To spend an entire college year (two semesters) studying epistemology seemed like a colossal waste of time when I was 19. We had no choice; we had to take it, and I got a pretty good mark, as I recall. It took a half year to find out what it was about, but it seemed to concern itself with how we obtain knowledge. There is inductive reasoning and deductive reasoning plus knowledge gained through experience. As scientists, we were all familiar with those, but how do we integrate intuitive reasoning with learning scientific facts?
As college students, all we had to do was regurgitate the correct facts on a quiz.
Perhaps if they had named it “gut feelings,” we would have had more respect and understanding. But with time, we learned the practical applications of this type of knowledge and then learn to recognize it, respect it and use it to help our patients.
An example occurred when I was working in the ER and a young man was brought in with back pain, the second or third such case of the day. This one was different; it was mid-back, not low back, and not precipitated by any trauma or strain. I entered the room, went around the gurney to his right side, and did a quick exam. Suddenly, the voice spoke out of my mouth, but without the brain being aware. “This man has a dissecting thoracic aneurysm and needs an immediate ultrasound.”
While they rushed him to X-ray, I began investigating options for moving him to a major medical center where definitive surgery could fix him. The ultrasound was positive, and we sent him to MGH by chopper where he had a synthetic aorta installed and even replaced two coronary arteries that were in jeopardy.
Once the patient was whisked away, a reflective moment took place. What could have influenced me to come to that diagnosis? I did remember the close quarters around that gurney, and I also remember his legs hanging off the end by about two feet as he was very tall. Specifically, I remember having to suck in my gut to get around the feet. I also remembered his hands with their very long fingers! Could my pre-conscious brain have picked up on these signs of Marfan’s syndrome, a condition associated with dissecting aneurysms? Stranger thought processes have occurred.
More recently, a case occurred this past year that could have had a catastrophic outcome.
On a Monday morning, a 52-year-old patient called, saying that he had some mild chest pain over the weekend. No coronary history or family history, no crushing substernal pain with exertion, no radiation to arm or jaw. What was significant was that he rarely came to the office and always minimized symptoms rather than maximized them. So I told him I would check him out at 1:20 after lunch. His wife drove but didn’t come into the room with him. To this day, I do not know what alarmed me, but I listened and examined for a few minutes, then got his wife and asked her to drive him immediately to the hospital ER about 15 minutes away. Apparently, I didn’t want to call, then wait, for an ambulance with the inevitable argument about where the municipal ambulance could take him.
He arrived there at 2 p.m. and by 2:20 was on his way downtown for a cardiac cath, and at 3:30, he was getting a stent placed in his 100 percent blocked coronary artery! I was dumbfounded and have been unable to follow or remember the thought processes that worried me so much.!
Since he was at a downtown hospital where they know everything about everything (just ask them!), he was discharged the very next morning. That Friday evening at home, he suffered a cardiac arrest. He was resuscitated by his daughter, a student nurse, who had just covered CPR in class. Back to the medical center where two more arteries were stented. He has been fine since, and I am sure he has no idea how much luck played in his survival!
Another case involved a phone call at 5:15 in the afternoon from a patient’s wife.
“Bob came home early from work with a headache and now was slurring his speech.”
This was a family under my care for generations. I cared for her mother and their two girls, delivering six grandchildren and caring for them all. My knowledge of the family was intimate. I knew 55-year-old Bob was not a drinker, would never leave work unless it was the worst headache of his life. Right away, the voice appeared, telling her to drive him to the hospital immediately for a CT scan.
Meanwhile, I called my neurosurgical colleague at St. Elizabeth’s. He was in the OR, and they patched me through. “Don’t go home, Tom, I am sending you another brain hemorrhage,” I said. He asked where the bleed was on the CT, and I told him we didn’t have the results yet. But he knew me and hung around anyway.
The CT showed the expected bleed, and we packed him into an ambulance off to St. Es. At 7:30 p.m., he was having his aneurysm clipped and definitive curative neurosurgery. He was in the office last week and just celebrated his 87th birthday!
The advantages of having the same physician for many years are incalculable. Not only does each part come to know the other; the communication is as good as it can be; the medical record, complete though it may be, is a pale reflection of the relationship. Knowledge of values, moral code, family strengths of integrity and honesty, and awareness of the family dynamic is invaluable when parsing difficult diagnoses.
Being in the same practice with many similar patients for over fifty years makes the doctor-patient relationship so much more valuable and so intimate that the quality of the care is enriched.
One final example. A 31-year-old female had been my patient since birth. She came to see me about the Dalkon Shield IUD that I had inserted a few years ago, which was now being questioned about safety and efficacy. Before we started the visit, I asked how things were going for her in Georgia, as she had moved there in a very successful business promotion.
When I asked her what brought her back to New England, she answered, “To see you.” In a somewhat chastising voice, I mentioned that she must have driven past 500 very capable gynecologists able to offer advice.
She came right back in a very critical tone and admonished me.
“Dr. Corcoran, you have taken care of me since I was born. You have advised my parents and me on how to be well and healthy, and every bit of advice has been spot on. During my teenage years, you counseled me and advised me how to stay well and make progress in my life. Why, in the name of heaven, would I ever listen to, or heed the advice of another physician.”
I was overcome at this declaration, and with tears in my eyes, I had no response. My one consistent thought was how blessed I have been by God to be in such relationships.
Gerald P. Corcoran is a family physician.
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