Mr. X was about thirty years old and had been dealing with severe, unexplained chronic abdominal pain for years. Before seeing him, the ER staff physician I was following, Dr. Y, showed me his test results – a huge collection of x-rays and scans and blood tests and laparoscopic procedures that all failed to give us any insight as to why he felt such crippling pain from a day- to- day basis. Dr. Y was not very optimistic and gave me a generous fifteen minutes to take a lengthy history but stated that she had seen this patient before and he likely just wanted some more opioids. When I walked into the small room, Mr. X was sitting on the bed. He looked like he had experienced a rough life and had missing teeth, bones protruding from his small frame, and a forlorn expression. Mr. X told me that this pain had been ongoing for years and years, that he didn’t know what to do about it, and that the medications were not working. It was unbearable last night, which is why his dad brought him in today. He told me about his smoking and drinking, work, past surgeries, poor appetite, unstable living conditions, previous medical history and medications, and I added everything up to the list of differentials in my mind.
Luckily, we had just been studying abdominal pain, and I ran through the differentials to Dr. Y, which were one by one struck down based on the tests results. Liver function tests were normal despite multiple alcoholic drinks per day. But maybe they’re just abnormally normal because so few liver cells remain to pump out enzymes! But then why would the biopsies and scans show a healthy liver? Could it be kidney stones?! No, his ultrasounds were clear… Fibromyalgia? Symptoms didn’t really match… Diverticulitis? Appendicitis? All had a corresponding test that gave a resounding “No”. I asked Dr. Y what she thought, and she said there was likely nothing we could do at this point, for Mr. X had already been seen by multiple specialists. Dr. Y and I returned to Mr. X. She told him our thoughts and said that he was already on the highest dose of pain medications that she is comfortable giving. She said that she could give him a local numbing shot but that the efficacy was well below the medications he is already on and so he would likely not feel any difference. Mr. X didn’t accept this. He demanded a better answer and solution to his pain but Dr. Y explained that over the recent months, he had already gone through every test she could order, which had all come back as negative.
In the end, we didn’t do anything at all for Mr. X. He had simply sat in the waiting room for hours, talked to me for fifteen minutes, then both Dr. Y and I for five minutes, before walking out of the hospital that day. As he left, I smiled at him, but he didn’t see me. Between other patients, I voiced again how disappointing it is that we couldn’t do anything for him and Dr. Y casually mentioned that he had had previous suicide attempts.
I regret not sitting with him to just chat and show him that we do care and are thinking about him, even if it doesn’t seem like it. I regret letting him walk out of the ER without a nurse or doctor or medical student to reassure him and keep him company. This day happened many months ago, on a day where there was still snow on the ground. I do not know how Mr. X is feeling right now, if he has seen any other health care professionals in the meantime, if he still has a place to call home, or even if he is still alive.
I am certain that if Mr. X had been an affluent, good looking, middle-aged man, we would have acted differently. That same day, a cardiovascular surgeon came to the ER because his chest had been feeling tight during an operation. The way this surgeon was treated was in stark contrast to the way Mr. X was treated. Of course, one can argue that this was the surgeon’s first episode of chest pain, that chest pain in an older man is very worrisome, that it is potentially life threatening. But I highly doubt the same care and consideration and utter respect would have been granted onto Mr. X if this had been his first time in the ER as well.
Looking back, I’m not sure if we could have done anything differently with Mr. X. In pro comp, we have done several scenarios now to contrast “bad” behaviour with its corresponding “good” solution. But that is often too simplified of an approach. It is too easy to say that a good physician would give up his lunch break everyday to sit with a patient and the family and spend enough time with everyone to build a strong rapport that ends with the sharing of personal stories and tears of relief. That is not reality. If one patient receives 2 hours of undivided attention, then 10 others go without being seen. I am realizing more and more that it is perhaps practicing this woven balance between low voices of reassurance and pointed questioning and direct tests that is the art and science of medicine we hear so often of.
I still think about Mr. X from time to time. I wonder how he is doing and although I’m still not sure if I acted in a way most representative of this balance between art and science, this experience has illustrated to me more about the humility, balance of resources, and diagnosis of medicine than any other.