Schrödinger’s anaemia
This is one of the Back Pages articles I used to write for the British Journal of General Practice towards the end of my career as a GP. It was published in June 1998 and describes a true incident which had happened just before I wrote it.
I think it says something about the reality of front-line medicine which is timeless and worth repeating here.
“I see, I think I understand now – you don’t know what’s wrong.“
He’s got it.
He’s here in my evening surgery to find out why the consultant he saw this morning wants him straight in hospital. Something about “ulcers”. Grey, anxious face. Deep lines deeper. Brave, frightened eyes.
Time to recap before he leaves to face the weekend’s wait. “Three reasons you could be anaemic . . .” Tick off the fingers. “. . . it could be your arthritis doing it all by itself, it could be the new tablets affecting your bone marrow, or it could be the Naproxen giving you an ulcer in your stomach which is bleeding.
So at the moment we’re covering all three possibilities – you stopped the Sulphasalazine as soon as I rang you, the consultant has asked you to stop the Naproxen until he’s looked in your stomach, and when he’s done that and we know what’s going on, we can get back to treating your arthritis.“
I make a joke of it as he goes out through the door, “At the moment we just have to treat you as if you’ve got all three . . .“
Except that it isn’t a joke. In a very real sense, at this moment he has got all three. Like the quantum physicist Schrödinger’s imaginary cat, which is somehow both alive and dead until the moment you open the box and look inside, this man really has, in effect, got all three things at once, in a kind of weird superimposition, until we resolve the matter by reading the tests.
No joke at all. It is the reality I’m having to work with at this moment. Utterly different from the reality which will appear in retrospect or to an external observer. That way it’s all going to seem wonderfully simple. We’re going to have a nice clear diagnosis; perhaps we will know he had a bleeding ulcer all along. Then we’ll be able to write that down and perhaps code it in our computer. Fixed. Definite. Countable. Simple. That will be that. That will be HIM.
But it isn’t like that at the moment. At this moment, and for that matter for the weekend ahead, he’s going to go on having all three problems, mutually-exclusive though they are. Or actually he’s going to go on having more than three; the subtle variations on the possibilities which are open are almost limitless. And my job, certainly, is to deal with all of them at once.
So that’s the way it seems when I’ve finished my surgery. I’ve seen a patient with a gastro-intestinal haemorrhage, one who is profoundly anaemic from a toxic reaction to Sulphasalazine and one whose essential treatment for Rheumatoid Arthritis has been summarily stopped. And that was just one of the patients, one who actually came for a different reason entirely – because he thought he might die over the weekend from something called an ‘ulcer’ eating away in his stomach.
So he was right, I didn’t know what was wrong. And that is the way it is all the time when we are actually doing medicine, particularly when we are doing general practice. It doesn’t look that way in retrospect, or to an external observer, and we often try to conceal this truth from the patients. But if we forget this we allow everybody, including ourselves, to vastly underestimate the size and the difficulty of our role.
Generally Speaking 