All patients deserve to be treated as family

Special to The Times

Two years ago, after returning from an Alaskan cruise, Jean, a widow in her mid-70s, mentioned a disturbing new health problem: During the trip, she had started having severe episodes of neck pain. Although I was not her doctor, I put on my physician hat and asked a few questions.

It was difficult for Jean to pinpoint the location of the pain; it seemed to begin at the back of her tongue and spread across her neck. The episodes occurred mostly in the middle of the night and kept her awake for an hour or more. On a severity scale of one to 10, the pain rated at least eight or nine.

Given Jean's age and history of smoking, my concern was clear: "See your own doctor as soon as possible and have your heart checked," I said. "The pain could be angina, the classic symptom of coronary heart disease."

Jean's internal medicine physician made space to see her quickly and, to our relief, his examination and the electrocardiogram were normal. He made a referral for her to see an orthopedic surgeon because of Jean's long history of spine arthritis. Appropriate X-ray tests of her neck were ordered, and the orthopedic surgeon reported that, yes, Jean had degenerative arthritis of the cervical spine. He recommended monthly injections into the affected areas to treat the pain.

Jean followed doctor's orders and started with the injections. She tried to be patient, thinking that several months might be required before any improvement occurred. In the meantime, she continued to have excruciating episodes of pain every night. The symptoms were always the same.

I stayed in touch, commiserating with Jean about the pain while trying to be optimistic about the treatments. After six months of injections, Jean was no better, and the orthopedic surgeon thought there was little more he could offer.

Her internal-medicine doctor, with similar sentiment, continued to see her on an "as needed" basis. The painful episodes persisted, and Jean endured, with characteristic stoicism and ibuprofen.

Eighteen months into this, with no significant letup from the pain, Jean dropped the bombshell. She told me that for two days she had been having trouble breathing with each episode of neck pain. Just speaking to me over the telephone caused shortness of breath. My heart sank into a deep pit as I thought, "Angina! It must have been heart disease all along, and now she is having heart muscle failure with each episode! Cervical spine disease had been merely coincidental."

"Get yourself to the emergency room immediately," I said. "You need more cardiac evaluation."

It turned out that Jean's correct diagnosis was severe coronary artery disease for which surgery would be the only reasonable alternative to a painful, suffocating death. She underwent quintuple bypass of tiny coronary vessels by a superb academic surgeon and his team.

The neck pain (the angina) disappeared immediately -- an undeniable relief -- but she never made a significant recovery. Her heart continued to fail, and she died three months later. Throughout the ordeal, I never acted as Jean's doctor and tried not to meddle. I was only her son and had viewed my role as supportive and advisory. Two years later, I still carry some guilt and resentment over the delayed diagnosis, and in my mental replays, I regret not having pushed for more diagnostic evaluations.

Angina in women is known to be difficult to diagnose, so I am reluctant to be too critical of the medical profession (although even as a specialist in dermatology, I distinctly recall the back-of-the-tongue symptom, from medical school days, as being suggestive of angina).

But what I have learned over 30 years in medicine is this: To help every patient requires going beyond our routine bag of tricks. It often necessitates rethinking a case over and over, getting a second or third opinion if answers are not forthcoming. Helping patients often means treating every patient the way we, the doctors, would want our daughters, our spouses, our mothers, to be treated.

We will never know whether diagnosing my mother's angina sooner -- when her heart muscle could have been stronger -- would have changed her outcome. But in a suffering patient, there is almost always something more that can be done, especially when a diagnosis is not yet established. Too often, the real cause of the problem is recognized only in retrospect.

James Channing Shaw, a dermatologist at the University of Toronto, is a writer of medicine-related essays and the author of "The Quotable Robertson Davies."

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