Patients and doctors: life-changing stories from primary care; Edited by Jeffrey Borkan, Shmuel Reis, Jack H. Medalie and Dov Steinmetz; University of Wisconsin Press, Madison, WI; 1999; 228 pp. US$24.95 (cloth) ISBN 0-299-16340-7 FIGURE
I've been interested in the value of anecdotal evidence for a long time. It all began years ago when my wife and I went out to dinner to celebrate a wedding anniversary. We chose our favourite restaurant on the northwest out-skirts of Glasgow. The weather was foul on this particular February 3, and we were ushered to a table near a roaring fire. Only one other table was occupied, by four people who looked to us like an engaged couple and a set of parents. We couldn't quite match them up. It didn't really matter, as the father of whomever, a distinguished-looking middle-aged gentleman, dominated the table and spoke in a loud voice impossible to ignore. We concluded he was a medical man, as he recounted story after story with but a single theme: how he had solved clinical conundrums that baffled boatloads of professors. "I don't know how you do it," one bewildered colleague had said after another (according to the raconteur), "but you're absolutely right every time." From my point of view, the interesting thing was that he didn't know how he did it either. This was a man whose thought patterns were atypical and whose approach to problem-solving was individual, indirect and intuitive. Our paths never crossed again - to my regret; I would have liked to talk with him.
Patients and Doctors: Life-Changing Stories from Primary Care is an anthology of anecdotes contributed by no less than 47 authors. One or two of the authors are respected colleagues, several are friends and acquaintances, some have names so familiar to me it seems I know their owners although we have never met. The others have the kind of profile that tells me we could talk. Each one has an interesting story to tell. Each one has sought sense in an apparently senseless world, and I commend them for their highly readable, personal testimonies.
I believe that doctors write for two reasons, expiation or celebration. Expiation: seeking to exorcise a personal demon, searching for forgiveness of a professional error whether real or perceived. Celebration: recording with admiration the many facets of the human spirit it is our privilege to observe and the remarkable heights to which it soars.
When I was in practice in Glasgow many years ago I looked after two elderly sisters who lived together and seemed to get a lot of respiratory infections. They came to my office most of the time, and it was unusual for them to request a house call. They did on one occasion and I was surprised to see that the reason given was "both very sick." I've often said that you learn more about people in one house call than in a lifetime of office visits. This was one of the experiences that shaped that opinion. The sisters lived in a small but absolutely spotless home in a quiet culde-sac. I was ushered into the parlour and left for a few minutes while the ladies got themselves ready for examination. In a cage by the fireplace was Onan the budgerigar. Aloof and inscrutable, he ignored my efforts at conversation. There were pictures on the piano of two men in World War I uniforms. I found out later that both had been killed at the Dardanelles, one the husband and the other the fiancé of my respective patients.
The sisters had remarkably similar problems. Each gave a history of a few days of malaise, fever, cough and increasing chest discomfort. Examination of both found nothing but low-grade fever and a few crackles over the right middle lobe in the mid-axillary line. How very odd! Inspiration struck me and I went to some trouble to get blood samples from both ladies tested for psittacosis antibodies. This would have been around 1969; general practitioners had little access to diagnostic facilities in the National Health Service of the day, and the concept of atypical pneumonia as a specific syndrome hadn't quite reached communal consciousness, certainly not mine.
The laboratory report came back just before I had arranged a return visit, and I was just tickled pink to find their psittacosis antibody titres sky high! They had both improved on the tetracycline I had prescribed but seemed less than impressed with my news that their budgerigar was making them sick and would have to go. That's when I was informed that his name was Onan. One of the sisters remarked enigmatically, "He's a very messy eater, doctor." I had expected praise and even admiration for an astute piece of diagnosis, but, to my chagrin, what was eventually forthcoming was a reluctant statement to the effect that they would change doctors rather than get rid of Onan. We eventually reached a compromise - my introduction to patient-centred medicine - and Onan went to the vet for a micro-dose of tetracycline or whatever sick budgies get.
I suppose that's by the way of both expiation and celebration. Education as well, as I found out later why the budgie was called Onan. My patients, observant Presbyterians who knew their Bible, pointed out to me that Onan was the second son of Judah and Bathshua, ordered to impregnate Tamar, his brother's widow. Whenever I feel that my ego is getting a bit too inflated, I remind myself of the beloved budgie who, like the Onan of Genesis 38:9, "spilled his seed upon the ground"!
Read Patients and Doctors. It is full of life-affirming stories that will challenge you to place your professionalism within the context of your patients' lives.