Late Presentations: A New Perspective

When medical students and doctors get bored, they start sharing “late presentation” stories. My first such experience was in third year, when a homeless man presented to us with horribly advanced rectal cancer. I was so disturbed that he had allowed it to progress so far, and I shared the story in a post.

I have lost count of the “late presentation” I have seen since then – one of the joys of working in a tertiary hospital. Women with breast cancers that have basically consumed entire chest walls. A man with testicular cancer the size of a soccer ball (I kid you not). Children with painful impetigo superimposed on severe scabies infestations.

And always, my response in my head has been the one that comes most naturally: WHY ON EARTH DID THEY WAIT SO LONG? Although I always tried to figure out in a respectful manner what the hold-up was, I never considered that my internal frustration could be wrong.

Until during exam preparation I was browsing through Figure 1 (instagram for medical personnel). A picture was shared of a young girl with severe necrotising fasciitis of the perineum. This is incidentally something I have seen often. It spreads rapidly, is life-threatening, and often leaves survivors with severe morbidity. (You can see the picture here – not for the queasy. Note also that the picture is taken post-debridement.)

The general response in the comments of the image was, “How irresponsible of the parents to let it get so far.” I was immediately angered because this is a condition that can advance so rapidly that irresponsibility may not have been a factor at all. But even if it had been two days, who are complete strangers to assume that it was easy for the girl to get to hospital?

I guess it was easy for me to get annoyed because many of the people commenting had no idea what it was like not being able to get immediate health care.

From then on I became more cognisant of these reactions in my own thoughts. The homeless man in the first example I mentioned had no transport and was probably wary of the contempt with which so many homeless people are treated, even in hospitals.

On my rural Family Medicine rotation earlier this year, I went for a hike through the lovely surrounds. We walked past many of the houses in the hospital’s drainage area. Although they weren’t that far away, they were situated on steep cliffs without road access, and much soil erosion. We huffed and puffed for those few kilometres, and I couldn’t imagine how challenging it would be if one was ill and needed to get to hospital.

There is no doubt that denial is a factor in many late presentations, but the more I think about it, the more I feel empathetic, rather than angry. Of course when you discover a lump in your testicle you’re going to think that you want to wait a while and see if it disappears by itself – because what if the doctor wants to stick a needle in it! Or what if an inexperienced medical student has to examine the lump?!

Of course, those reactions are not “right”. But nor is it right to judge the late presenters. That’s not our job.

A kind doctor will ask why the patient waited so long, not because they are angry with them, but because they want to prevent the same thing from happening in the future. I believe that public health is every doctor and nurse’s responsibility, and by identifying stumbling blocks to health care, we take ownership of that responsibility.

Do I still share my “late presenter” stories with my colleagues? Heck yes. But I like to think that my approach to it has changed, because I refuse to become a patriarchal and harsh doctor.