As I walked in the room, he stuck his hand out to shake mine.
Sixty-six years old, average height, lean build, a little more pale than I remembered him, and the tip of a fresh scar poking out from the top of his button-up shirt. He was an established patient in the clinic but as I only work one day a week, I'd seen him only a handful of times. I knew he was local. I knew his wife, who worked in town. Having just rounded the magic age of 65, he now had Medicare, but he chose to remain here, in the health department, for his primary care.
A student asked me recently whether I see complicated health conditions in my practice or just do medication refills and uncomplicated visits. I thought about my answer before I responded.
The patients I see don't know the difference between complicated and simple visits. They come to their rural healthcare provider for the compassion and reputable care they know they will receive, regardless of their medical need. They know that the providers are there not because the facility has state-of-the-art technology or because they receive premium specialty pay but because they truly care about the patients and possibly relate to their situation. These patients are their providers' neighbors and cousins, members of their coworkers' families, the guy who changes their oil, or the woman who bags their groceries.
One month ago, this patient was in for a routine physical examination and annual checkup—a simple visit.
“My wife made me come,” he said. “I feel fine. Just got Medicare but I don't take any medications.” He said he was active, semiretired, hiked for hours at a time, kayaked routinely. No tobacco use. He had a remote history of alcohol abuse but hadn't touched a drink in 10 years. He had an intermittent history of low platelets but was being followed by a hematologist who just monitored his blood cell count. His platelets had never been so low that treatment was required. No steroids, no transfusions. No further workup—but also no explanation. He was otherwise healthy. No shortness of breath, chest pain, abdominal pain, blood in his stool, easy bruising, or bleeding.
His vital signs were stable, his body mass index normal. No bruising noted. The remainder of his physical examination was in fact unremarkable, except for one thing. As I listened to his heart, I closed my eyes and exhaled, a practice that has become customary. I tuned out the whisper of the air conditioning, the chatter in the hall, and my own breath sounds as I focused on the patient in front of me. Listening intently over each heart valve, I heard lub-dub, lub-da-dub, dub-lub, lub-dub-dub. Irregularly irregular. No denying it, his heart rhythm was atrial fibrillation (AF).
As an educator, I know the power and importance of the physical examination. Abraham Verghese, MD, once said at a TED talk, “When we shortcut the physical exam, we overlook simple diagnoses that can be treatable early.” He went on to say, “One of the most important innovations in medicine is the power of the physical exam to comfort, to diagnose, and to treat.”
Initially, the physical examination was all I had to go on. Normally I wouldn't worry too much about an asymptomatic patient with AF. I would check the CHA2DS2-VASc score, prescribe a medication, and consider anticoagulation. Except for his low platelet count... and that feeling in my gut that something just wasn't right.
I made a quick referral to cardiology, where an echocardiogram demonstrated an ejection fraction of less than 25%. An urgent cardiac catheterization was scheduled. The procedure began but couldn't be completed because the patient had nearly 100% blockage of four major coronary vessels. The surgeon sent him directly to a larger hospital 90 miles away for immediate open-heart quadruple coronary artery bypass graft surgery. His wife was told he was lucky to be alive. Her head was spinning as each step in the medical process took them into new and foreign territory quicker than they could have imagined.
I reviewed his chart before seeing him today. A new stack of scanned documents, including my referral note, consults, diagnostics, procedure descriptions, labs, and discharge instructions, were waiting for my signoff. Having never been outside his small town for healthcare, the patient now had a team supporting him—new surgeons, new nurses, new physical therapists, and new medicines. His wife, whom I knew well, was sitting next to him holding every reminder card, informational brochure, nurse name, and new medication bottle in her lap. Even though the procedures he'd undergone had been routine for the providers involved in his care, I could tell that nothing was routine for my patient and his wife. They still felt uncertain about what the future would hold.
As I walked into the room, he stuck his hand out to shake mine. “Thank you,” he said. “You saved my life, you know.”
I wasn't the cardiovascular surgeon who cracked his chest and sewed the bypass grafts in place but in retrospect I suppose my patient was right. Through a simple clinical examination and quick intervention, I actually had saved his life.