Thursday, March 30, 2006

Sometimes You Just Have To Listen To Your Gut

You wake up & have this bad feeling in your stomach (& you know it’s not the curry you ate last night). Things just go downhill from there. The car has a flat. Or the traffic is horrendous. You’re late for work. The F-O-N patient you usually try to avoid turns up & ends up in your consultation room. The waiter gets your dinner order messed up.

You also read about people with close calls who didn’t get on a plane because of a “bad feeling” & the plane ends up crashing with everyone on board losing their lives.

This sixth sense (no, not the I-see-dead-people variety) that you get sometimes is inexplicable, and unexplainable. I don’t know if it’s a gender-biased characteristic (the so-called “women’s intuition”); maybe the guys have a different name for it.

Whatever you may want to call it, this gut feel that you get can sometimes be a life-saver for your patients. I remember a few cases I encountered…

Patient A was a Malay gentleman in his early 40’s, who presented to me with mild gastric pain. Medical history & physical examination were unremarkable & he had only had the symptoms for a few weeks. Usually, I would prescribe an antacid and/or a H2 blocker with some lifestyle advice & review the patient again after a week or two, depending on the severity of symptoms.
However, in this case, something made me feel the need to refer him to a tertiary center for further investigations. 2 months later, I received a reply letter from the specialist who saw him at the specialist clinic giving me an update on his condition. Turns out that endoscopic examination revealed a gastric ulcer with very early malignant change. Fortunately, it was early enough that the patient did not need a total gastrectomy & just needed the affected area to be resected. I can’t begin to describe the feeling of relief (& some incredulity) I felt that we had caught this in time, thanks to my gut feel.

Patient B was a Chinese gentleman in his early 30’s who complained of a persistent cough of 2-3 weeks’ duration. He was not a smoker, & had no significant family or medical history of note. He had previously been prescribed cough mixture & lozenges by another doctor in the practice, without any relief. When I saw him, there were no physical signs to suggest any infection or malignancy. But again, gut feel made me order a chest x-ray…and to my horror, I saw a suspicious looking mass in the right lung. The radiologist report had daunting words like “suggestive of malignant change” & “infiltration”.

I referred him to a tertiary center. He returned to see me two months later to let me know that after undergoing a bronchoscopy & biopsy, the mass was not malignant, neither was it tuberculous (tested negative for acid-fast bacilli); even the specialists were puzzled by the diagnosis & thought that is was some unusual mycobacteria strain that had caused the infection. They ended up treating him empirically with what I believe to be a combo of Rifampicin & Streptomycin (patient was unclear as to the name of the drugs used). Happy ending – the treatment worked, & the patient was eternally grateful that number 1, the illness had been picked up, & number 2, it was NOT cancer.

Patient C was a Chinese lady in her early 20’s whom I saw as a health screening patient. During history taking, she revealed that she had a history of colonic cancer (!!!)& had a partial colectomy done. Apparently, she had seen her personal GP for (get this) epigastric pain (!!!), & the GP became suspicious & immediately referred her to a specialist for further investigations. Colonoscopy revealed early Ca Colon. I suspect that this GP had a gut feel too, that something was not quite right in this patient.

So the moral of the story is: don’t ignore that niggling voice that comes from that gray area between your conscious & subconscious, which sometimes makes you do things which you otherwise would not do. That strange feeling in your gut may not be indigestion, but your intuition telling you that things may not be what they seem to be.


Dr Oz bloke said...

I get what you say and when I was at the A&E I made a few of such gut feeling calls and turned out to be right too. But A&E is where you have the full gamut of services at your disposal and patients are generally prepared for it.

In General Practice, it's a different ball game though.

You make the assumption that the patients do not question the doctor's recommendations.

Perhaps things are changing from since you first took your sabbatical.

These days patients can say "But I don't think it's so serious lah. I don't have time to go for X-ray lah"

Gut feeling?

aliendoc said...

Well, it wasn't that long ago :) & I was in a corporate GP clinic.

For the most part, patients here still tend to listen to their doctors (may be good or bad, depending on how you look at it:))...for those who declined further inx, I normally would not insist unless it was life threatening. Like a lady who had the classical signs of DVT & ADAMANTLY refused to go to the A & E because she had too many things to do that day!! She went in the day after where it was CONFIRMED that it was DVT - fortunately, it didn't embolise & was treated in time. In these kinds of cases, I make it a point to DOCUMENT their refusal to follow my recommendations. Documentation, documentation documentation....I can't even begin to emphasis how important that is these days!!!

Dr Oz bloke said...

Documentation is one aspect. The other thing we need to do is to get the patient to countersign the documentation also.

You can have a look at this powerpoint presentation by Assoc Prof Catherine Tay

It's interesting that these days the courts are moving towards the Bolitho Principle rather than the Bolam Principle.

aliendoc said...

Agree. And I did that exactly with the DVT patient. There is an increasing need for docs to cover their behinds.

Dr Oz bloke said...

One thing though. I find that patients get absolutely horrified and offended if you ask them to sign such declarations!

I mean it's basically just telling them you take responsibility for yourself. That's what they want isn't it?

But they just don't want to sign it!

I guess it's the culture here.