Tempting fate: the perils of reassurance

keats and pinion2

Keats as drawn by Benjamin Robert Haydon, and a bird’s wing (with pinions)

 

A patient comes to the clinic with common enough symptoms – say a slight change in bowel habit and a single episode of bleeding. It could be a cough that doesn’t go away, or a lump in the groin, or a pain in the back that doesn’t settle – but something about it has led the GP to refer on to a specialist. By the time he sees you the bowels have gone back to normal and the bleeding has settled. You examine him – all is well, but nevertheless you explain that the only way to exclude anything dangerous is to do a colonoscopy. But he is anxious, and presses you.
“Do you think it’s anything serious doctor?”
“We need to wait for the camera test. It’s impossible to say without looking inside.”
“But what do you think doctor? Honestly.”
“I wouldn’t want to second guess the test.”
“Well you must be worried if you think I need it.”
“Your symptoms are a bit worrying, as your GP explained to you. And there’s no escaping the fact that the main reason we arrange colonoscopies in these situations is to exclude serious diseases, like cancer.”
“But you don’t think…”
“I don’t want you to be worrying excessively over the next few weeks Mr. Evans. But I can’t rule it out.”
“Oh God.”
“Look. If you pressed me, I’d say that the fact that you haven’t had any bleeding or loose stools for 6 weeks, and your normal blood tests…suggest you’re probably OK. Lots of people get symptoms like yours and in the end we find nothing. But we must wait. Sorry.”
“That’s OK doctor. I feel better now.”

And two weeks later you see him again. You have already been informed that the colonoscopy found a cancer. Mr Evans had a staging CT scan yesterday, and there are suspicious lesions in the liver. It’s terrible news, although, in an era of highly effective chemotherapy and adventurous liver surgery, not necessarily a terminal diagnosis. He looks at you rather coldly. The hopes that you allowed him to develop, leading up to the colonoscopy, have been brutally dashed. You discuss options, plans, schedules…

Was it a mistake to proffer an opinion? Isn’t that what doctors are for? Nine times out of 10 your impression, your gut feeling as to the seriousness of the diagnosis, would be right; perhaps more than that, probably 99 out a 100. And by giving some encouragement, albeit with caveats, you ensure that many patients suffer less anxiety, or spend less time in unhealthy pre-occupation with their impending tests and results. And in 99 cases out of a 100 that encouragement proves well founded, until…you get it wrong. Then it feels as though you have misled the less fortunate patient – colluded in their natural wish to see the bright side, contributed to the trauma of the sudden, more precipitous fall.

After one of these experiences, you will be more guarded. For the next 6 months, the next year, you will maintain an inscrutable front, until, having received numerous negative test reports, you dare once again to reassure an anxious patient who comes with seemingly innocent complaints.

– – –

Sweet Hope, celestial influence round me shed

Waving thy silver pinions o’er my head.

 

Keats, To Hope, February 1815

– – –

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