doubt that.” I say, forcing cheerfulness. “The chances of dying from surgery are small.” Deep purple blotches around her fingers make my own hands appear strangely too young. I wonder how much she is already suffering.

“You people can’t cut me up just because you want to!”

“We don’t want to. We, uh…” I pick up the remote and mute her television. She shoots me a menacing glance.

“You don’t get it, do you?”

“Miss Sanders, we want to do what is best for you.”

Annabelle pulls her knees up close to her chest. She searches me for allegiance. Then her voice drops to despair.

“Promise you won’t let me die?”

“Well I can’t, I mean we…” I begin to riffle through the pages of her chart looking for a rope hold, a life ring, any solid ground, but I am confronted only by the blank signature line of her informed consent. All the pride I have earned from pulling high scores on written exams seems instantly outstripped by her life experience. I muster a bit of feigned confidence. “You are in good hands. Don’t worry, you will be just fine.” But something feels wrong. “I’ll tell you what, maybe I’ll come back later?” I take a few steps toward the door. As if bargaining with fate itself, Annabelle pleads,

“Don’t let me die.”

I let the door swing closed.

Back in the doctor’s lounge, our chief resident is not amused. He is certain the patient in bed 313 with ITP simply enjoys creating her own little drama. With a firm grip on the sanctity of surgery, he teaches me how to obtain an informed consent. We return. He impresses upon our patient the importance of her decision. He outlines for her the benefits, the risks, and her futile alternatives. He dutifully notes her concerns, and then he hands her his pen. Thirty-two hours later, after an uncomplicated splenectomy, to everyone’s shock, Annabelle Sanders dies.

Since that day, my hair has greyed, and under my care countless patients have benefited from surgery. I never fully understood why she died, but on the day she died, Annabelle Sanders handed me a precious gift: pay attention. Even when circumstances seem innocuous, pay attention. Even when timing is woefully inconvenient, trust your gut. A successful doctor will fold into the brew of medical decision-making one or two drops of the elixir of intuition.

By example, recently a 9-year-old boy was referred for second opinion. The child inconsistently reported 20/20 vision one minute, and total blindness the next. There were no other symptoms. On physical examination, everything checked out. The eye exam was normal, so I reassured his mother. “Lots of kids pretend. Glasses are cool.” I sent them both home. By the end of my workday a gnawing voice spoke. This mother knows her child. She left unconvinced. Maybe he is not that kind of kid? No, he’s fine. He has no headache. I heeded my intuition and picked up the phone. “Mrs. Gonzales? Sorry to bother you this late, but could you please bring your son back in tomorrow? I’d like to run one additional test.” It was a difficult computerized test requiring prolonged concentration, something not typically performed on young children.

That afternoon the technician called me urgently out of a room. Blind spots, scotomas, had divided the child’s vision down the center. The right halves of both of his eyes could see 20/20. The left halves of both of his eyes were blind from a brain tumor.

In medicine, we cast our gaze through the lens of logic and reason. The keystone upon which we build our knowledge is our ability to prove fact and disprove assumption. The exacting discipline of medicine requires that which is measurable and repeatable. It can be frustrated by the enigmatic or the mystical. Intuition does not fit, and yet it must fit. A scared young woman who died in 1989 taught me this. Embracing intuition allows us to honor the whole of what makes us human. It accesses a kind of understanding that can enhance and enrich. It makes us better doctors.

Editor’s Note: Names have been changed to protect privacy.

download issueDownload Issue : November 25, 2018 edition

Related Content:

Money