The Yale Journal for Humanities in Medicine

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Notes from a Healer

The Beauty of Clinical Medicine

“She coughed up blood this morning. When my son came running down the stairs with the news, I thought, ‘Yeah, right.’ But then my daughter showed me the phlegm in the tissue. I got a little panicky when I saw the blood.”

In spite of the concerned look on this father’s face, he remains calm as he continues his story.

“She coughed again, and this time there was more blood—bright red blood, mixed in with the mucus.”

“Did you hear her cough? Was it a particularly hard cough? Did she retch with it?” I ask him.

“No, not at all. I would say it was just a small, soft cough. But the sneezing—wow! She must have sneezed a dozen times beforehand. Then, after all this, she blew her nose. When I saw more blood, I said, ‘That’s it—we’re going to see the doctor.’ ”

I nod my head. Then I ask: “The blood in the mucus from her nose—how would you characterize the color? Was that bright red as well?”

The father wrinkles his forehead in thought. “No, it wasn’t bright red. I would say it was more,” he searches for the word, “muted. You know, dark.”

I collect my instruments—throat lamp, tongue blade, stethoscope—and step over to where my nine-year-old patient sits on the table to begin my examination.

“We just saw ‘The Bells of Saint Mary’s,’” the mother pipes up from the chair in the corner. She has been listening quietly to her husband’s rendition of these morning events. A registered nurse, she had been on shift at the hospital when all this took place. “Of course, the first thing I thought was, ‘Oh my God, she’s got tuberculosis!’”

“Had she been ill lately with fever, night sweats, weight loss?” I ask over my shoulder as I peer into the girl’s nose and throat. “Any exposure to a known source of TB?”

“No, she’s been a healthy girl. But still, you wonder about such things.”

I nod my head again as I pop the earpieces of the stethoscope into my ears. Sometimes a medical education can be a curse when it’s your own child that’s sick. You know too much; your mind races ahead, straining to hear the distant hoof beats of zebras. Those of us in medical practice know that, although zebras exist, in this neck of the woods all we see for the most part are horses.

The girl’s lungs are clear, clear as the bells of Saint Mary’s. There is no fever. I noted the small amount of dried blood in the nasal passages. Otherwise I have examined a perfectly healthy nine-year-old girl, who smiles up at me and giggles.

“So, what do you think—should we get a chest x-ray? Does she need blood work? How about a TB test? Or do you just want to treat her for a sinus infection?” The mother pummels me with her questions like a professional boxer in the ring.

“Actually, I don’t think that we need to do any of those things right now,” I say, choosing my words carefully. A silence descends on the room; neither parent speaks, waiting for me to continue my explanation.

“Putting it all together, it probably went like this. Your daughter had a severe sneezing fit this morning, resulting in a posterior nosebleed. This dripped down the back of her throat, mixing with the mucous post-nasal drip from her recent head cold. This was the bright red blood-tinged phlegm that she coughed up immediately afterwards.

“The blood in her nasal passages clotted, turning darker as it dried. This was the more muted blood that you saw in the mucus that she blew out of her nose,” I explain. “There’s no sign of systemic illness, nothing that would suggest tuberculosis at this point. I think you can safely take her home and just watch her over the next day or two.

“And if things get worse?” the mother asks.

“Just give us a call. We can always reassess her and order any additional tests we might need to. But I predict a speedy uneventful recovery,” I say, smiling at the girl.

She beams back at me. Her parents collect their coats and prepare to leave. “Thanks, Doc. This was a bit scary for us.”

“I can well imagine. You did the right thing bringing her in to have her checked.”

Satisfied, the family walks down the hallway and disappears around the corner. As I watch them go, I think, clinical medicine has a beauty all its own. When we’re not rushed and can take the time to listen to our patients, many times we can make the diagnosis on clinical grounds without having to order all of those specialty studies. And close follow-up with the family is a wonderful bit of tail-coverage.

About the Author

Brian T. Maurer has practiced pediatric medicine as a Physician Assistant for the past three decades. As a clinician, he has always gravitated toward the humane aspect in patient care—what he calls the soul of medicine. Over the past decade, Mr. Maurer has explored the illness narrative as a tool to enhance the education of medical students and cultivate an appreciation for the delivery of humane medical care. His first book, Patients Are a Virtue, recently reviewed in The Yale Journal for Humanities in Medicine, is a collection of fifty-seven patient vignettes illustrating what Sir William Osler called “the poetry of the commonplace” in clinical medical practice.

Published: January 14, 2008