'The Operation Was a Success, but the Patient Died'

Schopenhauer would have enjoyed the spectacle of grand rounds in academic hospitals: his theory that people argue for victory more than for truth would have found confirmation there.

In grand rounds a physician presents a complex or enigmatic case to the other physicians of the hospital, who then discuss it in detail. The ostensible purpose is to teach, learn and sometimes to enquire; but such human desires as to show off, to appear more-learned-than-thou, and to appear brilliant are often much in evidence. I once worked in a hospital where an ancient and celebrated physician, who had had more diseases, albeit rare and obscure ones, named after him than any other physician in history, attended such rounds until well into his nineties. Once he had spoken he would ostentatiously turn off his hearing aid, the entire matter having been settled to his satisfaction by his own opinion.

The New England Journal of Medicine carries each week a case report from the Massachusetts General Hospital, presented on a grand round. Generally speaking they record a triumph of diagnosis and often of treatment, somewhat like a Sherlock Holmes story. The more obscure the diagnosis the more brilliant appears the solution, seemingly reached effortlessly by the teamwork of clinicians and pathologists. One cannot help but wonder, sometimes, what has been left out. Certainly the patient’s experience doesn’t get much of a look in.

Recently there was a case reported in the journal that brought to mind the old saying of Victorian surgeons, “the operation was a success, but the patient died.” It concerned a fifty-three year old woman who suffered from persistent redness of the skin and enlargement of the lymph nodes. She was susceptible to infections for which she had repeatedly been admitted to hospital (not the Massachusetts General) and treated with antibiotics.

The diagnosis was very uncertain. She had been given steroids on the supposition that the skin condition was a severe form of psoriasis. The latter is a common skin condition, and it is another old saying that common diseases occur commonly. But she continued to be ill and eventually was admitted to the Massachusetts General, as law cases are taken finally to the Supreme Court.

The patient underwent an immense number of tests of enormous sophistication, among them repeated skin and lymph node biopsies. Immunological and genetic tests were likewise performed. Eventually a diagnosis was reached: she had a cutaneous kind of lymphoma that has a bad prognosis.

The case report discusses the various possibilities for treatment, none of them guaranteed to work and all of them with serious side effects. The best option seemed to be pegylated liposomal doxorubicin, which had a cure rate between 20 and 60 percent, though it can cause serious damage to the heart. “This agent,” said the report, “was considered but could not be obtained because of a national drug shortage.” Other drug treatments could produce remissions, but short-lasting and at the potential cost of severe complications.

In the end, the patient “received alemtuzumab followed by total-skin electron-beam therapy and a reduced-intensity-regimen stem-cell transplant.” The dermatologist adds that the patient “is currently doing well, 1 year after the transplantation.”

A triumph, then, you might think! But in the next paragraph the pathologist says, “Unfortunately, she died approximately 1 year later of transplant-related coronary artery disease, with the lymphoma in complete remission.”

This rather peculiar juxtaposition of the patient doing well, in the present tense, and of having died at the same time, rather casts doubt on the way in which such case histories are constructed or redacted. The patient is cured, but the patient died. However, it is by such contradictions that medicine makes its strides.

******

images courtesy shutterstock / Johan Swanepoel / Roblan