Nightmare Alley - a Bad Turn in Consultative Medicine

Occasionally, performing a pre-operative consult, especially on another physician's patient can be rather maddening. It can become a nightmare for both the doctor and the patient. However, there must be some mysterious, grievous and cryptic reasons that vex the patient and force the consultant (me) to feel like smashing my head against the wall. On the other hand, the inferences are self-evident and understandable.

Case in point -- numero uno: a 72-year-old man was seen by me prior to a vitrectomy and membrane stripping. As most readers appreciate, such a patient is frequently afflicted with the usual co-morbid conditions - diabetes, coronary heart disease and hypertension, all in diverse levels of control, not infrequently out of control. This particular patient could not obtain an appointment with his own primary care physician for several weeks, so the patient, ever anxious for an improvement in his vision, opted to see me.

Overall, I feel that most patients planning surgery here should be evaluated here. There are opponents to this, but that is another debate for another time.

As I examined this patient's abdomen, I felt an enormous spleen, down to his iliac crest. "Do you know your spleen is enlarged?" I asked him. He replied that he had mentioned this fullness to his private doctor, who told him not to fret about this trifling finding. You've gotta be kidding, I thought.

I then ordered some blood work. His white cell count was over 100,000, mainly lymphs, and his platelet count was 35,000. Needless to say, he was not a candidate for eye surgery. I sent him to heme-onc clinic and I thought the remainder was history. Wrong! About 3 weeks later, the patient called me and vigorously complained: 1) why did I cancel his eye surgery? and 2) why did I have to inconvenience him by diagnosing leukemia? Actually, he was quite piqued. I was now held accountable for his protracted poor vision.

Case number 2: A 58-year-old woman with a 20-year history of myasthenia gravis, treated in part by years of corticosteroids, with resultant osteoporosis of the hip. In addition, she was a heavy cigarette smoker. I performed a pre-op physical on this poor lady, in preparation for a hip replacement. Since she had abnormal lung sounds (probably related to chronic obstructive pulmonary disease) and complained of dyspnea with the slightest effort, I ordered a chest film and pulmonary function studies. In addition to airway obstruction, the pulmonary function test showed severe diminution of both MEP and MIP, supposedly related to her myasthenia. The chest x-ray divulged a 1.5 cm nodule not present on a film done only a year earlier. I must add that the patient's response to having even obtained these studies was one of passionately shrieking at me and the nurse. Obviously, I was quite reticent to notify her with the results. However, she astonished me. As expected, she was tearful but unusually cooperative in allowing a further work-up that could eventually result in a thoracotomy. Three hours later, her husband called me to grumble about the mental trauma I had inflicted on his wife. He criticized me for ordering the x-ray and the pulmonary function tests. It was now my fault that her hip replacement was delayed. He also was indignant.

Readers, I hope your initial response to the above is not "lack of communication". Hardly. In both situations, the patients were so very optimistic that surgery would alleviate long-term adversity. They had counted on their surgeries for months. Along comes an unknown consultant delivering bad news and cancellation of the anticipated surgery. This was being hit with both barrels. I was the proverbial bearer of bad news; they felt like executing me.

There must be a psychological name for such predicaments. If not, I'll invent one. In essence, this kind of medicine is uncertain. Fortunately, such cases are sporadic. More often, it is just a matter of tuning up a little congestive heart failure or diabetes. I feel it is quite demoralizing for a patient. The pre-op consulting on a patient is an absolute indispensability, especially with serious co-morbid disease. However, anticipate the disgruntled patient who takes their frustrations out on the consultant. It may lead you down a blind nightmare alley.

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.