Friday Reflection 24: I Would Rather Go Back in Time

KW was a 58-year-old man with long-standing type 1 diabetes mellitus and hypertension. He came to an appointment one Friday afternoon with chest pain. The pain had been present intermittently for 10 days. It was on the left side of his chest and beneath his sternum. It did not radiate, was not related to exertion, and was not associated with diaphoresis or shortness of breath. It was also not positional, and there were no areas of tenderness. Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber. When I was a kid, we often played “Would You Rather?” to pass the time on the bus. This game had remarkable staying power. When we first started playing, the questions were mostly things like: Would you rather eat a cicada or a cricket? As we aged, the questions progressed through the usual male adolescent fare to more profound philosophical quandaries: If you managed the Mets, would you rather pitch Seaver or Koosman? Would you rather have a Ferrari or a Porsche? Would you rather date Lauren or Lizzie? Would you rather visit the past or the future? Professionally, there is no question: my answer to the final question would be “the past.” There are a dozen or so patients that I want a second chance at. I wonder if, knowing what I know now, I would manage things differently? Would the outcomes be different? Would some of the people still be here? I should not have admitted him. For my entire career, I have had a clinic scheduled on Friday afternoon. My reasoning is two-fold. First, I know that if I didn’t have patients scheduled Friday afternoon, I’d probably kick off early. Having a full schedule on Fridays ensures I stick it out to the bitter end, making me more productive each week. Second, most people opt not to see patients Friday afternoon, so I tend to get more support as one of the few doctors working. The downside of seeing patients on Friday afternoon is that my management options are somewhat limited. Patients present with troublesome symptoms that they “just want checked out before the weekend,” and I’m left either worrying about them all weekend or admitting them to the hospital where I know little will happen for the next two days. There was a lot about KW’s chest pain that was not concerning for symptomatic coronary artery disease. It was not exertional. The episodes sometimes lasted minutes and sometimes hours. It was not accompanied by shortness of breath, diaphoresis, or a feeling of impending doom. He also had had a normal stress test a couple of years before. On the other hand, KW was a middle-aged American man with chest pain and significant risk factors for coronary artery disease — hypertension and diabetes — neither of which had ever been terribly well-controlled. I made the decision that I felt was safest for him and the one that would let me sleep best all weekend; I admitted him to the hospital. I called the admitting resident; I let her know that I was (a little) worried that he had unstable angina and that I was admitting him so that he could be observed until he could get his coronaries assessed. The resident (not incorrectly) decided that if he might have unstable angina, he should be anticoagulated. In the end, KW did not have unstable angina, a coronary angiogram done weeks later was normal. Why did it take weeks to complete the angiogram? Because after being started on heparin, he had an intracranial hemorrhage. I should have admitted her. PH is a woman I have already written about. She presented to me early in my career having lost about a third of her body weight to an undiagnosed, metastatic cancer. She did not require hospitalization. She was well hydrated, and her vital signs were normal. She had walked into the office that first day and would need only a wheelchair to come and go to her last visit 6 months later. She did not require hospitalization for evaluation or treatment. There would be little we could offer her beyond palliative care. I managed her evaluation and her care while she remained an outpatient. By the time she died, this management had included intravenous fluids, pain medications, antiemetics, and seizure medications. My memory was that my effort to keep her out of the hospital was driven more by my philosophy than her and her family’s wishes. At the time, I believed that unnecessary hospitalizations were an anathema. They wasted money, put patients at risk, and were the refuge of lazy or unskilled physicians. I do remember that PH wanted to avoid aggressive care, but I cannot remember her explicitly resisting hospitalization. I do remember her brother once asking, “Shouldn’t she be in the hospital?” From my current vantage point, my efforts to keep her out of the hospital seem, at best, ill-advised. It seems my management decisions were more about me and less about her. It is hard to imagine that the experience, for PH’s family, if not for her, would have been less stressful had I brought her into the hospital a few times during her final months. Did I miss something simple? JJ was the rare patient whose health was at its worst when I first met her. She presented to my clinic in a heart failure exacerbation. I wheeled her to the emergency department where she was promptly intubated. Over the next 20 years, her heart failure became asymptomatic; her asthma — which I am pretty sure was misdiagnosed heart failure — disappeared; and I weaned her off all her drugs for diabetes. She and her family marked the date of our first visit as a second birthday and saw every year after this date as an unexpected gift. In her mid-70s, at a routine appointment, she mentioned an episode of vomiting followed by transient loss of consciousness. The episode barely troubled her, and a brief evaluation at the visit was unrevealing. Three months later, she died unexpectedly after a similar episode. The differential diagnosis of what I might have missed is extensive. I wonder if I could have made a diagnosis, the treatment of which might have saved her life. Did I miss something complicated? SV was a patient who kept me up at night for the better part of 18 months. She was in her late 70s, and she was dying. There was fatigue, weight loss, nausea, declining kidney function, and a few strokes. My workup was extensive, including imaging, blood tests, and biopsies. I consulted a cardiologist, neurologist, nephrologist, and rheumatologist. We treated many disparate issues but never discovered the unifying diagnosis that eventually took her life. Knowing what I know now, and with the diagnostic tools that exist today, could I have saved her? Could I have convinced her to get treated? TP was 80 years old when I diagnosed her with breast cancer. Long before we met, she had decided that she would never have a second mammogram. I did not set out to find a tumor. I discovered a breast mass when she came to see me with shingles. You might be thinking, how can you be sad that you did not convince an 80-year-old with cancer to be treated? Especially when this woman did not want to be treated? Well, first, 80 years old isn't the same for everyone. Everyone who met TP assumed she was at least 15 years younger than she was. Because she had no intention of getting treatment, she declined biopsy or evaluation of her cancer. I knew nothing about the biology of the cancer or the extent of the disease when I discovered it. Over the next 5 years, this vibrant woman declined in the most unpleasant and traumatic ways. I have to think that treatment could have made her life better, if not longer. I wonder if I am now better equipped to counsel her. Could I have convinced him not to get treated? KS was a man in his early 80s. He had COPD and depended on home oxygen. His symptoms were pretty well controlled on a regimen of inhalers. He continued to smoke, saying — with a wink — that it was his only pleasure left in life. He was adamant about not wanting screening tests or any medications not necessary to reliev… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe