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.

Thursday, December 18, 2008

Why Do I Even Bother?

So I saw this patient ten months ago.

Ten months ago. Got that? In March.

I found a lump in one of her breasts. Oh, that, she says. I'm sure that's just a cyst. I had it once before and it must have come back. That's all it is. I'm not worried. That's what she says.

Well, says I, you're probably right. But you never know for sure. I'd really like you to have a mammogram and an ultrasound, because it's been a couple of years since you've had those studies, and you can never be sure about these things just from feeling them. So it's really important that you go and have these studies done. Understand? Ok?

It's not like I just threw a mammogram requisition at her and walked out of the room. I spent a fair amount of time trying to explain to her why it was important to investigate this breast lump. She said that she understood what I was saying and that she would go ahead and schedule the studies.

I put her chart in a section of my file shelving where I store charts with pending studies. After a month, when I noted that the results hadn't come back yet, I called her. She hadn't scheduled them yet, but said that she would. The next month, I called her again. Same thing. This went on, month after month. Each time I called her, my urgings escalated. Each time I called, I documented it in her chart. Finally finally finally she got the tests. I'm sure everyone reading this is shocked -- SHOCKED -- to discover that the mass was not a cyst, but was in fact an invasive breast cancer now requiring treatment TEN MONTHS AFTER I FIRST DETECTED IT ON CLINICAL EXAM.

I'm not particularly worried about the liability issue, because of my pristine documentation, but jeez! It's times like these that I wonder why I even bother doing what I do at all.


At Thu Dec 18, 06:06:00 AM, Blogger Evil Transport Lady said...

She's a fool!.....Sad, now she'll have to pay the piper:(

Kudos for you, for keep up with her. Never had a doctor do that.

At Thu Dec 18, 07:04:00 AM, Anonymous Anonymous said...

I had a patient like that once, named Cleopatra. You know, as in Queen of De Nile.

Kudos for you for documenting your persistent efforts to get the studies done.

At Thu Dec 18, 11:02:00 AM, Blogger Jon said...

You can't cure stupid.

At Thu Dec 18, 11:48:00 AM, Blogger Alpine, R.N. said...

cancer is one of those things that DOESNT go away if you ignore it. Poor woman, she probably just thought she could wish it away.

At Thu Dec 18, 11:53:00 AM, Blogger Bookhorde said...

I am so sorry.


At Thu Dec 18, 02:50:00 PM, Blogger Lynn Price said...

Keep it up, Dino. My doc doesn't do nag calls. I think he figures that once he's made his recommendations and it's out of his arena, it's up to his patients to act responsibly. Your patient owes you a huge thank you.

At Thu Dec 18, 03:01:00 PM, Anonymous Anonymous said...

What can you do.
You cannot force people to be healthy.
You can't force people to take care of themselves.
You can't force people to listen.

You can apply an ice pack to your forehead after repeated hitting your head against the wall.

You can only do your best.

At Thu Dec 18, 08:41:00 PM, Anonymous Anonymous said...

It was not me!

(Though I DO owe you a visit...)


At Thu Dec 18, 10:17:00 PM, Anonymous Anonymous said...

You bother because some patients have enough sense to listen. And because if you hadn't nagged monthly, this one might still be putting off that mammogram.

At Fri Dec 19, 01:14:00 AM, Anonymous Anonymous said...

Evil Lady: sometimes fear keeps people from doing what their brain tells them. It's a primal and overriding force.

If it makes you feel better, doc, those 9 months probably didn't make a difference. When I was diagnosed with breast cancer, I had to wait over a month for surgery, three months for chemo. The oncs don't consider BC treatment to be an emergency. A palpable lump takes years and years to grow to that size.

Anyway, there is a school of thought that thinks most tumors will either respond or not respond to treatment, and that finding them earlier can only stall but not change the eventual outcome. It's a lead-time bias - finding it early only makes it look like treatment prolonged survival. In other words, if time of inception of disease to time of death is ten years (hypothetical example), a scan finding the tumor in year one will make it look like treatment caused a 9 year remission. However, find the same tumor in year 8, when it is a palpable lump, and the same treatment will give you a 2 year survival. So, same disease, same time from start to end. The difference in outcome is only an illusion based on when the disease was detected.

Many reputable oncologists are arguing against the emphasis on mammograms for this very reason - there really isn't much compelling difference that early detection makes that huge of a difference.

At Fri Dec 19, 02:38:00 AM, Blogger The Happy Hospitalist said...

the fact that you even have to document that you are her baby sitter is a testament of how America hos lost all sense of personal responsibility.

You tell her she needs further work up. She declines. That should be the end of it.

Is the new standard of care to fend of the lawyers, monthly babysitting calls, as if you are her mommy?

At Fri Dec 19, 10:41:00 AM, Anonymous Anonymous said...

@ Happy: Even without the lawyers, good documentation just makes sense. It keeps you accountable amd it covers your backside in case any questions arise from your peers or from the patient and/or family.

Or are you one of those people who throws out all their credit card receipts and doesn't keep copies of their tax returns?

At Fri Dec 19, 12:02:00 PM, Blogger The Happy Hospitalist said...

anon. I think the point was missed. Why is it Dino's responsibility to call the patient monthly to get a test she recommends but refuses. We are not parents. And as far as documentation, unless you are a physician who understands what the documentation game has become, I don't think you understand. What is documented these days is a giant invoice, used to justify payment against fraud. It is far less important and relevent medically for patient care.

And no, I keep all my tax returns. I have very organized file cabinets neatly categorized. I only keep the credit card receipts on stuff that has a warranty on it.

At Fri Dec 19, 01:36:00 PM, Blogger Doc said...

Something about horses and water....

At Fri Dec 19, 03:03:00 PM, Anonymous Anonymous said...

Obviously this woman is a true believer in the old saw about not being able to note a fever if a temperature is not taken. Wish I hadn't seen so many of these folks in Hospice. I have clear advance directives and would never want heroic measures taken, but that is not the same as ignoring your body. I'd rather lose a boob than my life, anyday! This one is so NOT YOUR FAULT!!!Pattie, RN

At Fri Dec 19, 06:30:00 PM, Anonymous Anonymous said...

I'm due a dental exam and a smear test (Pap test?) and am putting both off. Even after really bad tooth problems and at the other end, treatment for CIN 3 pre cancerous cervical cells.
I can't explain it. I'm not scared about the smear, but I am mildly scared of the dental pain......I will sort it out.


At Fri Dec 19, 07:37:00 PM, Blogger DrWes said...

One word: denial.

At Sun Dec 21, 07:02:00 PM, Blogger Sid Schwab said...

It's a good example of something I used to harp about all the time: for a palpable lump there's nothing like a fine-needle aspirate done on the spot. At a fraction of the costs of the studies (which may or not ultimately need doing), you get at least a partial answer right then, no time to put it off. In this case, had it been clear fluid, she'd have been right, and relieved. But given the later news, it'd have been solid which possibly would have convinced her to do something. And the material from aspirating a solid lump is often diagnostic, smeared on a slide and given to a decent cytopathologist.

At Sun Dec 21, 08:33:00 PM, Anonymous Anonymous said...

@ Sid: Any family doc can do that? It never really occurred to me, but I'll think about it next time.

@ Dino: I'm still early in my career and I do the nag calls too, but I think the horses: water analogy fits here. You did more than your duty.

At Sat Jan 03, 11:55:00 PM, Blogger Charleen said...

Every person should be so lucky to have a doctor so concerned. Kudos to you!


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