As a medical student, I found the most powerful way to learn was to relate theory to practice, linking academic “book learning” to direct experience of a patient. Whenever I think about an uncommon disease, I try to recall a patient whom I have encountered who suffered from it. Even now, when considering a possible diagnosis of mitral stenosis (a tight heart valve), I think of Annie, a patient at my London Teaching Hospital.
In the olden days, a medical student was assigned to every patient who was admitted to hospital. It was the student’s job to “clerk” the patient, which means carrying out a clinical interview and physical examination, sometimes even before the junior doctor had seen them. Each day, the student would visit the patient to check on their progress, look at the results of tests, scrub in when they went to theatre and, on occasions, present their dead patient to the lunchtime pathology meeting at the post mortem examination.
I got to know Annie extremely well, as she had a prolonged stay in hospital. Like me, she was from the North East of England and recognised my faint accent, so we had a social bond. We were strangers in a strange land. She was too ill to benefit from surgery, her worn-out heart would not have been able to cope with a long procedure to fit a prosthetic valve. She was slowly dying.
In those days, doctors did not like to be reminded of their failures. The cardiology ward rounds passed her bed quickly and without comment. But my job was to pay her a daily visit. She grew to trust me and we became friends. Transference, counter transference? I prefer to think of it as compassionate humanity. I’ve just had an epiphany – perhaps this was an intentional, but covert and unwritten, part of old fashioned medical education. Of course, students needed to gain knowledge about fancy new drugs and the latest, technically brilliant, operative procedures But this part of the curriculum was where I learned how to deal with death.
Every so often, I would listen to her heart, straining my ears to identify a loud first sound, opening snap and a low-pitched, rumbling, mid-diastolic murmur. Her valve was so calcified and damaged from childhood rheumatic fever that it allowed blood to flow backwards, creating another pansystolic murmur that I could hear around her back.
Cardiac auscultation is a difficult skill to learn. I remember having a floppy plastic record which played on a gramophone at 45rpm. I listened to it so intensively that I can still recall how the recording began: “These are the sounds and murmurs heard in …” I found it so complicated that I had to play it over and over again, to memorise the murmurs. But what cemented it in my brain was listening to Annie’s chest.
Fast forward forty years to Matsapha Comprehensive Health Care Clinic.
The young woman rattled off a stream of symptoms. She said she had had asthma since childhood; she was short of breath on exercise; she had been seen in several hospitals, but the doctors had failed to cure her; she had rapid palpitations and had been treated unsuccessfully for a possible overactive thyroid gland; her symptoms were worse at night, to sleep she needed two pillows and would sometimes have to rest her back upright against the wall, blah, blah.
What? Sleeping up against a wall? Hold on, this was unusual, people don’t normally say this. It didn’t fit with asthma.
Experienced doctors speed up consultations using pattern recognition. If all your symptoms fit the disease blueprint, the diagnosis is easy. Scientists talk about the “signal-to-noise” ratio, a significant event occurring against background noise. For doctors, the trick is to stay alert during a long, busy clinic to pick up the symptom or sign which stands out from the ordinary. The intermittent-rapid-heartbeat and inability-to-sleep-lying-flat clues were clinical gold dust.
Instead of prescribing another asthma inhaler, I spent the next ten minutes doing a full cardio exam. Listening with the bell-end of the stethoscope over the tip of the heart, I found that she had a mid-diastolic murmur. It was not as long or as low pitched as Annie’s, but it was unmistakeable. Rolling the patient over onto her left side made the murmur louder and easier to hear. The first sound was possibly more prominent than normal. Her blood pressure was low and her pulse was thready, but regular. The pieces of the jigsaw were coming together with a diagnosis of mitral valve disease.
“I think you have a tight heart valve which is interfering with the blood flow through your heart. This is probably the cause of all your symptoms,” I said. “We need to get an ultrasound of your heart and a specialist cardiology opinion from the capital city hospital.”
“What? How do you know this? Why did all the other doctors not realise what was wrong with me?” she asked.
My translator answered, “Because he is good.”
Gulp, I had better be right!
What happened to Annie? I am sure that she died. I was posted to do paediatrics at the Belgrave Hospital for a few weeks. She was no longer an inpatient when I returned.