The Patient Was…

The American patriot Nathan Hale famously proclaimed in 1776 that he had but one regret. In a clinical career spanning over thirty years, I have had two.

Hale was hanged by the British as a spy. The two patients whose clinical courses I regret also tragically lost their lives; they died not, of course, by hanging but as a result of medical decision-making that I rue to this day. And although both instances occurred early in my medical career, their stories are forever in my mind.

The first patient was in her early twenties, a mother to two young children, and married to a warm and considerate young man whom I had met. The patient and her husband both came to New York City from Puerto Rico, met through their work, fell in love, and married young. The husband worked hard to support the family while my patient, the wife, took care of the children. Since their income was limited, they relied on the hospital clinics for their medical care.

I was in my Cardiology Fellowship at the time, and as part of our training we took care of patients in the hospital’s cardiology outpatient clinic. Although there were senior physicians available for consultations, patients generally saw the same doctor on each visit; so it was not too unlike a private patient-doctor relationship. Despite my still being in training as a cardiac specialist, I was her doctor, she was my patient, and both of us willingly understood and accepted that.

She had a condition called mitral valve stenosis, as a result of a bout of rheumatic fever in her childhood. Stenosis refers to narrowing, and it can occur in blood vessels, valves, or any tubular-type structure, even in openings in the spinal column through which where nerves pass.

The mitral valve is one of the four valves in the heart; it lies between the upper and lower chambers, the so-called atrium and ventricle, in the left side of the heart. Blood normally enters the left upper chamber from the lungs where it has received oxygen. The mitral valve allows the blood from the left upper chamber (the atrium) to pass to the lower chamber (the ventricle), from where it is then pumped out around the body.

If the mitral valve is stenotic (narrowed), the passage of blood from the atrium to the ventricle is impeded. The pressure in the atrium rises, and blood backs up from the atrium into the lungs, causing congestion of the lung tissues and interfering with the delivery of oxygen to the blood. And since not enough blood reaches the ventricle through the narrowed valve, the amount of blood that can be pumped around the body is limited.

The degree of narrowing of the valve can be determined with a fair degree of accuracy through various tests; the severity of the clinical consequences to the patient can also be assessed, by the symptoms the patient reports and by what is found on physical examination of the patient.

Her valve was severely narrowed by objective testing; in fact, the severity was such that it met the generally accepted criteria, established by experts, for undergoing open-heart surgery to repair or replace the valve.

But she had no symptoms suggesting impairment of function; she took care of her children, maintained the household, and didn’t suffer from breathing difficulties, excessive fatigue, or anything indicating an inability to carry on her life as she was doing happily.

I saw her in the clinic every three months or so, and always questioned her carefully about any troubles in functioning; she always denied any problems. On physical examination, she had the classic heart findings of mitral stenosis, but no signs of any other trouble such as lung congestion, swollen ankles (from fluid backup), or limited blood flow around her body.

I felt that as long as she could maintain her family responsibilities without any difficulty, that the risks of surgery were too high even in a young and otherwise healthy woman. Even the period of recovery from a successful operation would put a great strain on the family. Who would take care of the children, how could her husband manage his work and his family responsibilities? And what if something more serious occurred, leading to prolonged disability, or worse?

Because I was still in my training, I felt I should consult with more senior experts. Every month, there was a joint conference with the cardiologists and the cardiac surgeons at which difficult cases or cases of special interest were discussed.  Senior members from both the medical and surgical cardiology departments attended. I secured the patient’s permission to present her case and she, in fact, came to the conference so she could answer any questions the doctors might have.

I presented the medical details of the case. Then the patient came in and told the group that she was feeling and functioning fine. She left the meeting to wait for me outside, after the discussion by the senior attendings. There was little discussion: Everybody agreed that she should have surgery as soon as possible. They indicated that it should have been done already. It was wrong to delay. When I tried to explain how well she functioned in her personal life, and about her family responsibilities, nobody seemed to think that mattered. The test results were clear, they said; the valve narrowing was severe, and she met the criteria for urgent surgery.

When the meeting concluded, I met her in the hall outside the conference room.

“Well,” she asked, “what did they say?”

“All the experts say you need an operation,” I said.

“But what do you say? You are my doctor,” she said.

“Look, you know I am still in my training,” I said. “These are experts.”

Her response was so simple. “You’re my doctor. You know me better than they do. Tell me what you think.”

“I think,” I said, “that despite the test results, you are doing so well that I would not have an operation now. But you must report any new symptoms to me, any difficulty, any problems.”

“I promise,” she said.

For the next year, I continued to see her in the clinic every few months. Nothing changed. She continued to feel well, to take care of her family, to enjoy her life. But I was increasingly concerned that I had done her a disservice.

So, I persuaded her to allow to me to re-present her case to the combined cardiology – surgery conference. Once again, she came to answer questions. Once again, I presented her case, both the objective test results showing the severity of the valve narrowing and my and her subjective feelings that she was doing really well from a functional standpoint. And once again, the experts’ opinion was unanimous: she needed surgery. And this time it was accompanied by criticism of me for not following the same recommendation made earlier.

When I met her after the conference, she again asked, “What did they say?”

“Everybody says you need the surgery, “I replied.

“And what do you say? You’re my doctor.”

In truth, I still thought she could safely delay the operation. If there were no panel of experts to consult, I would have persisted in the course we were following: careful and regular examinations, with particular attention to any changes in her symptoms or clinical signs. But I felt the contrary weight of expert opinion, and concern if I were wrong.

“I think they are right,” I said, despite my misgivings. “They are the experts. You should have the operation.”

She agreed readily, and two weeks later was admitted to the hospital for surgery on her mitral valve.

She died on the operating table.