Notes from a Healer

Number Games

Brian T. Maurer

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It's the cough that brings him in today – that and the sore throat.

The cough has been there for two weeks. It's been dry for the most part, occasionally productive of clear phlegm. The sore throat, on the other hand, just came up two days ago. He had a mild headache early this morning, but there's been no elevation in body temperature. Normally, these signs would not be of any particular concern, but in this 15-year-old adolescent they might be harbingers of major import.

Two weeks ago the CT scan of his chest showed something, perhaps a tiny bit of fluid or congestion in the one lung, though it could have been an artifact, some undefined aberration. His mother tells me they weren’t certain; the oncologist said they would watch it closely to see if anything developed.

The PET scan demonstrated an area of increased uptake on the left side of the throat. They couldn't be sure: it might have had something to do with the fact that he had just come in from the cold before the scan was done—an aberration due to brown fat and that sort of thing, they said. In any case, the boy is scheduled to meet with the oncologist in 48 hours for a recheck.

I examine the boy. Overall, he seems to be comfortable. Mentally, I recall the humdrum medical acronym, NAD: no apparent distress. His throat is mildly injected; I can feel no swollen nodes in the neck. He aerates well over all lung fields; his heart sounds are normal. His body temperature registers 98.4 in the office.

"It looks like he's coming down with a cold," I say. "I don't detect any signs of an impending infection at this point. We’ll have you monitor his temperature at home. Call the office if fever develops or of there is any change in the character of the cough or sputum."

The mother nods her head. "It's just so frustrating," she says. "They've been following his AFP. It's been rising steadily over the past several months.  The last they checked, it was over 500.  When they found the nodule in his lung, they were sure the cancer had spread; but in the end the biopsy was benign. No one can explain that one. What do you make of it?"

"Unfortunately, medicine is not an exact science. As amazing as modern technology is, it's not foolproof. Sometimes you end up chasing lab values to no end. Scans can detect artifacts as well as bona fide lesions. You try to put the pieces of the puzzle together as best you can.”

My words sound so coarse; for a moment I question the wisdom of having tipped my hand. I know that this mother and her son seek facts, not nebulous pontifications. Still, that is the best I can offer at present.

"Sometimes illness—in particular, serious illness—can overwhelm us. I don't mean to sound trite. It's important to maintain your perspective, to look at the big picture. Yes, some of these signs are disconcerting; they have to be followed up. But overall, you seem to be doing rather well. You new liver is functioning fine; there's no sign of rejection. You're growing well, putting on weight, getting taller, filling out. You can last through a 2-hour JV basketball practice, which is more than I could do at my age. In spite of everything, you've been having a good run."

The boy nods his head. His eyes have not left my face. He seems to have hung onto every word.

His mother looks up at him. "I just wish..." she starts, but then her words drift away. "Well, I suppose there's nothing more to be done right now. We'll keep our eyes on him and call you if there's a problem. Otherwise, we'll follow up with his oncologist day after tomorrow."

They rise to go. The boy pauses in the doorway of the exam room to offer me his hand. "Thanks," he says. I can see in the depths of his eyes that the word is heartfelt.

Mentally, I blow on the dice, give them a good shake, and toss them down the table against the boards.  I’m hoping it’s a good roll for him.

Even with the best medical science, when you play the number games sometimes it's still a crap shoot.


About the Author

  • Photo of Brian T. MaurerBrian 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 patient vignettes illustrating what Sir William Osler called “the poetry of the commonplace” in clinical medical practice. Interested readers can read more of the author's writings at his website and blog.

  • Published: March 4, 2012