Uncertainty

Medicine is a science of uncertainty, and an art of probability.

Each time I met a patient with not-so-straightforward diagnosis I would remind myself and my junior this teaching by Sir William Osler at the turn of the last century.

Lub dub, lub dub, lub dub. Lub dub, lub dub, lub dub. That's what I heard with my stethoscope yesterday when I examined a gentleman coming to emergency room after feeling breathlessness for two days. Out of pride I refused to rush through the case as that will inflate my chance of failing to crack the puzzle. It wasn't pleasant to miss the additional sound after the usual "lub dub" heart sound, not least after my reading of a medical journal article The Art of Constructive Worrying yesterday morning. I made sure I'd heard that "lub dub whirr, lub dub whirr, lub dub whirr" melody.

Diagnosis resembles a jigsaw puzzle. We are supposed to find the pieces first, then fit them together. One by one. Before the full picture.

My patient clearly had a problem with his heart. What puzzled me is which piece I should focus at the emergency room. Was it because his heart turned oversized after wear and tear from clogged coronary arteries? I didn't have long to reflect on the counterargument that the gentleman neither smokes nor complains of crushing pain of heart attack. A glance at his ECG showed more jigsaw pieces than that of a leaking heart valve; I spotted abundant premature heart beats. Those frequent extra beats, if too frequent, could have caused what we call arrhythmia-induced cardiomyopathy.

Simply put, I was nowhere. There was one possibility after another. Two or three at a time, the possibilities were weighed, and discarded. Other possibilities then cropped up. A good talk with my patient revealed his story of multiple surgery procedures for removing lumps in his neck, torso and legs. I could also palpate some, one of them lurking behind his right calf, not yet operated. By the time I checked his computer record I was pretty sure that he was suffering from a plethora of nerve tumours with a funny name schwannoma. To be honest I don't recall seeing a case of Carney complex, but that could have been the first case in front of my eyes. In short, that's an exceptionally rare inherited anomaly in the human anatomy, with numerous spongy schwannoma and even a tumour inside the heart. Rare, but it can happen.

I don't think I have yet solved the puzzle, but I learned the essence of constructive worrying. Thinking and worrying about the jigsaw pieces that matter most and making plans based on this worrying.