The Patient Was…

The patient was the 65 year old man described earlier whom I had convinced to have heart valve surgery because, as he said, “Nobody ever put it to me that way.”

At the time of this encounter, heart surgery was still in its relative infancy. There were far fewer heart surgeons than there are now, and not many of them had yet accrued sufficient experience to manage really sick patients, those in severe heart failure and dire straits. In fact, at that time I not infrequently referred those of my patients who were seriously ill or whose condition was unstable but who needed heart surgery to surgeons who were at different hospitals from my own because I felt their experience and expertise was greater. Fortunately, such expert surgeons were available in nearby medical centers.

There were, at the time, two “giants” in heart surgery in the U.S. They were each at different medical centers, but both were more than half a continent away from New York City. I knew the reputation of each, and it was superb, and I actually had had some professional acquaintance with one of them.

While the patient’s decision to have surgery was the right one, the life-saving one, he didn’t make things easy. As soon as he agreed to have surgery, he set conditions. He apparently had done some research on heart surgeons on his own, and he was aware of the two experts. And he insisted that his surgery be done by the doctor whom I will call Dr. Y, the man with whom I had had some prior experience.

“I’ll only do it if Dr. Y operates on me,” he insisted. “I don’t care how you do it, but you’ve got to arrange it and get me there.”

“I try,” I said, “but I can’t promise anything.”

“If it’s not Dr. Y I’m not having the operation,” he said. And he ended the discussion.

Well, it took some doing, but we got it arranged. I spoke to Dr. Y and his staff. Fortunately, money was not as issue, so we were able to arrange a private ambulance plane with a medical attendant on board to fly the patient to the city where the surgeon was located, and an ambulance met him at the airfield and brought him directly to the hospital.

Surgery was done within 24 hours, and the report from the surgeon’s office was very favorable. A few days later, the patient himself called. The doctor, to whom he now referred by his first name  —  I don’t think the surgeon’s wife even took that liberty  —  was discharging him the next day. And the patient planned to come directly from the plane to my office. He insisted he wanted to hug me because I had saved his life.

“Dr. Y saved your life,” I said. “Why don’t you go home, rest up a few days, then come in to see me.”

“No,” he said, “you saved my life by convincing me to have the operation. I’m coming right to your office.”

Sure enough, the next afternoon, the patient burst into my office, where I was doing some paperwork; fortunately, he didn’t interrupt me with another patient, although I don’t think it would have bothered him. He threw his arms around me and hugged me. It was all joyous and fun, if a little unconventional.

“As long as you’re here,” I said, “let me examine you and let’s go over what happened.”

He proceeded to tell me in detail about the hospital, the surgery, the staff, how Der. Y (again, using the surgeon’s first name) and he were now friends. On examining him, everything did  look and sound fine.

“Let’s go over your medications,” I said, “because taking the right medicines is crucial to your full recovery.”

He took out his bag of medications, and the printed list that came with them. As I went over it, I noted the striking absence of a critical medication. He must have seen the puzzled look on my face, because he immediately asked what was wrong.

“There is a medication that is crucial after a valve replacement like yours,” I said. It’s called a blood-thinner and it prevents blood clots that can form on the new valve. If a clot forms on the valve, it can break loose, travel in the blood stream to your brain and cause a stroke. Was there a reason Dr. Y didn’t prescribe it? Did he find that you have a bleeding disorder that would make the blood-thinner dangerous?”

“He never said anything about it,” the patient replied.

“Look, this is serious,” I said. “If you have a bleeding problem, I need to know about it. And if the medicine was omitted by mistake, we need to correct that. Maybe the discharge medications were prescribed by one of the Dr. Y’s staff, and they forgot it.”

“No, the Doc went over the medicines with me himself and never said anything about it,” said the patient.

“I need to call Dr. Y and discuss this with him,” I said.  “This is really important.“

“I forbid it!,” he yelled, jumping up from his chair. “It would be so embarrassing. He couldn’t make a mistake like that. I forbid you to call him.”

“We’re talking about your life here,” I said, my own voice rising.

“I’m telling you, I forbid you to call and discuss my case with Dr. Y,“ the patient repeated, now calmer. “Don’t do it. And I won’t take a blood-thinner since he didn’t prescribe it.”

He left my office with a plan to return for a follow-up visit in one month.

I resisted the urge to ignore the patient’s wishes and call Dr. Y. A patient had a right, I reasoned, to direct his own care in some fashion, to decide who could talk about him, and who could discuss his case. But the decision not to confer with the surgeon on this potentially crucial clot-preventing matter continued to bother me.

Three weeks later, the patient had a massive stroke and died.