Scoring a hole in one for the generalist

Sometimes a compromise on guidelines can be in the best interests of the patient, writes Dr Leon Piterman

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“Doctor you look after me. My cardiologist just looks after my heart”. 

These were the words Bessie uttered as she proudly displayed her trophy … a mounted golf ball with which she scored a hole in one on the par three, 130m, eighth hole at her local course. 

Scoring a hole in one is an achievement for any golfer at any stage in life. What made Bessie’s achievement more noteworthy was that she was 84 years old and being treated for cardiac failure and osteoarthritis of her hips and knees.

I had looked after Bessie, as well as her late husband, for more than 20 years. John passed away 12 months before Bessie’s momentous achievement. A keen golfer himself, he would have been extremely proud of her achievement.

Bessie had a multitude of complaints which included hypertension, ischaemic heart disease (treated with stents) aortic stenosis, gastro-oesophageal reflux and osteoarthritis of hips and knees. She had a right hip replacement and was contemplating replacement of her left hip.  

Had Bessie been alive today, she may well have had her aortic valve replaced though a transcatheter aortic valve implantation which might have overcome the objections that she was medically unfit to survive open heart surgery. As it stood, Bessie had already had two admissions to hospital with acute pulmonary oedema associated with chest infections.

 Following John’s death, Bessie felt overwhelmed with all the legal and accounting matters that she had to attend to. John had been a chief executive of a large food-distributing company prior to retiring and had always taken care of all financial matters.

While she received some help from her son and daughter, Bessie felt she needed to learn basic book-keeping to manage her finances, so she enrolled in a council of adult education course on computers and book-keeping. This gave her confidence and reinforced her independence.

Six months after John’s death, Bessie decided to start playing golf again, having given it away a year earlier to look after John during his terminal illness. She found herself able to manage nine holes without too much effort from a cardio-respiratory perspective. But her knees and left hip caused considerable pain after three holes.

This was debilitating and depressing. Golf was not only a useful form of exercise, it also was an opportunity for social engagement and was emotionally and spiritually uplifting. Being unable to complete a round once a week, let alone twice, as she had hoped for, meant a major source of enjoyment was gone and the quality of her life was consequently diminished. 

John had been taking celecoxib for his joint pains. Bessie decided to try John’s celecoxib a day or two before the golf games, and on the morning of the game. She found that she could get through the game comfortably if she did this.

During a visit to her cardiologist she mentioned the celecoxib. He was most upset. “You must never take celecoxib. It will raise your blood pressure, cause fluid retention and worsen your heart failure, not to mention the effect on your reflux. I really forbid you to use it,” the cardiologist told her.

Bessie was quite surprised by his reaction. It was as if he was taking it personally.

Bessie was tearful and distraught as she explained her predicament to me. She was sure the cardiologist was acting in her best interests from a medical perspective, but at the same time she felt he was removing one of the few pleasures she had left. She sought my advice – not an unusual reason for a GP consultation following patients leaving specialists’ rooms in a confused state. 

We teach our medical students to take a bio-psycho-social approach to diagnosis and management. It is a pity that much of this is lost in contemporary hospital training, or if not lost, is compartmentalised so specialists no longer care for the whole person, but for only for a particular organ or system.

Fully appreciating Bessie’s dilemma, I felt it was time to compromise on guidelines in the interest of her enjoyment of life. I acknowledged the possible dangers of celecoxib, but felt that these could be modified through controlled and judicious use of the drug.  I suggested that on the two or three days she takes celecoxib, that she should take an extra half a furosemide and monitor her symptoms over this period, as well as her weight and blood pressure, using her home blood pressure machine and contact me if she gained a kilogram or more, or if her blood pressure went beyond 140/90.

I also advised her to restrict her golf to one day a week instead of two, or one day a fortnight.

Bessie was already taking a PPI, so hopefully her reflux would be controlled. She agreed to this compromise, and I continued to see her on a monthly basis. Her golf had never been better and nine holes were no longer a challenge.

Three months later I heard laughter and cheering in the waiting room. Was it birthday celebrations, perhaps? 

No, it was Bessie showing off her golfing trophy. I have never forgotten her remark: “Doctor you look after me. My cardiologist just looks after my heart.” 

Surely reductionism has gone too far. It is time to celebrate the generalist. 

 Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40  years 

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