On the theme of ‘That one patient’, Dr Peter Nutley writes about a patient he never saw, but who remains with him
Some patients are memorable for the wrong reasons. I did what I should have done. I even got a ‘thank you’ note, which is uncommon for a locum, but the events still sadden me. I never even saw the patient.
She was 62 years old and generally in good health. She had first contacted the surgery during the Covid pandemic, concerned that she was unable to lose weight. As she was taking levothyroxine, the GP she spoke with arranged a thyroid function test, the result of which was in the normal range.
She rang back to ask what to do next. I spoke with her. She sounded sincere. She had lost seven stone over a couple of years, and then regained almost three which she now couldn’t lose.
‘I know what to do,’ she said. ‘I walk 20,000 steps every day. I know all about dieting. I record everything I eat, and I cook our food. Others in the family are losing weight.’
I suggested a slight increase in levothyroxine of 25 micrograms a day, as the TSH was towards the top end of the normal range. I couldn’t think of anything else to do, so I arranged additional blood tests.
I rang her with the results, which were normal except for her haemoglobin which was 99 g/l, and her MCV which was low at 76.6 fl. I explained that these results suggested an iron deficiency anaemia, and she needed further investigation. I arranged a faecal immunochemical test (FIT).
The FIT test was strongly positive at 200 ug/g. I rang her again to explain that the FIT test showed that there was blood in her stool and she needed a two week wait referral to exclude bowel cancer. That was the last time I spoke with her.
Three months later I was shown a letter she had sent. She had written to the practice:
‘Please pass on my thanks to [the doctor] for believing in me when I phoned regarding continued weight gain. He could have just said it was due to lockdown, but no; he sent me for blood tests which did end in a diagnosis of cancer but thankfully detected early as no symptoms.’
I was shown the colonoscopy report which revealed multiple polyps and a rectal carcinoma. She had surgery and an ileostomy.
A few months later I heard that there had been complications with the stoma requiring admission to hospital. Unfortunately, she contracted pneumonia and passed away.
Sir William Osler famously said: ‘Listen to your patient, he is telling you the diagnosis.’ I had listened to this patient. And indeed, she was grateful that I had. But if she was telling me the diagnosis, I didn’t hear it.
At the time I couldn’t come up with a reason why she had difficulty losing weight. But, thinking about her again, as I have done over the years, I wondered whether there was a link between colorectal cancer, the gut biome and weight gain. A topic for next year’s personal development plan.
I often remember this patient. I was pleased that I took the correct action. But I remain sad for the unfulfilled hope in her letter.
Dr Peter Nutley is a locum in Hertfordshire
