An internal medicine resident is dining with his family in a restaurant. As the server brings their food to the table, the resident notices her hands. She is in her 50s and exhibits subtle but definite finger clubbing — an important sign of possible serious disease.
The resident shared this experience with hundreds of thousands of his peers via Figure 1, the global knowledge-sharing platform for healthcare.
“Do you point this out as a potential harbinger of disease?” he asked in the community. “Do you remain silent not wanting to break social norms and highlight potentially sensitive physical conditions?”
More than 100 healthcare professionals shared their opinion. Here’s how they responded:
About a third of respondents said they would have mentioned the finger clubbing:
“I think it depends very much on the setting: if the person is not looking frazzled, seems approachable, and things are not busy, I might take a gentle minute or two to encourage them to see a physician; if the setting would result in a rushed, perfunctory commentary then I would not.” – Pediatrician
“Clubbing I wouldn’t mention, so many possible causes, too aspecific for me. Now, if I noticed a melanoma, for instance, I would feel obliged to speak up. My bringing it to the person’s attention might save their life.” – Family medicine physician
“Interesting question. I go to a bank where a younger man was a teller. He was always pleasant, knowledgeable, and helpful. He was there several years, and I always noted his finger clubbing. I never mentioned it to him, as he otherwise looked generally healthy, however on the thin side. Went to the bank one day, and a sign at his teller station stated he had died suddenly. Always haunted me.” – Physician assistant
“I very strongly disagree with remaining silent. As physicians, it’s our calling to help patients that are in need of medical help, whether they ask for it or they are unaware of their predicament. I have been in that situation many times and I always said something to draw the patient’s attention to a symptom. It can be done gradually depending on the patient’s initial response.” – General Surgeon
“I’ll never forget my dermatology teacher, one of the famous men of his time. He saved the lives of some people by approaching them wherever he saw them and sending them to their doctors because of malignant tumours.” – Pediatrician
Many zeroed in on the larger idea of informing a stranger that they appear to be at risk for disease.
“I think it’s interesting that people are willing to point out things like clubbing and melanoma, yet, if this woman was obese would you say anything then? How about the rest of the obese population, which when you’re out in public is a massive amount. These are people that walk around everyday as ticking time bombs and I highly doubt you’d say anything then….” – Registered Nurse
“That little tidbit of information is not going to escape their notice. It’s not like noticing something that only a healthcare provider would know to look for. I’m overweight, and I struggle with it every day. I know very well that extra weight isn’t good, but losing it is easier said than done. Somebody who randomly says ‘did you know you’re fat?’ isn’t going to accomplish anything useful.” – Medical Student
“Fat people know they are fat and that it means they are not living the healthiest. Clubbed fingers can be a sign of internal malignancy, faults in oxygenation, etc. If they were sunburned I wouldn’t say “Hey, did you know you’re sunburned?” If they complained about their knees hurting to me I would very much bring up their obesity and talk about Q&D weight loss strategies.” – Medical Student
Most healthcare professionals took a strong stance against saying anything.
“I would not say anything. She may be already aware of her condition and being treated. I would only bring this up with a close friend, not a stranger.” – Registered Nurse “I wouldn’t say anything unless they asked. Health is a very personal decision and you wouldn’t want to unnecessarily put her in a weird space. Now, often if people know you are a healthcare provider they will have an implicit level of comfort (trust) and may ask your advice — then it’s OK.” – Orthopedic Surgeon
In the end, the internal medicine resident who posed the question offered this conclusion:
“While medicine is often focused on the right answer, part of the art is knowing how, when, and where it is best used. As many of you point out, certain conditions, social circumstances, and other factors play into your level of comfort when engaging in a potential patient-provider relationship in the community. Personally, I did not mention the clubbing, but I don’t think doing so would be wrong.”
What would you do? Do your colleagues disagree? Healthcare professionals can join the discussion here.