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Feb 11, 2013

Faint Hope

Author Affiliations

Author Affiliations: Medical School for International Health and Department of Geriatrics, Ben-Gurion Univerity of the Negev, Beer-sheva, Israel, and Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada.

JAMA Intern Med. 2013;173(3):180. doi:10.1001/jamainternmed.2013.1536

I have much in common with my 92-year-old dad. Both of us are bald, and both of us are men. We both grew up in Toronto, and we both dislike buffets. And, unfortunately, we both have a tendency to vasovagality.

When I awoke one day feeling nauseous, I tried at first to ignore the symptom. I went early to the office prepared to tackle my e-mails, which I try, Sisyphus-like, to clear away at first light. Soon, I felt severe nausea, now accompanied by light-headedness, and sweating. Having learned from experience, I quickly lay down on the floor and put my feet up. Within 20 seconds, I began to feel better, and a minute later, I had apparently quite recovered.

Not really too worried, like any good doctor, I took a history and did a brief physical: no chest or abdominal pain; no shortness of breath, chills, or rigors; no other localizing complaints; pulse, 75 beats per minute and regular; respiratory rate, 14 breaths per minute. My expert opinion was that this middle-aged male patient was experiencing a mild gastrointestinal tract upset.

A few hours later, while I was on the wards going over a clinical presentation with medical students, my symptoms returned. Knowing that my self-help technique might spook them (after all, I am the school director), I lay down on the seminar room floor calmly saying, “Don't be concerned, but I am feeling just a bit unwell. It's really nothing at all. Please continue.”

Being students, albeit somewhat stupefied by this unexpected turn, they went on while I kept up my supinely Socratic patter. However, one student, an ex–Marine Corps combat pilot, bravely, albeit hesitantly, got up the nerve to query the reclining clinician.

“Dr Clarfield, I am really sorry to question you, but I mean, I hope I'm not being out of line here. . . . are you, maybe, using denial? It happened once to my dad and I did want to make sure . . . You're not . . . I don't know . . . ”

“Not to worry,” I quickly reassured, touched by her obvious concern. “I'm just fine; you see: 75 and regular, no chest pain, no shortness of breath, and I am feeling better already. As you were!”

And she was—deferring to rank although with understandable reluctance. After a few minutes, I got up and the students finished the clinical presentation.

I returned to my office on my own steam in time to meet a cardiologist and the vice-rector from a West Coast medical campus to discuss a possible collaboration between our institutions.

Soon after we began, I felt the wave of nausea with resultant faintness. As I had done earlier in the day, I slid off my chair and sank to the floor, doing my best to reassure my guests. The cardiologist seemed nonplussed, but the administrator became very excited and thrust his smartphone toward me as he prepared to photograph me.

“Hold it!” I said, holding up my hand as authoritatively as one can from such a compromised position. “Do not photograph me, please!” I commanded. “Let us just continue with the meeting shall we?” Which is just what we did.

Clearly, I did survive these episodes. Whatever they were, the pathophysiology was unlikely to have been anything more serious than a family-friendly vasovagal dip. All the fuss was probably secondary to a mild viremia, which during the course of the day, developed into a benign upper respiratory tract infection. Tincture of time had uncovered the underlying pathology.

Returning to Dad, while we have much in common, we clearly do differ in some ways. For example, I am a doctor and he is not. Now, I have always chosen (short of an emergency) to maintain my role as his son and not physician. I have found him the best doctors and have instructed Dad as to when symptoms were trivial or required the immediate collegial attention. But he is a pretty good student and usually knows when and when not to seek external medical help.

And it is here where we also part ways. He is a much more compliant patient than I am, as evidenced by the events of the tale just told. As my physician-wife pointed out, given my status as a 62-year-old male, my faintness and light-headedness certainly could have augured something more serious.

In retrospect, on the one hand, my obvious use of “informed denial” seemed, at least this time, not to have done any harm. On the other hand, it is clear that I should have involved a more disinterested clinician—proving the old adage that a doctor who chooses to look after himself has a fool for a patient.

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Article Information

Correspondence: Dr Clarfield, Medical School for International Health-Bet Caroline, P O Box 653, Beer-sheva 84105 Israel (markclar@bgu.ac.il).

Published Online: January 14, 2013. doi:10.1001/jamainternmed.2013.1536

Conflict of Interest Disclosures: None reported.