Rad Rage: Part Two
(Part One is here, in which I coin the term "Rad Rage.")
One of the latest developments in "Patient Oriented Services" is the replacement of the "Mammography Department" with the "Breast Health Center." I suppose the principle of offering mammography, ultrasound and the various other radiological interventions in the management of breast abnormalities under one roof (or at least in close proximity) makes sense. But one local group of radiologists has gone too far.
A word of explanation: mammography is a breast x-ray that is currently our best screening test for breast cancer. ("Best" in terms of value; MRI is reported to be more specific, but at such a higher cost as to make it a poor value in women with no breast complaints or abnormal history.) When an abnormality is seen on a mammogram, the appropriate next step is to perform an ultrasound to determine if the mass is cystic (hollow/fluid filled) or solid. Solid masses often (not quite always, but close) require a tissue diagnosis. This means there needs to be some sort of biopsy, which is defined as "getting tissue for diagnosis." There are several different approaches to biopsy: the whole mass can be taken out, which also might need a needle placed into the breast tissue to guide the surgeon to the abnormal area if it can't be felt. Or a larger needle can be used to poke directly into the mass to get tissue or sometimes just cells for pathological examination. This is a clinical decision which takes many things into account: the patient's age, personal and family history, the size and location of the mass, and the patient's preferences, among other things.
The determination that an abnormal mass on breast imaging requires a tissue diagnosis is properly the radiologist's call. The most appropriate way to obtain that tissue is not; that is the job of the surgeon. And it's my job to explain to a patient that she has an abnormality in her breast that needs biopsy, and to refer her to the surgeon. Contrary to what you surgeons probably think, I do more than just give her your number. I try to prepare her for the kinds of things you're going to be saying to her; talk about some of the available options, but impressing upon her that the surgeon is better equipped than I to help her choose among them. I give her an idea about whether or not the radiologist is seriously concerned about cancer, not to scare her, but to prepare her. (I'm not telling her anything she hasn't already thought about and dreaded.) Besides, most of the reports stress the benign features of a mass while still advising biopsy; information that can be quite reassuring.
I received a mammogram report the other day that described a new nodule in a breast. The conclusion read, "Biopsy recommended." I called the patient and asked her to come in for a breast exam to see if the abnormality could be felt, to which she readily agreed. But when we got into the exam room and I began telling her about the report, she said, "Oh, I already have the biopsy scheduled."
I looked at the report again. Right above the "Conclusion" it said, "Recommend mammotome ultrasound-guided biopsy."
"Did they tell you to call me?"
"No. They said they'd send you the report."
"Did they tell you there was a chance they wouldn't get enough tissue and you'd have to have another procedure?"
"NO! I hate needles, but they kept saying it was so small and non-invasive. I asked for more information about it and the next thing I knew, they were scheduling it."
So not only was the radiology department recommending a specific biopsy procedure (with a specific proprietary device, no less) but they were doing a pretty shitty job of obtaining informed consent.
I did the breast exam, couldn't convince myself I could feel the nodule (which didn't change its management at all) and referred her to a breast surgeon -- at a different hospital, needless to say.
I was livid. I called over and ended up talking to the nice lady with the spiffy title of Breast Health Liaison, or something like that, about radiologists doing their own biopsies. "Oh, no," she told me, "We tell the patients to call their doctor. We just schedule the test right away for their peace of mind."
"What exactly did you say to my patient?"
"I told her to confer with you, to get a script for the procedure and any referrals that might be needed."
Sure doesn't sound like, "See your doctor to discuss this." More like, "You need to get paperwork from your doctor for this procedure."
"Did you tell her about the possibility of a non-diagnostic biopsy and the need for an open procedure?"
"The radiologist spoke to her and discussed all the options. She chose to schedule the procedure. She can always cancel it if you or she decide otherwise."
"How often do you get non-diagnostic results with the Mammotome device?"
"Well, since I've been here I don't remember any."
Oy f#%&ing vey. Sounds like they've got a new toy they can't wait to use to make money.
Look, I understand perfectly well that the words, "You have a lump in your breast" is among the leading causes of cardiac arrest in women, and that waiting around to find out whether or not you have cancer is its own special circle of hell. But how much peace of mind is there, really, from having a suboptimal test scheduled quickly? What's scarier still is the impression they left with my patient, who had no way of knowing just what kind of shenanigans they were trying to pull. I'm still so mad I can barely type straight.
The patient thanked me, though. She was glad I had seen the report and called her, setting her straight about what she really needed to do.
"No problem," I answered. "That's what I'm here for. I've got your back."
I waited a beat, then added, "And your front."