First, do no harm

When I see Madeline is my first patient for the day, I try not to let my heart sink. As usual she has only booked a short consultation, but she always takes longer despite promising, ‘this won’t take a minute’.

I call her in and feel the day slipping away from me when I see the folder of notes she has brought to her consultation. The day is fully booked, and I offer silent apologies to the patients who will languish in the waiting room as the day progresses.

Madeline is not the usual heart sink patient. She is not drug seeking and is always polite and compliant. I suspect her myriad of unrelated and inconsistent symptoms are related to grief following the death of her disabled daughter seven years ago. Madeline has been consistently resistant to any suggestion she seek grief counselling or support, so instead, I give her my time and attempt to manage her symptoms by following the adage in the well-known Hippocratic Oath, first, do no harm, by avoiding interventions that may cause adverse outcomes, including over investigation.

‘I’ve been to see the naturopath,’ she advises, opening her folder of articles and information. I suspect Madeline will leave a selection of these for me to read and I feel guilty that they will sit indefinitely in my to-do tray.

‘The naturopath thinks my immune system is malfunctioning and has asked me to get the following blood tests done.’

There is a long list of blood screens. Some are routine, but many are for things I’ve never ordered before. I hesitate and suggest that I print out the blood test results she had done only two weeks earlier to take to her naturopath, but she is adamant that she needs a fresh lot done.

The admonition to be judicious with ordering tests takes a back seat as I keep one eye on the time, her 15 minutes rapidly ticking by. I add a highlighted note, ‘requested by naturopath’, to justify to the pathology lab, or perhaps to myself, why I am ordering costly and unnecessary investigations.

‘And she says I need to go gluten- and dairy-free and she has given me a detox which will help with my fatigue’ Madeline continues.

I find myself torn between the wisdom of Hippocrates and the desire to allay Madeline’s fears of a missed diagnosis. It is so difficult to resist the urge to order one more investigation, just in case. I make certain to go through the motions of a detailed history and examination. At medical school we were warned that most things are missed not because we didn’t know, but because we didn’t ask and didn’t look.

‘Let’s go through all your symptoms again,’ I suggest. ‘I’ll note the details down while you talk.’

‘I’m tired all the time. Even when I go to bed early and sleep well, I wake up exhausted. And I get bloating, and this funny pain in my shoulder and headaches just at the back here.’ She vaguely waves her hand across the back of her head. ‘And when I eat bread, I feel nauseous.’

I print out her results and reassure her she doesn’t have coeliac disease and that her iron levels, which were low, are now replete. She is dismissive and tells me the bloating has improved since going gluten-free two days ago.

‘And how are things at home?’ I ask.

Madeline and her husband have a son, Damian, who was born seven months after their daughter died. Freya had multiple complex disabilities and was fed through a tube. She had been nonverbal and couldn’t respond to external cues. Despite intensive occupational therapy, speech pathology and physiotherapy, Freya made no progress. She died at 7 years of age. I recall Madeline telling me her mother-in-law called her callous because she didn’t cry. ‘I’d done all my grieving during the seven years I looked after Freya. I didn’t know if she knew me, if she had pain, or if she was comfortable.’

When Madeline learned she was pregnant with Damian,  she wept and wasn’t sure whether she could go through with it. ‘I just need some time to myself. Am I selfish?’

Damian is now a thriving boy who is at primary school. Madeline was terrified during her pregnancy with him despite reassuring ultrasounds. She eventually agreed for him to be vaccinated but spread the vaccines out so that he never had more than one at a time. It was a fraught time and I regularly checked in on her to see how she was travelling. She declined formal counselling.

‘I think Damian has allergies and his immune system could do with a boost. I might take him to the naturopath too. She really listens to me and understands.’

I do my best to listen carefully and can’t help wondering what the naturopath charges and how long her consultations are. I take Madeline’s blood pressure and weigh her. I listen to her heart and lungs, palpate her abdomen and check her lymph nodes are not raised.

My printer spits out the blood test form and I prepare to end the consultation when Madeline remembers, ‘I get really short of breath, even when I walk up the stairs. It started a few days ago.’

We are now 20 minutes into her 15 minute consultation and my mind does a rapid scroll through the diagnostic sieve for shortness of breath in a 42-year-old woman. Her oxygen saturation is 99% and her ECG is normal. I’ve stopped looking at the time and ask for an urgent D-dimer even though she has no risk factors for a pulmonary embolus. I send her for a chest x-ray and promise to let her know the result. She gets up to go and leaves me articles about chronic fatigue syndrome and Lyme disease, and a piece from a women’s magazine about autoimmune diseases. I shove them onto my teetering tray once she is gone and waver about how much to charge. I have no doubt I am a bargain next to the naturopath.

When I see the chest x-ray results later in the day, my heart sinks. The radiologist notes some nonspecific changes and suggests clinical correlation and a CT scan – just vague enough to make me anxious. I find myself back with the dilemma of how to manage this uncertainty and wonder how to balance my piece of mind against endless and costly investigation with the risk of finding minor abnormalities that Madeline will compel me to treat.

‘There’s nothing major in your chest x-ray,’ I tell Madeline on the phone, ‘but…’

That word but carries a weight of what ifs, potential diagnostic grenades. She opts to proceed.

The results of the CT scan of Madeline’s chest leave me shocked. The scan went a little higher than usual and found a thyroid malignancy. I arrange an urgent review with a surgeon and Madeline is booked in two weeks later for a thyroidectomy. I am grateful she has not relied on her naturopath for treatment.

The following year, I see Madeline less frequently as she has regular follow ups with her surgeon and endocrinologist. Madeline doesn’t end up going for those blood tests requested by her naturopath – a small saving for a health system already overwhelmed by demand. I receive frequent letters and test results from her specialists and am relieved Madeline does well. The malignancy is completely excised with no complications. I wonder if her symptoms are finally cured and shudder that I wavered about doing the CT scan. Without the adrenaline rush experienced by my colleagues in emergency rooms and operating theatres, it feels as though I have quietly saved a life. I find myself hypervigilant with other patients and my threshold for ordering investigations shifts. It makes me anxious about leaving any stone unturned and less willing to linger in the grey zone of uncertainty where so many GP presentations sit.

After a long absence, Madeline presents again. It is one year after her thyroidectomy, and she has just returned after a holiday in Bali. She has a folder tucked under her arm.

‘This won’t take a minute,’ she begins. ‘I’ve been getting a weird tingling under my left breast, I’m tired all the time, and the naturopath says I’m allergic to the chemicals in processed food. That CT scan you ordered unbalanced my immune system, so she suggested I get you to order these blood tests.’ 

I can’t help wondering what Hippocrates would say.  MT