Teaching and Learning Moments
Dr. Schattner is head, Department of Medicine, Kaplan Medical Centre, Rehovot, Israel, and professor of medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel; e-mail: amiMD@clalit.org.il.
A petite, dark-skinned young woman who met all the criteria of “fever of an unknown origin” was admitted to our department. While we ran all the usual tests and debated the meaning of some likely false-positive results, I got to know her, her supportive husband who was never far from her side, and their two little children.
A couple of weeks went by, and we still had nothing definite to show for our pains. Sarah remained very sick with a high temperature daily, drenching night sweats, and dramatic weight loss. Her tension and fear were almost as palpable as her enlarged spleen. After we had exhausted all the imaging, cultures, and other studies, and our daily clinical examinations revealed nothing new, I decided to discharge her and have her report once a week to our clinic instead.
I still can vividly remember our parting conversation. Sarah and her husband were very worried, thinking of cancers and other catastrophes. I could say nothing positive to them. Or could I?
Deriving confidence from the meticulousness of our investigations and the absence of any demonstrable pathology, I slowly repeated to them my point of view: “We still do not know what you have, but no news is good news in your case. The fact that we found nothing serious is in itself reassuring. It looks like some inflammatory condition, so we should wait and watch until a clue surfaces to provide us with a solution.”
We all were braving uncertainty. They took it very well. Sarah went home as sick as before but seemingly reassured.
Two weeks later, it came—a new carotid murmur detected by nothing more than patience, thoroughness, and repeated clinical examination. It led to a magnetic reasoning angiography and a diagnosis of Takayasu arteritis. Our uncertainty about Sarah’s diagnosis disappeared at once, only to be replaced by an uncertainty about which treatment would be best for her arterial occlusions. Fortunately, Sarah responded to the treatment we selected.
Over the years, I have enjoyed watching the utterly normal life Sarah has led and how her children have grown. Whenever I am faced with diagnostic uncertainty—and this occurs quite often, as patients with perplexing illnesses keep appearing regardless of how long one is in the field—Sarah’s case gives me new strength.
Our 15 years of friendship has provided me with many lessons—my students are quick to tell me that they have heard them all more than once! First, I learned that when uncertainty arises, the patient’s anguish far exceeds that of the doctor. As physicians, we must remember to put our patient’s needs first. Second, I learned that when faced with uncertainty, honesty and full disclosure is the best policy. Patients will trust you if you are candid, if you do your best, and if you do not feel for a moment that clinical uncertainty is a weakness, something to be ashamed of. Third, I learned that when you have exhausted all the sophisticated and costly tests, repeated methodical follow-up examinations often will solve the problem. Finally, I learned that the more you know about your patient and your patient’s life, beyond the clinical facts, numbers, and imaging test pictures, the more committed you will be to leave no stone unturned, to the benefit of bothparties.
Uncertainty can be a powerful ally if you are able to share it frankly with yourpatients and are careful to do yourvery best.
Author’s Note: The name in this essay has been changed to protect the identity of the patient and her family.