Posted by: notdeaddinosaur | July 11, 2011

Not Taking No Answer for an Answer

62-year-old black man with a two inch (that’s inch; not centimeter) lump under his left arm. It is determined that he needs to have it biopsied in order to tell for sure what it is. The differential diagnosis includes a simple reactive lymph node, lymphoma, leukemia, granuloma, sarcoidosis, and several other more esoteric entities, all of which require tissue for definitive pathologic diagnosis.

The dialogue:

Patient Who Will Not be Reassured: What is it, Doctor Dino?

Me: We won’t know for sure until we get the report from the biopsy.

PWWNBR: But what do you think it is?

Me: I have no idea. We have to see what the pathologist says.

PWWNBR: Could it be cancer?

Me: It could be any one of several different things. Yes, cancer could be one of them, but there’s no way of knowing without the biopsy.

PWWNBR: Dr. Dino, do I have cancer?

Me: I don’t know. We can’t tell until we get the biopsy report.

PWWNBR: But what do you think?

Me: I really don’t know. There are some features about it that make me think one thing, but there are other features that make me think something else. So the only thing to do is get the biopsy and see what it shows.

PWWNBR: What do I have?

Me: You have a mass under your arm that needs to be biopsied.

PWWNBR: But what is it?

Me: There’s no way to know for sure until we talk to the pathologist.

PWWNBR: Dr. Dino, what do you think it is?

Me: I can’t tell just by feeling it. We need to get the biopsy and wait until the report is ready.

PWWNBR: Do you think it’s cancer?

Me: I have no idea what it is, and the only way to find out is to see what the tissue looks like under the microscope.

PWWNBR: But what is it, Dr. Dino?

Repeat…

and repeat….

again…..

and again……

and yet again…….

forever…………..

Or so it seems.

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Responses

  1. I will admit, when I have a “mystery condition,” I will often try to get my doctor to speculate about what it could be before the tests results are in – not because I think she knows for sure, but because if I have a handle on the various possibilities, I can look into them and prepare myself. Otherwise it’s just mysterious and scary. Not sure if that’s what this guy was trying to get you to do, but maybe?

    On the other hand, I can definitely see why as a doctor you’d be hesitant to speculate, because it’s no good making people panic if they think your speculations are a diagnosis. My doctor has gotten to know me and trusts that I’ll understand that speculation is speculation, but I imagine not everyone reacts that way.

  2. How come we have the same patients in our practice? We’re 3,000 miles apart!

  3. I think they were in my office last week. Aieee!

  4. who’s on first?

  5. Psst…Dino…Rule 4!

    🙂

    As a tech, I’ve had to do my own “I’m going to let the guy who graduated from medical school take a look at this, as he probably knows EXACTLY what he’s looking at” speeches.

    Some familes will NOT take “I can’t tell you” for an answer, I’ve discovered.

  6. I’m just curious: why is his race relevant here?

  7. Isn’t that how a history usually begins? Age, race, sex…

  8. I’m a Caucasian, middle-aged female, two children, homeowner, politically left-of-centre, Canadian citizen with a driver’s license. Oh, yeah, also a heart attack survivor.

    Your (62-year old black man) patient was just saying out loud what every patient facing a terrifying and potentially life-threatening health issue is thinking nonstop every minute of every hour of every day once the first symptom hits.

    You think it feels crazy-making to have to listen to a patient’s questions like this? Try being that patient…

    On the other hand, the E.R. doc who sent me home with a misdiagnosis of GERD (in spite of textbook heart attack symptoms like chest pain, nausea, sweating and pain radiating down my left arm) seemed pretty darned emphatic in his misdiagnosis when he pronounced that I was clearly “in the right demographic for acid reflux”. So go figure….

  9. Underneath the endless questions is someone who is scared. I don’t expect my doctor to speculate on the basis of limited information. But if a scary dx is one of the possibilities, it can be reassuring to have the doc say, “I hope this will turn out to be a false alarm, but if it isn’t, we will face this situation together.”

    We need to think with our hearts, not just our logical scientific brains.

  10. I’ve been in that boat (turned out okay). We understand you don’t know. Or maybe you do and are trying to avoid telling us. We want odds. Also as I told a friend, the doctor thinks its okay, but until he _knows_ exactly what it is they keep checking.

  11. I could recite that conversation in my sleep–as a patient with undiagnosed Cushing’s for over two decades. (I’m now 5.5 months post-op and recovering nicely.) It sparked a blog post of my own. Don’t worry, it isn’t a rant. Just a reflection about patient expectations. You’ll find it at http://cushielife.multiply.com/journal/item/44/A_DoctorPatient_Conversation_from_a_Patient_Point_of_View.


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