Saturday, June 19, 2010

Hedging

Pathologists and radiologists don't have the luxury of spending time with actual patients so they have to render professional judgments and determinations based on indirect data (radiographs, a mashed up slice of breast tissue, etc.) I don't envy them; the utter detachment from patient care would make me miserable. But they do have a tough job. They get one shot at getting it right. There's no patient follow up. They never get the opportunity to explain a missed diagnosis to a patient, to soothe things over. Once they stamp their name on the final report, there's no turning back. They can't afford to allow a sliver of a chance that they haven't "covered" themseleves.

And so they hedge. The radiologist will write "cannot rule out possible neoplasm" on an incidentally seen 4mm white blotch on a CXR and recommened "follow up CXR in 6 months advised." I understand it. I get it. But there are consequences to this hedging. And nowhere in medicine do we see this more than in mammography and the pathological analysis of breast biopsy specimens. We are prodded into far too many needle and open biopsies by mammography reports that "can't rule out cancer, biopsy strongly encouraged". Often, these reports come across the desks of primary care docs and they have to call them on the phone and inform them that "something was off on your mammogram; we need to do a biopsy. Please make an appointment with the surgeon as soon as you can."

My initial encounters with breast lesion patients are always emotionally charged. They've been crying, or are on the verge of tears, wrapped in their flimsy exam gowns. Often, a terrified-looking spouse is sitting uncomfortably next to them. They are in a surgeon's office. For an abnormal mammogram. It's every couple's worst nightmare. The first ten or fifteen minutes are spent defusing the situation, reassuring them that the overwhelming majority of abnormal mammograms end up being much ado about nothing.

The pathology reports are similarly hedged. Fine needle aspirations are notoriously non-specific. A result of "cellular atypia" could mean anything. More tissue needs to be obtained, you inform them. Another biopsy needs to be performed. The whole waiting process has to be repeated. You may as well have told them they have to walk non-stop from Cleveland to Buffalo carrying an anvil. I had one younger woman recently (35, no risk factors) whose OB/Gyn had ordered a mammogram for a palpable mass. The palpable lesion ended up being a benign-looking cyst but nearby was a cluster of calcifications that were deemed "suspicious". I sent her for a stereotactic core needle biopsy. Three days later the pathologist filed his report. Most of the core specimens were benign. Unfortunately, on one slide, at the edges of the specimen, there was a small area of cellular atypia. The pathologist noted that, given the location of the area of concern, this most likely represented an artefactual effect of crushed tissue during preparation of the slide. Nevertheless, underlying neoplastic change "could not be ruled out".

What do you do with that information? Well, you call the patient and you explain that despite overwhelming evidence to suggest a complete absence of cancer, the pathologist felt that he could not definitively rule out the possibility of a small focus of neoplastic change. She was 35 years old. Do you tell her to not worry, that the pathologist is just covering his ass? You can't say with 100% certainty that I don't have cancer, she asks me? No, I say. We'd have to do a formal open breast biopsy. There's always a pause on the other end of the line. You can hear a kid playing, laughing somewhere else in the house, the television blaring too loud. My son is five years old, she whispers, her voice cracking. I know. I'm sorry, I say. It's going to be fine. I promise you.

5 comments:

BR Morrissey said...

I'm a third year student, who just recently finished a brief rotation through a breast clinic during my surgery clerkship.

Your words mean all that much more now, having experienced this process first hand.

Thank you for continuing to share your strong voice on the issues that are often so difficult to put into words.

Frank Drackman said...

Great Post Buckeye, and I actually wanted to be a Pathologist till I found out they don't really get to solve murders like Quincy used to...
And thats what I love about Anesthesia, No Hedging, you definately need Anesthesia for that Median Sternotomy, otherwhise it's really gonna hurt.
One Question?
Why do they call some Operations "Formal"??? In 3rd year Med School I showed up for a "Formal" Colectomy in Black Tie and got shown the door...
are there "Informal" Operations??
"Casual Colostomy Fridays"?

thanks,

Frank

rlbates said...

Happy Father's Day, Buckeye!

Nice post.

Andrew_M_Garland said...

Doing rational follow-up testing requires that "can't rule out" must instead be a probability.

Such as "1 in 10,000 chance that cells are cancerous". Then, the patient could decide if the follow-up biopsy is warranted, consulting with the doctor.

Possibly, there is a 1 in 1,000 chance of harm from the biopsy, which would far exceed the harm from the possible cancers discovered.

Or, in a medical free-market, one could buy insurance that covered follow-up procedures only where the cost/life-year saved is (say) $30,000 or less. That is something like the idea of a government panel to set the costs of medical care, but it would be a choice of the consumer who would face the risks and pay the premiums associated with a given level of insurance support.

These considerations exist in a world where the chance of death in an auto accident is approximately 14 per 100,000 each year, being 1 chance in 100 over a lifetime.

Kellie said...

Those are tough ones.

FWIW, I always see the patient fully clothed first. I have them change after I've done the history and "diffused the situation". I think they are more comfortable. It takes a little more time, but well worth it in my humble opinion.

With many of the pathology reports I"ve been seeing in the past few months, makes me long for the day we did all breast biopsies open, none of this fooling around with FNA and Stereotactic. I understand the reasoning and the science, but sometimes it is hard to explain all that to the patient.