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‘The Operation Was a Success, but the Patient Died’

When the cure is worse than the disease.

by
Theodore Dalrymple

Bio

September 4, 2013 - 5:00 pm

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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.

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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

Theodore Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute. His new book is Second Opinion: A Doctor's Notes from the Inner City.

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Top Rated Comments   
I've come to the conclusion that death is a side effect of life.
1 year ago
1 year ago Link To Comment
"First, do no harm....." is a precept often ignored by physicians when considering treatment.
1 year ago
1 year ago Link To Comment
Of course the final bill was handed to her surviving family: $14,345,560.67, of which $145.67 would have been covered by Obamacare.
1 year ago
1 year ago Link To Comment
All Comments   (16)
All Comments   (16)
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They made the symptoms go away, but who can say they ever really figured out what the cause was. Sometimes the operations fails but the patient lives.
1 year ago
1 year ago Link To Comment
One of my close friends just passed away last Sunday. He had inoperable cancer. His doctors were recommending that they surgically remove his soft-palate, insert a feeding tube, and stick him in a managed-care facility. With no other benefit, no prolongation of life.

He told them to shove off, as there was not only no benefit, his remaining quality of life would have been ruined.
1 year ago
1 year ago Link To Comment
I've come to the conclusion that death is a side effect of life.
1 year ago
1 year ago Link To Comment
Yeah! Let's all sue our parents!
1 year ago
1 year ago Link To Comment
I believe our friend the Doc is doing us a great favor with his honest articles. Many Docs are so busy they are hard to see, hard to understand, hard to believe, and hard to please. But when one gets relief, it's like heaven.
1 year ago
1 year ago Link To Comment
I went to several doctors over a ten year period about some problems I had. I got all sorts of diagnoses, usually allergies. The last doctor I went to spent about two minutes looking at me, came up with some off the wall diagnosis about a low grade infection, gave me a prescription, and sent me on my way. I tried his prescription, exactly as he said to follow it. He was dead on. Sometimes doctors do get it right. Heart and blood pressure problems went away. Migraines gone. I still have a few minor problems, like sniffles, but they are just because I was sick and untreated for 10 years. My body is still trying to cope with a problem that is cured and gone now.
1 year ago
1 year ago Link To Comment
"First, do no harm....." is a precept often ignored by physicians when considering treatment.
1 year ago
1 year ago Link To Comment
Of course the final bill was handed to her surviving family: $14,345,560.67, of which $145.67 would have been covered by Obamacare.
1 year ago
1 year ago Link To Comment
Priceless!
1 year ago
1 year ago Link To Comment
When what she really had was a allergic reaction to something in her diet.

Well I suppose that is why they call it a practice...
1 year ago
1 year ago Link To Comment
Well, every patient is going to die of something *eventually*.
1 year ago
1 year ago Link To Comment
"The patient is cured, but the patient died. However, it is by such contradictions that medicine makes its strides."
By which, I assume you mean, we need to work on the patient dying part a bit.

"total-skin electron-beam therapy"
Wow. Amazing procedures are available these days. I can't help but wonder what the after affects of that procedure are, and how painful is the reaction to having your skin vaporized off. What courage she had to even face all that.
1 year ago
1 year ago Link To Comment
It looks like the total-skin electron-beam therapy is not having your skin vaporized -- it's just a low-level irradiation that does not affect the inner organs. The transplant mentioned is the stem-cell transplant; a separate procedure.
1 year ago
1 year ago Link To Comment
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