People talk about all of the factors you cannot measure that make a good doctor — moral imagination, empathy, intuition, humility, a sixth sense.
One story still sticks in my mind, and it continues to puzzle me more than 25 years later. This incident happened about three months into my family medicine training. We had primary care clinics one morning a week, no matter where else in the hospital we were rotating. These clinics were a relief, a visit home amidst monthly service changes and having to prove yourself again and again to new attending physicians.
All I remember of this patient is that it was his first visit. He had dark hair and needed a complete physical for work. He was 40ish, slim but not thin, reserved but not nervous. Really nothing out of the ordinary jumped out. I did my review of symptoms and there was nothing. I examined him, still nothing. He was a smoker, but his habits were otherwise healthy. No big family risks.
Early on in our clinics, we were required to tell our supervisor about a case before sending a patient home. I told Dr. X that the dark-haired man was well and, apart from being a smoker, there was nothing to report.
“Should I do a chest x-ray?”, I asked.
“Definitely not!”, Dr. X replied, peering at me over his bifocals. “It’s unlikely to be positive based on what you’ve told me and if it’s clear, it will just give him permission to keep on smoking.”
“Ok”, I said and went back to the patient.
I told him I would be doing blood work. Then it slipped out. “I’d like to do a routine chest x-ray” (even though it had been hammered into our heads quite correctly that there was no such thing).
I was not a maverick resident, and the supervisor I was disobeying was a big shot in Canadian family medicine. I have no idea why I did it. The patient agreed to this. I betrayed no alarm. He betrayed no alarm. We said goodbye.
Two weeks later, Dr. X called me into his office, holding up that patient’s chart. “Peterkin, I thought I told you not to order a chest x-ray on this guy.”
I blushed scarlet.
Dr. X tossed a report at me, which I picked up rather gingerly.
There it was in bold letters, the description of a conspicuous lesion on the man’s left lung, unmistakenly the big CA.
“Well”, I said, as I gathered myself up.
“Can you say why you did it?”, Dr. X inquired.
“I’m not sure. I had a … gut feeling.”
“Exactly!” Dr. X said as he shook my hand. “Intuition is part of what makes a great doctor; be sure you always listen to it.”
I smiled, feeling both confused and somehow acknowledged as a “real doctor,” and left his office. I’ve since had the same moment, but in reverse, where I celebrate trainees paying attention to their feelings as well as thoughts when making a diagnosis. They often have different takes on what intuition might be: Psychic attunement triggered by fatigue. Synchronicity. Random chance. Hyperacuity of the senses (Aren’t they training dogs to sniff out lung cancer from the breath?). Unconscious associations based on verbal and nonverbal cues. Even divine providence.
I never saw that patient again as he didn’t become a regular patient with us. I do know (from Dr. X) that he went on to have surgery and apparently did just fine. I may have saved his life but based on what?
Footnotes
This article has been peer reviewed.
This is a true story. Patient details have been changed.