It was one of the usual slow sunrises of this time of the year, and the sky, pure violet in the zenith, was leaden to the northward, and murky to the east, where, over the snowy down or ewe-lease on Weatherbury Upper Farm, and apparently resting upon the ridge, the only half of the sun yet visible burnt rayless, like a red and flameless fire shining over a white hearthstone. The whole effect resembled a sunset as childhood resembles age.
-Far From The Madding Crowd, Thomas Hardy
Experience is fallacious and judgment difficult.
-Aphorisms I, Hippocrates
Doveryai, no proveryai.
-Russian proverb
Sir William Osler, the great Canadian internist, opened his magisterial textbook The Principles and Practice of Medicine with the above quote from Hippocrates. For many years, it seemed to me somehow both right and wrong. Judgment surely can be difficult but to accept that experience might be fallacious was not easy to accept. For surely experience, hard won and well-earned, must not be fallacious. If so, what value could there be in the decades of accumulated wisdom that my mentors had tried to bestow upon me?
It has taken nearly two decades of a life in medicine to understand that experience can be potentially both a lifesaver and a pitfall. With regards to the decisions that we make based upon our experience we should, per the old Russian proverb, trust but verify.
One morning, early in my career, I had the opportunity of relieving my somewhat older colleague from a night shift in a sleepy little rural emergency department in southern Georgia. We had time to chat as he told me about the one active patient he was signing out to me. He was a young man, quite obese but otherwise healthy, who had come in with a cough and fever for several days. He’d developed severe back pain the evening prior and it had scared him a little and so he’d come into the emergency department and was seen by my colleague. He’d had a low-grade fever on arrival, which had resolved with ibuprofen, and his oxygenation had been fine, but my colleague noted that he looked a little short of breath, like he was “working for it”. His labs had showed a slight white count and his chest x-ray had been clear without any evidence of pneumonia. He had felt better with his fever down but my colleague, older and wiser than I, had sensed that something was still amiss and had ordered a CT scan of the chest.
“Do you think he’s got a PE?” I remember asking him. A PE is short for a pulmonary embolism, or a clot in the lung, and can be a devastating cause of acute shortness of breath.
My colleague sighed and shook his head. He didn’t think so but he couldn’t be sure. He hadn’t any risk factors for PE but stranger things had happened in the haunted house of medicine. He admitted that he was more concerned that the patient could have pneumonia.
“But his chest x-ray was negative?” I asked.
He nodded his head yes as he packed up his bag before waving and heading out the door.
After he’d returned home to a warm bed and a well-deserved rest, I went in to see the patient. He was a young man in his twenties, surrounded by two friends, laughing over a joke shared between them. LGFD, I remember thinking as I walked into the room, Looks Good From Door.
Indeed, he was amiable and smiling, glowing iPhone in hand (positive iPhone sign). He told me the same story he’d reported to my overnight colleague. Upon closer examination, he looked just a little short of breath after longer sentences and, I noticed warily, there was a faint sheen to his brow. Again, one should sweat a little when one’s patients are sweating. I noticed he would occasionally wince when he laughed. He was perhaps breathing a little harder then he ought to though not trying to look the part with friends in the room. I listened to his lungs and his right base sounded a little diminished. Did I hear a crackle or two? It was hard to say…
I informed him that CT would be by to take him any minute and left to review his chest x-ray. It was not a great x-ray as the patient had failed to take a deep breath however it was otherwise definitely negative for anything acute. I sat and pondered the young man and wondered if I would have even ordered the CT scan. Didn’t he just have a viral upper respiratory tract infection and some back strain from coughing?
A few more early morning patients arrived and distracted me before I received a call from radiology.
“No PE, but your patient has right lower lobe pneumonia,” came the oracular voice on the other side of the phone.
“Who?” I asked, briefly confused.
“Mr. Adams,” came the reply. “On his CT scan he has right lower lobe pneumonia. We missed it on the chest x-ray. He looks like a big fella and didn’t take much of a deep breath. It’s hiding behind his right hemidiaphragm.”
I quickly pulled the CT scan up and scrolled down through the chest. Sure enough, there behind the diaphragm, elevated on account of his poor inspiratory effort during the x-ray and due to fatty liver from the patient’s weight, was a nasty bit of pneumonia currently ravaging the poor man’s right lower lobe.
“Thanks,” I replied numbly, thinking about how I had thought that I might not have even ordered the test earlier in the morning and that my colleague might have just needed a little more sleep. I went and informed the patient and saw that his oxygenation had dropped. He was no longer joking with his friends or playing games on his phone. He suddenly looked sick and, to that end, I put him on some oxygen and some antibiotics and admitted him to the hospital for right lower lobe pneumonia, which had proved to be the cause of his shortness of breath, fever, cough and back pain.
What makes this story especially poignant for me is that about 7 years later, in the same emergency department, I was working an overnight shift when a young woman in her twenties checked in with back pain and cough. She had a fever. I went to go and take a look at her and she was smiling with a few friends in the room-iPhone in hand. She had a wisp of sweat on her brow as she spoke to me and winced when she inhaled deeply. I listened to her and thought I might have heard a few faint crackles at the right base.
I was immediately brought back to the young man from 7 years earlier. I knew, without a doubt, that this young woman had right lower lobe pneumonia. Her chest x-ray was also clear but it too was taken with poor inspiratory effort and she too was obese and had an elevated right hemidiaphragm. I ordered the CT scan and there, hiding behind that elevated right hemidiaphragm, was her pneumonia.
I often wonder that if I hadn’t had the experience of the first patient would I have had the clinical gestalt to order the CT scan on the second? I don’t know the answer to that but I do know that as soon as I saw her, I thought of the other gentleman from seven years prior. The words “right lower lobe pneumonia” flashed across my conscious mind like a marquee. I was dead certain of it and, sure enough, there it was.
It is in this sense then that experience can provide the careful doctor with invaluable insight into his patients. The observant and caring physician with many years tucked away under the belt will have an entire army of old patients and presentations at his disposal from which to draw upon as he examines the newest patient to sit before him. This kind of knowledge cannot be taught in textbooks and is the fruit of experience and yet, as the hoary Hippocrates and the more recent Osler have commented, experience can be fallacious.
The great tiger trap of experience is that it may lull the physician into a state of breezy and self-assured complacency. Experience can be a truly formidable arrow in the quiver but nobody has seen everything and many diseases look alike. Furthermore, many illnesses have variable presentations. Syphilis was once considered “The Great Imitator” given its diverse and manifold clinical appearance across the spectrum of organ systems. Tuberculosis has also been awarded the moniker and then later HIV/AIDS and now even COVID-19. The truth of the matter is that medicine is not easy and experience may be either a sail or an anchor. It can save you or sink you, depending upon how one uses it.
Perhaps this gets at the core of the matter. We should seek experience for the wisdom it provides but then, critically, we must know how to use it properly and to its greatest effect. Once we step in and talk with the individual patient in front of us and perform a focused physical exam and understand the patient’s concerns, signs and symptoms within that specific patient’s context, only then can we step back out again and integrate that information within the overall higher and more battle-tested vantage point of our experience as physicians. Once again, we take the tacit and intuitive step back to grasp the overall situation, the explicit, focused and empirical step in to gather critical details for this or that specific case and then the final implicit drawing back again to apply the case to the broader medical canvas that we’ve accrued over the years and to the individual patient in front of us.
Experience has a role in each of these three steps, and can be of immense value in each of them, but the humble physician will always remember that experience blindly relied upon can lead the unsuspecting doctor astray. As they say in medical school, our patients do not read medical textbooks and it is our experience that allows us to both rise above the dusty precepts learned behind a desk or, possibly, fall into a certain kind of “expert” self-assuredness. The goal, as is so often in life, is Aristotle’s “Golden Mean”. Experience should be a guideline more than a rule; a very helpful crutch but never an infallible one.
The accomplished physician will have as much of an understanding of what he knows as about how much he doesn’t know and indeed, it is the inexperienced physician who will place the greatest confidence in the small amount of experience that he has managed to obtain. In a somewhat counterintuitive way, the greater the experience: the greater the doubt and the greater the humility. Like that old midwife Socrates, the more one knows, the more one knows how much he doesn’t know. Or to put it more poetically, as Shakespeare puts into the mouth of Hamlet, “there are more things in Heaven and Earth, Horatio, than are dreamt of in your philosophy.” We must not become so complacent in our experience that we forget about the legion of possibilities that our patients represent. To do this would be to fail to hear the beating wings of Nemesis at our back. Pride goeth before the fall.
Put another way, books are well and good, necessary even, as a foundation but it is putting in the hours that counts and only then does one realize how truly lost at sea one really is. As such, it would appear that books beget knowledge but experience (correctly accrued, understood and applied) begets humility and humility illuminates the road to wisdom. The experienced and self-aware physician must always be a humble one. If there are no other lessons to be learned from this series of essays, let that one take root and flower in any who would embark upon this mad and beautiful and worthy quest. For to heal is hard and if one thinks otherwise then I would submit they, much like Socrates’ interlocutors, don’t know that they don’t know.
Thought provoking……….