Jan E. Siegersma
The Netherlands;
E-mail: eizesmail@hotmail.com
DOI: https://doi.org/10.35975/apic.v24i5.1374
Taking my residency into account I have now been in the field of ophthalmology for 20 years. That is a good moment for some reflection. Have I chosen the right specialty? Have I seen some remarkable patients? Not a lot of medical students starting medical school desire to become an ophthalmologist. In fact amongst most medical students ophthalmology is not quite popular. It is not ‘sexy’ or ‘heroic’ like surgery, traumatology or intensive care medicine. It is considered by many as boring. In ophthalmology you do not save lives. The only thing you do is prescribing glasses, … is it not? Most of us doctors have started their careers with the desire to save lives. To be there where the action is: in the OR or ER. But being an ophthalmologist you can also save lives. I wondered how many lives I had saved. At least a few. This is one of them. This is the story of ‘My Most Memorable Patient’.
The story is the well-known story about ‘Everybody’, ‘Somebody’, ‘Anybody’ and ‘Nobody’. I am sure you must have heard about that story.
1
It was during my residency at an eye department of a University Medical Centre somewhere in the Netherlands. The workload was very high, maybe well too high. The story is about a patient with Marfan syndrome (MFS). For those of us who are not well familiar with MFS, it is a connective tissue disorder. It can give a range of cardiovascular, ocular, neurological, musculoskeletal and neurological disorders.
2 The cardiovascular abnormalities include thoracic aortic aneurysm, aortic dissection and mitral valve prolapse, which can be life-threatening. Ocular abnormalities include tendency to retinal detachment, high myopia, lens subluxation, early onset glaucoma and early cataract.
Because of the possible life-threatening complications it is important that these patients are under regular control by a multidisciplinary team. In our hospital these patients were seen every year by a cardiologist, ophthalmologist, neurologist and also a dermatologist. They got an ultrasound exam to detect aortic aneurysm/dissection. People made a kind of carousel visiting all the different involved specialisms on one day. They used to show up with a bunch of paperwork to be filled out by every doctor they were consulting that day.
Someone with MFS came to me during my residency for a periodic eye check-up. I had never seen him before. He had a long and complicated ophthalmic medical history. He had been a patient at our department for many years. In all those years he had been seen by almost all our doctors, including many residents, all the vitreo-retinal surgeons and even our head of the department. He had had all the eye complications related to MFS you could imagine. He had had several retinal detachment surgeries in both of his eyes as well as lens replacement surgery for the for MFS typical lens subluxation. I was surprised by the fact that the patient had not given me the paperwork to be filled out for the MFS screening program. So I asked him, if he was in the screening program. He was not! He had never heard of it. I was astonished. In all those years he had been patient with us, nobody had referred him to the screening program. And nobody had ever asked if he was in the program. I contacted the coordinator of the program and referred the patient immediately. Of course I talked about this case in our weekly department meeting. One year later the same patient came again to me for his yearly eye exam. He was very grateful for having saved his live. Soon after my referral to the MFS screening program he had been called in. There was found a large thoracic aortic aneurysm, and aortic prosthetic surgery was needed. Also all his family members had been called in for screening.
What can we learn from this case?
MFS patients have a high risk of developing an aortic aneurysm or aortic dissection. This is life threatening. Everyone with MFS should, therefore, be in a screening program. It is incredible that someone with MFS could have been a patient on an eye department of a University Hospital for many years, without having been referred to the MFS screening program in the same hospital. Why has never someone of all those doctors in all those years checked if that patient was participating in the screening program? Was it indolence? Had it to do with the high workload? I think it was, because everyone was assuming that patient would have been in the screening program, because it would have been incredible he was not. The mistake was that no one verified his assumption. We should never assume something without verification! In aviation many serious flight accidents have happened because of something was assumed. Therefore, they work now with checklists. In medicine, lives can be lost by assuming. My advice is to ask questions to confirm your assumption, even if the assumption looks evident or the question looks silly or stupid. We should also work more with checklists, like it is done in modern aviation. Don’t focus only on your own specialty, but focus beyond your own domain.
So…every doctor can save lives. Even an ophthalmologist! By keeping an open mind. On the other hand, not having an open mind, or making assumptions can cost lives!
REFERENCES
- LOLLY DASKAL. The Story of Everybody, Somebody, Anybody And Nobody (Blog). Available at https://www.lollydaskal.com/leadership/story-everybody-somebody-anybody-nobody/
- Marfan Syndrome, Medscape. Available at https://emedicine.medscape.com/article/1258926-overview