Zero

Zero is a total absence of measureable quantity, an insignificant person or thing. The first recorded use of the word zero in the English language was in 1598.¹ However, the concept is ancient, perhaps first captured by the Sanskrit word śūnya. In ancient Egypt, the word for zero was nefer, a word whose hieroglyphic symbol is a heart with trachea. Nefer could mean “beautiful, pleasant, and good.” But it was also used to represent the base level from which temples and other buildings arose. It is from that meaning that our current concept of zero evolved.

Figure 1.

The Egyptian hieroglyphic symbol nefer, thought to represent a heart and trachea.

Yesterday I opened my monthly Press Ganey report. There had been four responses. My score was 75%. Three had been 100% and one was zero. The rating was on a scale of very poor (0) to very good (10): friendliness, concern, information, instructions, time spent, and confidence in the provider.

What had taken place in my exam room that day that led to zero? Had I not been there, leaving the patient to wait and ultimately leave unseen? Had I forgotten some portion of the history and physical exam? Why had this patient felt that the time spent with me had no value? Or that I had no value? I felt sorry for myself immediately. I was, after all, being victimized by a capricious and malevolent patient. I felt helpless, asking, “Why don't I have the opportunity to rate patients? Why can't I give them a zero?”

In her comments, the patient had left a clue: “Dr. Michel only listened to my heart in four places.” When I told colleagues, this comment elicited laughter. After all, how many places did most physicians listen? One? The so-called triple point where lungs, heart, and bowel might be auscultated by the lazy or the rushed? But on reflection, I realized that something entirely different had taken place.

I suspect that the patient's side of the story is more interesting. I went into the chart and reviewed my prior notes. On a prior visit I had written, “The patient states that she does not feel that I am meeting her needs, and I have offered her referral to a different specialist. She reports that she would like to continue to see me.” Fascinating. I was failing even then, but she still wanted to give me a chance. I had known this going into our last visit. So why had I failed?

For decades she had been cared for by of one of our group's most senior providers, a man who had trained in cardiology before Andreas Greuntzig performed the first angioplasty.² He was a cardiologist of the old school. His patients were accustomed to long visits and subjected to physical exams not properly performed since Paul Dudley White, Samuel Levine, and Paul Wood walked the wards: squats, Valsalva, left lateral decubitus positioning. Wood had famously required his students to sign a pledge to examine each patient's neck veins with enough care to distinguish “v” from “a” waves.³ During our visit, I had not looked beyond the absence of jugular venous distension, clicking “not present” in the electronic medical record. I had listened for, and heard, S₁ and S₂ but had not timed the splitting of S₂ or palpated for a right ventricular heave or thrill.

I had listened in four places, with the patient sitting up in a chair before me. She had removed her coat but not her shirt. She had never climbed onto her accustomed exam table. There were no deep breaths and held exhalations; no turning on her side or leaning forward or coughing. She had had no opportunity to participate in a dance she had shared with her cardiologist for more than a quarter century. Her partner was gone. She had been left behind with a new doctor who did not know the steps.

So, I have begun to build my physical exam anew from a base of nefer, or zero. Before her next visit I will relearn all of the steps. I will disrobe my patients from the waist up and place them into supine, sitting, and standing positions. There will be palpation, auscultation, and percussion. And when my patient returns in December, she will dance a dance long forgotten.