British Journal of General Practice 2020; 70 (695): 299. DOI: https://doi.org/10.3399/bjgp20X710261
‘I JUST DON’T FEEL RIGHT’, HE SAID
The man had come in one grey December afternoon complaining of fatigue and that something wasn’t right. Without much to go on we did some general tests, which showed new-onset diabetes with an HbA1c of 104 mmol/mol, but nothing else seemed wrong. This gave a reason for his fatigue and I referred him to the diabetic nurses. Something still didn’t sit right and I remembered a revision question that new-onset diabetes in the over-60s should be referred for a CT scan. I ummed about this before finally requesting one. It came back showing metastatic pancreatic cancer.
It is not the purpose of this piece to reflect on my diagnostic acumen, which was more based on good fortune than anything else, and if I had been strictly following the guidelines set out by NICE1then I might not have referred for a CT as there was no acute weight loss or any other disturbing symptoms. Instead, I want to unpack the strange set of emotions and feelings that came with this news.
Being a doctor asks us to occupy an unusual space in society. It asks us to learn to the infinite degree the vagaries and workings of the human body and mind, so that we may then interpret and diagnose what is happening when it begins to break down or become unwell. Our thinking process is built on looking for problems, identifying them, and then, if all goes well, eradicating them. This logical mindset can lead to great satisfaction when this goes to plan. We have spent and continue to spend years refining our art to catch that disease or cancer red-handed and call it out. This is how we make our professional way and reputation.
So in one sense hearing the results might have been satisfying, and it was on a certain level. I was even congratulated for it by various colleagues on return. However, on another level it was deeply troubling and unsettling. The last thing I wanted was this man to have cancer; in fact I’d have preferred him to have nothing wrong with him.
‘I JUST DON’T FEEL RIGHT’, THE DOCTOR SAID
It is moments like these where I feel being a doctor can be so problematic. The truth is that if people were not sick we would not have a job. It is the existence of illness that provides us all with a way of living and an income. Professionally and academically the pursuit and study of disease can be very rewarding, both in terms of career progression and financially. Yet this also means that we ultimately make a life for ourselves generated from our involvement in the suffering of others.
As doctors we find ourselves with feet in two opposing camps, that of the trained objective observer and that as a human being. And how we manage this tension will, I’m sure in many ways, define how each of our careers pans out. There is a deep paradox to what we do that can, on occasion I feel, be irreconcilable. I remember always finding it strange when we talked about ‘great signs’ at university as we stood at the bedside of the stricken patient. It always seemed ironic when working on call days in hospital that colleagues would habitually complain of being bored when there were no patients coming in, essentially wishing illness on someone to fill their time!
For me there is no right or wrong here, simply awareness that it is so. While there is life, there will be illness. This is a job unlike any other and one in which all of us are tested in ways that are unique to our own individuality. How to reconcile the essential paradox of what we do? There is no easy answer. All we can do is continue to do our best and faithfully live this question on a daily basis.
- © British Journal of General Practice 2020
- 1.↵National Institute for Health and Care ExcellenceSuspected cancer: recognition and referral (NG12)LondonNICE2015Last updated July 2017. https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621 (accessed 23 Jun 2020).Google Scholar