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, December 21, 2007

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."


At Sat Dec 22, 08:08:00 PM, Blogger rlbates said...

Good post!

At Sat Dec 22, 11:43:00 PM, Anonymous Anonymous said...

"You have a lump in your breast" is among the leading causes of cardiac arrest in women
Is this for real? If so, I think that the researchers saying that one needs to look at all-cause mortality and not just desease-specific mortality when looking at screening studies have a point. Considering that over 10 years period between 25 and 50% of women have at least one false positive and one quarter of these false positives ends in biopsy, this is an important risk.

Keep in mind that no study had enough statistical power to show all-cause mortality reduction with mammograms and that if one looks at these numbers one gets interesting results (Welch has a paper on the subject).

At Sun Dec 23, 09:29:00 AM, Blogger #1 Dinosaur said...

Anon: I am speaking metaphorically, as in, "When I heard those words, my heart stopped." I do not mean it literally, in the sense that every woman with a breast lump dies of it.

At Sun Dec 23, 10:06:00 AM, Blogger Lynn Price said...

Good post, Dino. All my medical research that I've done for my writing taught me one thing: It does not pay to be an ignorant patient. If I ever have a question, I ask my family doc because, like you, he's got my back. And front...

At Sun Dec 23, 12:36:00 PM, Blogger Hygeian said...

How is what the radiology group did legal, let alone ethical? When I was younger, a friend of the family was investigated for referring too many patients for imaging at a facility he had some kind of ownership in.

The radiologist referring your patient for a questionably useful procedure, which procedure it isn't normally the radiologist's place to recommend, and from which this radiologist or group will profit certainly seems to be at least as bad.

At Sun Dec 23, 04:34:00 PM, Blogger The Angry Medic said...

"...I've got your back."

I waited a beat, then added, "And your front."

ROFL. Classic Dino. I enjoyed the rest of the post, too, despite the limited understanding of my ickle-liddle-medic brain.

Merry Christmas and a Happy Noo Yer, Dino!

At Sun Dec 23, 10:35:00 PM, Blogger MadMT said...

OM-freakin-G. Somehow I am so not surprised. I too am mystified at how they get away with financing their new toys this way.

And just think, if you weren't in solo practice and had the lovely insulating layers large commercialized practices have, you might never have even seen the report or even if you had, might not have had time to catch it.

At Mon Dec 24, 09:23:00 AM, Anonymous Anonymous said...

Sounds like these rad folks have forgotten that they're doctors first and salesmen second. (Incidentally, pharmacy managers tend to behave the same way.)

This attitude is trickling down to the front office staff, who seem to think they're qualified to give medical advice because they "work in a doctor's office."

I could get really ranty right here about front-end staff, but I won't...

At Mon Dec 24, 06:07:00 PM, Blogger Candace said...

Truly, doesn't this fall into some sort of interest conflict? Double billing? I mean, I can't staff the wound clinic as the ID guy, then refer the wound patients to my general ID clinic for evaluation.

That's what they're doing--essentially.

At Wed Dec 26, 12:39:00 AM, Blogger janemariemd said...

Hygeian has a good point; it does sound at least like a conflict of interest, doesn't it?? Thanks Dinosaur for ranting about something that has been bugging me lately--the incredible self-promotion of additional radiological studies--in radiology reports. I am guessing maybe 40% or more of the xray reports I read suggest further studies. It seems to be out of control! One thing I've seen is some ludicrous schedules of multiple chest CTs recommended to follow-up a nodule to "assure stability"--at 3, 6 12, 24 months--where are the data supporting this?? Another new one the other day: a chest xray with an infiltrate, for a patient I saw in my office who looked pretty ill and whom I treated with antibiotics--the report recommends a follow-up film the exclude neoplasm--for a simple pneumonia! Needless to say, I wasn't surprised to hear the radiologists in my town make 3-4 TIMES my salary (I practice primary care general internal medicine).

At Wed Dec 26, 01:28:00 PM, Blogger DDx:dx said...

Sorry, the new radiologist recruited to my town is paid 6x what I was making before I quit....But all those procedures, images make money for the hospital so they are glad to pay him...
I can remember spending alot of hand holding and referraling and explaining when the TECH for the RAD would call the patient and tell them they needed to come back in for "More views"....FEAR
Fear drives alot of "health care" marketing....Not common sense.
And as a family doc it was tough to admit that "annual physical" really didn't save lives either....

At Tue Jan 08, 11:27:00 AM, Anonymous Anonymous said...

Your complaint about radiologist needle Bx, Dino, shows your resistance to change. Your and others carpings about procedures being overpaid is misguided. Building primary care compensation up by pulling most other specialties down doesn't make the (minority) generalists many majority friends.

Your compensation jealousy contaminates your medical thinking, to the detriment of best care: see janemariemd's ill-considered opposition to a post-pneumonia follow-up CXR.

I found this blog on KevinMD, to which I'd linked from the Wall St Journal. I won't be back to you or Kevin because of your financial jealousies. Nobody forced you into primary care. You all chose it (as I did, but I left generalism after 2 yrs for specialty training). You made your bed, now sleep in it.

At Tue Jan 08, 12:24:00 PM, Anonymous Anonymous said...

Sending your patient to surgery when 99% of the time a needle biopsy will give you the diagnosis? Yeah, that is really looking out for your patient.

Suboptimal? Almost all well trained breast surgeons would want a needle biopsy before surgery anyway to know what they are dealing with, with rare exceptions such as a young woman with a likely fibroadenoma.

I am a fellowship trained breast imager. I read thousands of mammograms every year. I understand that there are many general radiologists out there doing mammo and breast sono who are horrible at it and you may be dealing with some of them.

As someone who knows what they are doing, when I see something that needs a needle biopsy, we schedule it as that is what our referring physicians want us to do since they know we are the experts in this area. It is VERY rare that I get an equivocal biopsy result and end up sending the patient to a surgeon for a repeat.

No offense Dinosaur, but stick to hypertension and diabetes and leave the advanced breast health to the experts.

At Tue Jan 08, 12:30:00 PM, Blogger Candace said...

For the last two comments, I think you two have missed the point. In your defensive posturing about going straight into an invasive procedure (albeit a less invasive one than surgery) and billing for it (not to mention self-referral), you are missing the point that nobody has discussed the major issues of this disease state with the patient, or his primary care provider. And, should that site get infected or have pain, I am doubtful you'll be on-call during the weekend to handle it. I'm sure you're going to ask him to see his primary care doc. So, it is prudent and COURTEOUS to involve the primary care provider in all these decisions.

And I am an internal medicine subspecialist.

At Tue Jan 08, 02:03:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

Interesting post, Dino, as usual.

I work closely with our docs in radiology here, and have no probolem with them doing the needle biopsy.

BUT - they always call me personally when they find an abnormality that needs a biopsy, and together we decide what to do next, which usually is a needle biopsy at their location. If they think the mass is better suited for open biopsy, we refer to surgery.

They now know me well enough that they will schedule the biopsy if they can't get me right on the line, or give the patient referrals for surgeons (We pretty muuch refer to the same ones), but ALWAYS tell the patient to call and discuss with me before scheduling anything, and we always touch base within 24 hours of the mammo.

It's a system that works well for my patients and for me.

That said, I'm not so comfortable with this if I don't know the radiologists - all told, there are about four different groups here in NYC that I know well and that do a great job in this regard.

At Tue Jan 08, 06:30:00 PM, Anonymous Anonymous said...

You're really out of step with the times. Here, it is a requirement for a tissue diagnosis, usually by needle before any definitive breast cancer therapy including lumpectomy. And the one stop mammo to biopsy approach is demanded by our docs and patients. On the other hand, we are a wealthy, well educated area. your approach delays diagnosis and some of the comments reek of ignorance, particularly the comment re chest nodules and CT scans. Check out the Fleischner Society Recommendations. And contrary to your comments, most often radiologists are extremely cognizant of the appropriate method to biopsy. They are required to take 5 credits of breast care education per year. No other doc is required to do that. They are up on the latest. However, communication is key and that is where your rads let you down. They need to keep you in the loop. Bad care on their part.

At Tue Jan 08, 08:25:00 PM, Blogger #1 Dinosaur said...

Interesting comments all (except for OncoDoc; "Compensation jealousy?" WTF?) Many thanks.

Mammodoc: These are not "fellowship trained breast imagers." They are the same generalist radiologists reading CXRs, CTs, MRIs, and nuclear scans on days they aren't rotating through Mammography. And I'm NOT "sending the patient to surgery;" I'm sending her to a surgeon, who has the specialized training to evaluate the most appropriate way of obtaining tissue for diagnosis (and will almost certainly do a better job of informing the patient about the pros and cons of the various approaches.) I agree it will often be a needle biopsy of some kind, in which case you'll get the patient back.

Then again, per another valid point made above: If you want to do it all by yourself, are you available 24/7 to address potential complications from the procedure like pain, bleeding or infection? Are you going to sit down before the procedure and talk with the patient about the possibility of cancer, including treatment options if the biopsy comes back positive? For that matter, if you're the one ordering the test, shouldn't you be the one who brings her back to talk about the results? Are you comfortable having those kinds of discussions with patients? I don't think so.

No; you just want to do the procedure (handsomely reimbursed, by sheer coincidence) and then leave me to deal with all that messy stuff we call "patient care."

No offense, MammoDoc, but stick to your enlightened population of referring docs (who let you do whatever you want) and let me continue to watch out for the poor patients who don't have access to your vast expertise.

At Wed Jan 09, 10:42:00 PM, Blogger Sid Schwab said...

I'm with you on this, dino. If all women were evaluated at centers with on-site radiologists, surgeons, and pathologists (my fantasy, when in practice; and there are a few out there) then one stop shopping would be the rule. Absent that, as a surgeon I always preferred to see the patient before any procedure (our radiologists are also wont to recommend stereotactic biopsy pretty freely). The reasons are two: most importantly, when the lump is palpable (and an experienced surgeon can find the majority of mass lesions (as opposed to calcifications), then an office fine-needle aspiration can be done on the spot, for a fraction of the cost of the radiologic procedure. In my case, I hand carried the slides to my favorite cytopathologist, and called the woman with the result the same day I saw her. MANY lesions for which guided biopsy is recommended could have been handled that way. Secondly, radiologists (rightfully, mostly) tend to overcall and over-recommend, for obvious reasons. Although it's hard to choose careful followup when such a recommendation is made (I disagree with you to some extent: in my view the radiologist should way what she sees and what he thinks it could be, and let the intervention decisions be made by others -- of course, that is distinctly a minority view), I have in fact recommended non-intervention in certain contexts. WIth careful followup, I never had reason to regret such a decision. Emphasis on "careful." Inference of good judgment.

At Tue Aug 11, 03:27:00 AM, Anonymous Shadow Merchant said...

As a radiologist I see four main problems here:

1) Not picking up the phone and calling the referring doc. In my partnership, you simply DO NOT recommend a biopsy without calling whomever sent the patient to you. I also stat fax all such reports after speaking to the clinician.

Not only does it prevent misunderstandings and hard feelings, but documenting such communication is also an important protection for me if the referring office is a shambles and mislays my report.

2) Not speaking to the patient. If I am recommending a biopsy, I always have the tech or nurse offer the patient a chance to speak to me about her findings and look at her images before she leaves.

There used to be a few old surgeons who grumbled about this perceived infringement on their prerogative, but I haven't got any flak about doing so for many years.

I think everyone's feeling over-worked nowadays, and appreciates all the face time their patients can get with a caring expert doctor who will put everything else on hold to explain things to an anxious lady. And again, this protects me and my referring clinician by letting me put "Findings and recommendation for biopsy were discussed in person with the patient" in my report.

I saw a patient just last week who had one of my old reports from 2005 with this exact wording. She had flaked off for several years of alternative treatment of her cluster of breast calcifications, which is now an invasive carcinoma as big as an orange. I feel terrible for her, but I'm sure glad I didn't leave an opening for her to come after me for not making the situation clear to her four years ago.

3) Overly specific recommendation for biopsy technique. Better to say something like "Tissue diagnosis recommended. Lesion is amenable to stereotactic biopsy if desired."

If I think something is a poor target for stereo or ultrasound biopsy, I'll say so and recommend surgical consultation. I try never to tie my referring docs' hands and make them feel that they MUST use my interventional services.

4) The pre-scheduling of biopsy is another ticklish question. We work very hard to keep track of each clinician's preferences in this regard.

Many referring docs like to send their patients to be handled by a surgeon whenever any question of a breast mass arises, well before any biopsy is scheduled or performed. Some have us reserve a tentative date for a biopsy and then refer out to the surgeon.

Some like us to notify them, then will see the patient in clinic, then have us schedule and perform a biopsy, then send them on to the surgeon if it's malignant or (quite rarely) inconclusive. Some offices have standing orders that allow us to schedule the patient for biopsy before she leaves after her diagnostic imaging.

We even have some offices that basically turn the patient over to us until diagnostic workup is complete, even having us call her with the biopsy results.

We have a couple of well-trained, experienced, empathetic "super nurses" who shepherd the patients through this process.

I think it's gross presumption to pre-schedule anyone for a biopsy if you haven't got permission to do so from her primary doc. It has happened once or twice by mistake with my partners, but we go to great lengths to avoid it.


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