The Uncertainty Principle

It’s been ninety-four days since I had coronary artery bypass surgery.  I feel fine.  Truly, the only reminders of the surgery are an impressive scar down the middle of my chest and somewhat shorter chest hair.  I’ve also started back to part-time work as a doctor.

I was worried when I started back that I might be a bit rusty.  Fortunately, that hasn’t been the case. But there’s one thing I forgot during my six-month break from practicing clinical medicine (I retired from my medical group at the end of May)—I’d forgot just how much uncertainty is involved in the practice of medicine.

In a general medical practice, most of the patients we see have well-defined problems, such as high blood pressure, carpal tunnel syndrome, shingles, backaches, and the common colds of either medicine (a virus) or psychiatry (depression).  But in the mix of cases there are also a number that defy classification either because the diagnosis is unclear or because the treatment involves too many variables.

Case in point: the 73 year-old woman I’ve just seen for a “cough”.  Her chest xray shows a tiny bit of fluid in her lungs and her history and physical examination suggest that she may have a mild case of congestive heart failure.  But she also had a mastectomy for breast cancer ten years ago, and recurrent breast cancer can also spread to the lungs, causing fluid to collect and producing a cough.

And while I’m pondering how to proceed with that case I see another patient, a young man whose complaint is that he feels “lousy” and has a headache  And, indeed, he has a low grade fever and a fast pulse.  Most likely he has some sort of infection.  But what?  And where?   I check his blood count.  He has an elevated white blood cell count, further evidence of an infection.

In general, this young man doesn’t look bad.  There’s no evidence that the headache represents a problem with his brain.  He drove to the clinic on his own; he’s able to eat and drink; and he has a comfortable home within a few miles of the clinic. So I decide to send him home with a diagnosis of “viral syndrome” and advise him to rest, drink some herbal tea, and take Tylenol for his fever.  I also know full well that he could have something else and something much worse.  These kind of vague symptoms could be harbingers of endocarditis or encephalitis or even some sort of smoldering tumor.  I have been fooled before.  But I have to trust my intuition here.

So both patients go home.  The woman with the cough is started on a diuretic for presumptive congestive hear failure and pulmonary edema.  I will see her in a few days to repeat the chest xray and see how she feels.  If the diuretic has done nothing and the fluid continues to collect I will tap her chest and examine the fluid.

The young man goes home with the admonition to come back ASAP if he feels he’s getting worse.

When I was a resident, one of my wise professors told me that to practice medicine one is often forced to act on insufficient information.  He also told me that in a busy clinic day– with dozens of back-to-back 15-minute appointments—doctors have to move fast.  It’s the combination of speed and uncertainty that I believe contributes most to the stress of practicing medicine.

And, not to keep you hanging, the woman with the fluid in her lung responded to the diuretic: the fluid decreased and the cough stopped.  The young man who felt lousy never did return to the clinic so after a week I phoned his home to learn that he and his girlfriend were “up at Tahoe on a ski trip.”

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