BMJ  2003;327:401 (16 August), doi:10.1136/bmj.327.7411.401

reviews

PERSONAL VIEW

Listen to the patient

The patient was a 79 year old woman with a history of ischaemic heart disease: two acute myocardial infarcts 10 years ago, followed by longstanding atrial fibrillation and worsening angina. Coronary artery bypass surgery six years ago had fully relieved the angina, and she had been free of symptoms (although still with atrial fibrillation) while taking digoxin, blockers, and warfarin, among other drugs. Now she reported two days of progressive shortness of breath with intermittent pain in the centre of her chest. She had obvious dyspnoea at rest, slight cyanosis, readily audible bilateral crepitations, a raised jugular venous pulse, marked dependent oedema of her arms and legs, and (I was pretty sure) a palpable tender liver.

It didn't seem the most difficult clinical problem—even for a public health physician without paid clinical responsibilities these last 20 years. I was not the patient's doctor, however, but her son. She had been discharged from an emergency assessment unit in the local teaching hospital the day before, with a reduced dose of digoxin after tests had excluded another myocardial infarct. This made me uneasy, but I was more upset that she remained so breathless that she could barely speak. Telephoning the assessment unit proved ineffective (except in raising my own blood pressure). The anonymous voice at the other end maintained that it was not policy to discuss or review patients even one day after discharge and suggested the accident and emergency department of the hospital on the other side of town.

Half an hour later we were there. Some time later a pleasant and helpful junior doctor kindly let me stay while she conducted a brief history and examination. She was even nice enough to pretend not to mind when I tried discreetly to point out the clinical signs. This approach was clearly not a success, however, as the working diagnosis was pneumonia, pending chest radiography. Two hours after our arrival, the film showed marked bilateral pulmonary oedema. My mother's shortness of breath, eased a little by oxygen, resolved fully after she was treated with intravenous furosemide (it seemed a long lost friend from my own days as a house officer). The expected dramatic consequences on urinary output added a further dimension to the discomfort and chill of the accident and emergency department, but on balance she was glad. In the early hours, after she had spent more than four hours at the hospital, an ambulance arrived to take her back to the assessment unit that had so recently discharged her. She arrived already restored to her usual condition and was discharged again the next day, with daily furosemide added to the drug cocktail.

Sadly, this probably sounds a mundane tale, likely to be repeated daily across the NHS. If so, my concern over some features is not lessened. Clinical assessments at the first admission and the first discharge clearly missed the point. The assessment concerning a recently discharged patient seems needlessly inflexible and led to an unnecessary, distressing, and prolonged stay in an accident and emergency department. Over a series of consultations with clinicians at all levels very little weight was placed on history and examination, in comparison with the results of investigations.

I was taught the dictum attributed to William Osler: listen to the patient—he or she is telling you the diagnosis. My mother was too breathless to tell us in her own words, but the physical signs more than made up for her enforced reticence. If radiography is needed to diagnose pulmonary oedema, somebody needs to order it, which did not happen during the first admission. I am grateful that somebody did so at the second attempt, but the pathophysiology was clear throughout. The doctor in the accident and emergency department observed that it was the first time she had known the patient's son make the diagnosis, but the unspoken element of surprise seemed to be that I had done so without radiological examination.

I can't help feeling that we have lost something of the art of medicine in a headlong rush to embrace the science. Perhaps this view makes me the kind of dinosaur that I used to scoff at in the days when qualification was still nearer than retirement. But quality of care in this instance could so easily have been improved significantly at no cost—in fact with a clear saving of time and money. If this tale really is commonplace across the NHS the implications must be considerable. I hope that it is not too late to listen to this particular patient.

Public Health Group North East, Department of Health bill.kirkup{at}doh.gsi.gov.uk

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Rapid Responses:

Read all Rapid Responses

what happened to the GP?

kathrin j thomas
bmj.com, 15 Aug 2003 [Full text]

Communicate - don't just 'listen'

susanne McCabe
bmj.com, 19 Aug 2003 [Full text]

Far from unique

Mark Aszkenasy
bmj.com, 20 Aug 2003 [Full text]

Re: what happened to the GP?

Bill Kirkup
bmj.com, 23 Aug 2003 [Full text]

Any role for the GP?

Catherine A J Dixon
bmj.com, 29 Aug 2003 [Full text]

Listen to the patient

Valerie F Hartley-Brewer
bmj.com, 8 Sep 2003 [Full text]

Try to make, the patient understand what is his problem.

Ionescu Sebastian
bmj.com, 15 Sep 2003 [Full text]