Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, July 18, 2008

A Tale of Two Titties*

(*Title credit to Darling Spouse)

Two patients with similar mammograms: a vague finding appreciated by only a single radiologist. Extra views are done; ultrasounds are done; MRIs are done; all are negative. Neither patient has any palpable abnormality within the affected breast. Here’s where they part company: one patient receives a recommendation for a 6 month repeat; the other an appointment to a breast surgeon, who, although unimpressed, bows to the suggestion of the original radiologist and orders a core biopsy of a poorly defined area near the chest wall, that is not seen on MRI or ultrasound.

Suffice it to say, neither woman was happy with the recommended course of action. Here’s why:

The first patient had had a delayed diagnosis of cancer in the other breast, and although now more than five years out from treatment with no evidence of disease, was emphatically NOT willing to wait 6 months with a possible abnormality in her remaining breast. Interestingly, the original radiologist, a part-timer, was out the day I called back to confer on the initial mammogram. The doctor I talked with couldn’t even see what the first doctor had, and said, “I’d have let her go for a year.” When the part-timer got back, though, he stood by his guns and said he definitely saw an area of "asymmetry." Although he was comfortable with a 6 month follow-up, he offered the MRI now to appease the patient.

Worried less about his comfort than that of my patient, I managed to locate a surgeon (with a great deal of kicking and screaming emphatic persuasion and numerous phone calls on my part) who agreed that the best course of action for this patient was in fact a prophylactic mastectomy on the second side, all so that she “wouldn’t have to keep going through this.” (the patient’s words) She has had her surgery (with completely benign pathology) and all is well.

The second patient is actually a physician, albeit one who has left clinical practice to become a pharma shill (a term of great affection and endearment, L; great affection and endearment!) with negligible risk factors for breast cancer, who knows damn well this is nothing. Yet because this isn't technically her area of medical expertise, she is as much at the mercy of of the goddamn specialists as the least edumacated of our patients. She is willing to accept the uncertainty and settle for a 6 month (or even 3 month) follow-up, but no; everyone is playing on her emotions, guilting her into a biopsy with a bolus of "just in case," followed by a continuous drip of "better safe than sorry." All because one radiologist -- just one -- isn't comfortable with something he saw on her mammogram.

So she hems and haws, and panics (and blogs) and goes for her MRI biopsy. One might wonder how you go about biopsying something on MRI that doesn't actually show up on MRI; well, I did, at any rate. It turns out that you don't. So what we have here is a wasted morning by a respected physician who could otherwise be churning out perfectly good pharma propaganda (feel the love, L; feel the love!) Not to mention all that adrenaline that could have been used to fight a tiger or wax indignant about an anti-Gardasil post. Frankly, this strikes me as a case of Someone Asleep at the Switch. Why the hell didn't *someone* (primary doc? surgeon? patient?) put 2 and 2 together and ASK why an MRI biopsy of an MRI negative lesion was being ordered!! And the upshot is (her words):
...a repeat mammogram in 6 months as follow up. Now who was it who suggested that course of action last week? Oh right. That would have been me.
Here's my point:

A radiologist notes a subtle finding but is comfortable with interval follow-up, a course of action that is completely inappropriate and unacceptable to the cancer survivor.

Another radiologist is uncomfortable with a mammogram, so patients undergo invasive procedures to assuage the concern of their doctors.

Excuse me, but isn't this just about the most ass-backwards thing you ever saw? Since when is it the patient's job to make the doctors comfortable? Luckily (?) someone was silly enough to schedule a useless appointment (though I'm certain her insurance company will still pay for the second MRI) so my new friend wasn't actually punctured, but still; how far should she -- or any patient -- be forced to go essentially to placate the single radiologist who read the initial mammogram? Although she's not my patient, if she were, I would have supported her in her acceptance of the (minimal) risk entailed in settling for short interval follow-up mammography.

Two patients; similar findings. Different recommendations from two different radiologists based on their different comfort levels (which are -- admit it! -- fundamentally related to their fears of malpractice litigation.) Different patient preferences based on very different clinical contexts. All other things being equal, I think we should be more concerned with our patients' comfort than with our own -- or even that of our consultants.

6 Comments:

At Sat Jul 19, 12:06:00 AM, Anonymous Anonymous said...

It's just this kind of shit that might make a perfectly good primary care doctor go to the dark side (pharma, urgent care, insurance companies...).

Speaking from experience.

 
At Sat Jul 19, 02:46:00 PM, OpenID Teendoc said...

And my insurance company is already reviewing the first MRI to determine whether it was medically necessary. I wonder what they are going to say about the second?

 
At Sat Jul 19, 03:08:00 PM, Blogger #1 Dinosaur said...

TD: The first was; the second was ridiculous. The facility better eat it, though. If they have the nerve to bill you, tell them to stuff it where the sun don't shine.

 
At Sun Jul 20, 04:58:00 AM, Anonymous James said...

This very issue is why we have to think so carefully about screening. Screening is not always an unmitigated good. Doing a biopsy is not always the "safer" option.

 
At Sun Jul 20, 07:19:00 PM, Anonymous mamadoc said...

Couldn't agree with you more. Clinical context (which the radiologist should be able to do, and the primary ought to do--but doesn't get paid for) would have made all the difference. Sounds like people going off without their brains engaged to me. And as you said, it's hardly the patient's job to make anybody "comfortable," whatever the heck that means.

 
At Mon Jul 21, 10:46:00 PM, Anonymous Diora said...

... followed by a continuous drip of "better safe than sorry."
It is such an overused phrase, that I think it should be banned, at least from doctor's offices. Most of the time when it is used, it is not entirely clear which option is actually the safer one.

What exactly is safe and what exactly is sorry? Unnecessary invasive procedures have risks too. When one's probability of benefit is so low, even a small risk may be significant.

 

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