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Incidental serendipity

Ober, K. Patrick MD

Journal of the American Academy of Physician Assistants: September 2013 - Volume 26 - Issue 9 - p
doi: 10.1097/01.JAA.0000433965.22547.5e
Mindful Practice

K. Patrick Ober is a professor of internal medicine, endocrinology, and metabolism and medical director of the department of physician assistant studies at Wake Forest School of Medicine in Winston-Salem, North Carolina. He practices endocrinology at Wake Forest Baptist Medical Center. The author has indicated no relationships to disclose relating to the content of this article.



Life is a series of discoveries; our cumulative discoveries become our life's education.

When we are students, our teachers prearrange discoveries for us with specific goals in mind to form the basis of our formal education. Most of the major discoveries (“lessons,” if you will) in our lives take place out of the classroom, though. They are not formatted in any systematic style; they are encountered erratically, unexpectedly, inconsistently, and without prequel or pattern. They come to us in unanticipated contexts and usually at the most inconvenient times. Such discoveries often create an initial sense of disorientation, as we tend to encounter them when we stray away from familiar territory.

Each life discovery, with its inherent discomfort, has the potential to change us, often in wonderful ways.

Discoveries can be mundane or monumental. We might find a new shortcut to work that saves 10 minutes of driving every day (discovered after being forced into an annoying detour); a wonderful new restaurant (discovered by eavesdropping on a conversation); the work of a remarkable artist or author previously unknown to us (spotted on a friend's coffee table); an old photograph of the grandfather we never met (the ancestor responsible for all of our undesirable traits, according to mother, and thus the one who has always been our unsung hero); or perhaps $3.37 in small change under the sofa cushion, discovered while fishing for lost car keys.

The word that best describes the unanticipated findings of life is one of the hardest words to translate from English into other languages. These fabulous occurrences that come out of nowhere and result in wondrous, unanticipated consequences are serendipitous discoveries. The English author Horace Walpole invented the word serendipity on January 28, 1754, to signify “a happy discovery made by accident.” He crafted the word from the story The Three Princes of Serendip. Serendip is an old term for Sri Lanka, and its princes were lucky travelers, for “as their highnesses traveled, they were always making discoveries, by accidents and sagacity, of things which they were not in quest of.”

A serendipitous discovery leaves us better off than we were before. Sometimes the value is in the thing discovered; other times the simple joy of discovering is worth more than the thing discovered. If we pay attention, life often presents us with all sorts of possibilities for serendipitous discoveries.

The exception is medicine. Without question, we do stumble across all sorts of unexpected things in our patients. Rarely, though, are these happy or fortuitous discoveries. Our medical discoveries tend to be abnormal physical findings and abnormal lab results. Medicine is different from most of life. In most of life, things could always be better. In medicine, being healthy is the ideal, the absolute, and you can't be better off than that. We don't consider the finding of an enlarged spleen or an elevated alkaline phosphatase or microscopic hematuria to be serendipitous, as they all portend a journey with potentially worrisome destinations. Serendipitous is not a medical word. If a discovery is tangential to our original search or purpose, found by accident, we label it an incidental finding. Incidental findings are not happy findings or serendipitous findings; they are a departure from the ideal state of health. They may not turn out to be anything serious, but they will be disruptive in the sorting out phase. The best we can hope from them is an ultimate neutrality, a conclusion that the incidental finding does not mean something bad. It can't mean anything good.

At first I thought the question was a joke.

After a month or more of unexplained dyspnea, nonproductive cough, and generally feeling lousy, a chest CT scan showed I was the owner of an extensive load of pulmonary emboli. I was hurried to the ICU to receive evaluation, oxygenation, and anticoagulation. My attending physician dropped in to check on my well-being, examine me, discuss my oxygen saturation, review my warfarin dose, ponder whether I needed a filter in my inferior vena cava, and wonder if I needed testing for aberrant blood clotting factors.

I had been doing my best to be a good patient, which to me mostly meant “not being a doctor.” I trusted my healthcare team to make the necessary decisions about my care and to inform me of my status. Right then, it just wasn't my job to be a doctor. No problem. I was perfectly capable of not being a doctor, I was sure.

The fact that I am a physician could not be totally overlooked, of course. It did create certain efficiencies. During my initial history and exam, I was asked, “Is there anything positive in your entire review of systems?” “No,” I replied, proud to be a part of the fastest review of systems in the history of medicine. There were some communication efficiencies too. Medical jargon was not an obstacle. My caregivers unabashedly used medical words and didn't have to explain concepts like pulmonary artery, V/Q mismatch, or right ventricular strain.

“Oh, by the way,” my ICU attending said as he walked toward the door, almost as an afterthought after his previous wondering and pondering, “the CT also showed that you have a 2-cm nodule in your left adrenal gland.”

Then he paused.

Hmmm, I thought. I bet I am supposed to say something now, to react to this news.

But this was too weird.

When I am healthy and not a patient in the ICU—when I am “a doctor”--I am an endocrinologist in an academic medical center. I am consulted on a regular basis to evaluate patients with adrenal “incidentalomas.” I am the guy who gets called to see patients with incidentally discovered adrenal bumps. I am not the guy who has one. Typically, I am the doctor who would be called in to see … me.

So, maybe the question was a joke, a quip to lighten the intensity of the intensive care unit. One of those bad news/good news one-liners: “Well, it could be worse; in addition to pulmonary emboli, you could have an adrenal incidentaloma to worry about too!”

It was not a joke. My intensive care doctor was serious. I did have a bump in an adrenal gland. About 2 cm in diameter. Smooth edges. Benign in appearance.

The other shoe dropped. “What would you like to do about it?”

“What would I like to do with it? ... As in, me?”

I had been doing my best to be the patient, remember?

I remembered the words of Sir William Osler, “A physician who treats himself has a fool for a patient.”

But now I had a problem. I had to answer a direct question.

The answer, frankly, should have been easy.

My “incidentaloma” had characteristics that screamed it was benign, as did the overall statistics around such findings for all patients. I had no clinical features to hint that it was making excessive hormones. I am relatively non-Cushingoid, at least by my own self-assessment, and nothing about me or my clinical course or on my blood pressure monitor or in my routine labs suggested I had Cushing syndrome or an aldosteronoma or a pheochromocytoma.

And if an adrenal incidentaloma is benign and not making excessive hormones, we should just leave it alone. That's easy.

But how should I answer the question?

One option was to continue in my role as a trusting patient, untainted by any medical background, and answer, “Just do whatever you need to do. You are my doctor.”

The second possibility might be a proposal, “Let's get an endocrinology consult.” Implying, of course, an endocrinologist who is not me.

Third option, I tell the ICU attending what to do (“Nothing!”), as though I am functioning as an endocrinologist who is consulting on someone who is not me. Or would that self-consultation make things too strange? I would become a chimeric, two-beings-in-one-body creature if I made myself a patient-physician, a hyphenated being like a soldier-citizen or a student-athlete. (Are the two roles ever equal for hyphenated people? Doesn't one usually dominate? Would I be representing the best interests of the patient, who didn't need any tests? Or the doctor, who might recommend some testing “just to be sure,” because doctors are bad to do that?)

In the back of my brain, I hear Osler scoffing. “A physician who treats himself [didn't you hear me the first time!?] has a fool for a patient,” he reminds me again.

But the reality was simple. Options 1 and 2 leave open the possibility that more tests could be done, with my implied permission. And I don't want a cortisol measurement. I don't want catecholamine measurements. I am in the ICU with pulmonary emboli, tachycardia, and a right ventricle that is working overtime. Cortisol and catecholamines are stress hormones that can be (and should be) high under those circumstances. That doesn't make a disease; that makes physiology. Laboratory testing now resolves nothing, but it might create confusion, or even foster bad clinical decisions. (Shouldn't I be the patient's advocate here?)

As clinicians, it is often difficult for us to avoid doing more tests to try to resolve uncertainty. In doing more testing, we often create more uncertainty. Clinical wisdom is often a matter of knowing what not to do.

To get Osler's harping out of my head (can I disregard his wisdom?), I reminded him of something else he said, “Medicine is a science of uncertainty and an art of probability.”

That should trump his other aphorism about having a fool for a patient.

I knew the probabilities as well as anyone. And any uncertainties were going to have to be my uncertainties to live with. And the reality was that I did not have features of Cushings or a pheochromocytoma. I didn't want anyone checking my cortisol or catecholamines and generating uninterpretable results that would only lead to confusion. I was not a surgical candidate in any case; I needed anticoagulation to survive. Testing made no sense.

All of those thoughts rushed through my brain in about 5 seconds, and then I answered my ICU attending before he even noticed any hesitation.

I chose Option 3.

“I don't need any adrenal workup right now.”

I received a quizzical look and a shrug of the shoulders. His nonverbal reply seemed nonjudgmental in the gesturing, and I translated it loosely as: “OK … it's your life.”

Hey! That was easier than I anticipated. I was geared for a big argument. It was my good fortune that the ICU attending for this week is known for being conservative in his test-ordering, and open-minded and attentive to his patient's perspective.

I guess it was serendipitous that I came into the ICU when I did….

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© 2013 American Academy of Physician Assistants.