A Collection of Clinical Case Stories as Emotional Landscapes of The General Physician - Waterfall

Short Communication

A Collection of Clinical Case Stories as Emotional Landscapes of The General Physician - Waterfall

Jose Luis Turabian ^*

Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia. Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain.

*Corresponding Author: Jose Luis Turabian, Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia. Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain.

Citation: Turabian JL. (2026). A Collection of Clinical Case Stories as Emotional Landscapes of The General Physician - Waterfall, International Clinical and Medical Case Reports, BioRes Scientia Publishers. 5(1):1-3, DOI: 10.59657/2837-5998.brs.26.058

Copyright: © 2026 Jose Luis Turabian, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: December 01, 2025 | Accepted: January 05, 2026 | Published: January 13, 2026

Abstract

This International Clinical and Medical Case Reports section is a collection of descriptive clinical vignettes, "like the plates in a geography atlas" that will present the emotional situations (empathy, frustration, sadness, joy, exhaustion, etc.) metaphorically described as emotional landscapes (which can have emotional, cultural and spiritual significance for people, evoking feelings of peace, beauty, nostalgia or belonging): mountains, volcanoes, rivers, valleys, islands, waterfalls, glaciers, fjords, estuaries, etc., and who are experienced by general practitioners, when they dealing with different clinical cases and patients, with the aim of achieving a greater understanding of what we are and what we do as doctors in relation to patients. This case illustrates a situation where multiple complementary tests, each showing slightly abnormal results, collectively raise concerns for the physician, making it difficult to ignore them and prompting further testing. This scenario suggests to the general practitioner a waterfall: a sudden drop of water caused by a layer of hard rock in a riverbed. The softer rock beneath is eroded by the river, causing the hard rock to overhang, thus forming the waterfall. With each additional test, the softer rock beneath is eroded by the river, causing the hard rock to overhang, creating a cascade of further investigations, as each test reveals more light abnormalities, leading to an ever-increasing number of subsequent tests. Waterfall impede navigation.

Keywords: diagnostic testing / adverse effects; unnecessary procedures / adverse effects; emotions; frustration; metaphor; general practitioner; cultural context

Clinical Vignette/Emotional Landscape: Sea Cliff

Theresa is a 40-year-old woman with bronchial asthma and an allergy to dog hair, and she experiences mild menorrhagia during the first few days of her menstrual cycle. She is generally well, and her asthma has been stable for years with the use of a formoterol-budesonide inhaler every 12 hours, and very occasionally a terbutaline inhaler. Five years ago, during her last pregnancy, her obstetrician referred her to a pulmonologist, and she continues to be seen by this specialist. During a routine check-up, with no clinical changes, no exacerbations, a baseline SpO2 of 98%, and spirometry results of: FVC: 79%, FEV1: 63%, and ratio: 69%, a complete blood count and a CT scan of the chest and abdomen were ordered. The results showed iron deficiency without anemia, positive ANA, and space-occupying lesions suggestive of hepatic angiomas. The pulmonologist referred her to a hematologist, gastroenterologist, rheumatologist, and allergist. The gastroenterologist performed a colonoscopy, endoscopy, took biopsies, ordered a breath test, an abdominal ultrasound, and an abdominal MRI, which diagnosed hepatic angiomas and external hemorrhoids. The hematologist prescribed ferrous sulfate during menstruation. The gastroenterologist repeated the blood tests and found an Hb level of 11.9 g/dL, so he ordered further tests and prescribed omeprazole and ferrous sulfate. In the meantime, she was seen by the rheumatologist who found no pathology, but scheduled a follow-up appointment. During a visit to another GP, while her regular doctor was on vacation, and since this colleague was interested in thyroid ultrasound, he asked Theresa to participate in a study; she reluctantly agreed. A thyroid ultrasound showed a thyroid nodule, and a fine needle aspiration biopsy (FNAB) was performed, which was normal, and she was advised to have annual thyroid ultrasounds. The gastroenterologist found a positive carcinoembryonic antigen in the new blood tests and ordered an endoscopy... Now, the patient tells her regular family doctor that she "does not want to return" for the follow-up appointments and tests requested by the five specialists: gastroenterologist, hematologist, rheumatologist, allergist, and pulmonologist, as well as the thyroid ultrasounds requested as part of the study, she agreed to participate in.

Every medical procedure carries a risk; "what cures one person may kill another." This warning, dating back 800 years, seems obvious, yet one might think otherwise when observing how modern physicians use tests on outpatients. Theresa's numerous test results are slightly abnormal-not enough to cause great concern, but enough to make the doctor uncomfortable ignoring them [1]. Detecting a disease is only important if it can be treated. Early detection is only important if early treatment yields better results than late treatment [2]. The fundamental, classical advice seems to have been forgotten: The general practitioner must ask himself three questions when considering ordering a test: 1) Will a positive result change the course of treatment for this patient? 2) Will a negative result reassure the patient? 3) Are there less expensive alternatives for making a decision for this patient? [3,4].

Laboratory, radiology, functional and nuclear medicine tests are affordable tools in modern medicine. However, concern about the overuse of these techniques has been growing. Although the traditional diagnostic process consists of the sequence of history taking, physical examination, and complementary tests, it has long been known that the final diagnosis is made in most cases by interview or anamnesis; physical examination and laboratory complementary tests achieve the diagnosis in only 20% of patients [5,6]. Over-ordering increases patient discomfort and harm related to iatrogenesis, may result in false-positive results, and wastes healthcare resources [5]. The concerns are different for GPs and hospitalists: while the hospitalist tries to avoid false negatives, the GP is concerned about false positives [7].

The GP sees Theresa [8] as a waterfall: A sudden fall of water, usually caused by a bed of hard rock in a riverbed, either horizontal or gently sloping upstream, overlying softer rocks. This softer rock beneath is eroded by the river, so that the hard rock overhangs, thus creating the waterfall. The layer of hard rock is undermined by the falling water, and from time to time, blocks of it break away; the waterfall thus slowly recedes upstream, its crest always remaining at the edge of the hard rock layer [9,10].

A test is never just a test. Each one erodes the underlying softer rock, thus forming the waterfall, and this itself continues to erode the base, breaking off blocks of hard rock, and thus progressively enlarging itself. Each test is like "a hammer floating above a jar of poison" [11].

Despite all this, the GP finds it difficult not to advise her to keep her appointments and undergo the tests. The GP feels frustrated. It is difficult to contend with the relentless, ever-increasing flow of additional tests. "It's hard to swim against the current; waterfalls impede navigation," the GP thinks.

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