So who is to say that excellence was or was not achieved in the management of a specified case? The practitioner? His peers? The patient? A duly appointed committee of all interested parties?
These thoughts and more have run through my head following a recent case.
My heart sank when I read the courteous and succinct referral letter from a general practitioner whom I know well and respect. A 17 years' old girl with intractable headaches. It was the last case on the list, the end of a long clinic. I was tired and running late. Sister had glanced at her watch.
Miss C entered and sat down. Quiet, mature, in school uniform with a prefect's badge, but uneasy, even a little hostile. Both parents came in too: well to do and worried. Father did most of the talking, prompted by mother. Their daughter sat and fidgeted, answering direct questions in monosyllables. The history was familiar.
All was well until three months ago. Her school reports were always good, and she was in for four papers at "A" level next year. Her teachers had spoken of a sixth form career leading to university - Oxford, perhaps, even medical school.
There were no physical signs; indeed, she seemed to be in excellent health. She was no more forthcoming about her troubles when her parents were absent.
The diagnosis was clear: tension headache syndrome. She needed explanation, discussion of precipitating factors (if admitted), and reassurance. But it was going to be difficult. Heads are mysterious and important. Pain must mean something is wrong. Brain tumours can cause headaches, and rarely might present like this. Surely a brain scan should be done?
At such times I become aware of an angel whispering into my right ear, and a snake into my left.
The snake is a realist. Nothing that l say will finally reassure the parents. I admit l cannot be absolute about the diagnosis. The general practitioner has suggested that a scan might be necessary and the parents are expecting it. If I do not do it then no doubt there will be another referral to someone who will, probably that old so and so in the next town who will see them privately and discreetly imply that I am careless in such matters. What if new signs appear and there is a tumour? I might be sued.
It had been a long day. I shied from the hassle. I listened to the snake.
The scan was normal. I heard that she did well in the examinations, and that the headaches are much less troublesome, but I have not seen her since.
Her parents and their general practitioner were pleased and satisfied. I cannot speak for the patient.
l am not. I know that I failed to achieve excellence in this case. Worse, l suspect that I shall do the same again next time. It is always easier in medical practice to do something than it is to explain convincingly why it is unnecessary.
Perhaps medical excellence is impracticable.