Physicians find lumps all of the time. Most of them are benign and transient (of course the pregnancy "lump" is transient but may not be so benign). So how does a doctor know which lump merits concern and investigation?
The basic tools are straight-forward. A simple history, which addresses a variety of issues including some of the following, may lead to the correct clinical impression: Have you ever had cancer or any unusual growth on your skin or elsewhere? What surgery have you had? How is your appetite? Have you lost weight recently? Have you had sweats at night or experienced fevers which have no obvious explanation? Have you been exposed to toxic environments or materials in your work or personal activities?
And then, the doctor takes the time to perform a competent examination, examining the lump, skin, lymph node areas, thyroid, abdominal organs, breasts, testicles and other areas which may harbor malignancy and which are accessible to palpation or examination.
Only then, does the doctor consider the differential diagnosis and possible laboratory and radiologic tests which may help to establish a diagnosis and differentiate a benign from a more serious condition. And then, after a discussion with the patient, the doctor orders the standard tests - and specialty focused tests such as fine needle sampling (biopsy) of the tissue in question.
Then the doctor and the patient (and those the patient wants to be involved) discuss the findings, the diagnosis and the treatment options and plan.
Medicine is not television drama. The physician - who has been carefully trained to understand and require each step that I have outlined - collects all necessary information to form an evidence-based diagnosis. Scientific evidence trumps intuition and conjecture.
Showing posts with label Diagnosis. Show all posts
Showing posts with label Diagnosis. Show all posts
Tuesday, September 27, 2011
Tuesday, March 16, 2010
Medicine: Art and Science
One day, I examined a patient who came to the office complaining about a "cold" and found a breast lump which another doctor had not found earlier that day. I visited her in the hospital, following her cancer surgery, and she asked me "after all, I only came in for a cold; why did you find the cancer that Dr. ***** couldn't find?" I gave her the best answer I knew: we all recognize in looking at a work of art that some of us see things that others don't; similarly, each well-trained and skilled physician may recognize something significant in an examination that the next physician may not appreciate.
I thought about my answer recently as I went from physician to physician seeking a diagnosis and appropriate treatment for my own painful condition. One doctor found the answer to one issue, but missed others; the second had a list of differential diagnoses pertinent to his own field, and when my diagnosis did not match his list, I knew it was time to move on; the third doctor put two and two together and came up with four, but the answer was really five, as I learned today from the next doctor in my tour of specialists in the Bay Area. Fortunately, "5" is benign and treatable.
The message to my readers is that medicine is a blend of art and science. The scope of knowledge and experience required for the diagnosis and treatment for a complex patient may go beyond what we can reasonably expect of a single physician or single system. Patients must some times be willing to put aside their confidence and implicit trust in their physicians or health systems to seek more complete and appropriate answers elsewhere. It isn't that their physicians or health systems are incompetent: it is that they represent humans who are limited in their capacities to solve all problems, even when they practice within the standards of their professions. Sometimes a second or third opinion is needed. Sometimes two plus two equals five.
I thought about my answer recently as I went from physician to physician seeking a diagnosis and appropriate treatment for my own painful condition. One doctor found the answer to one issue, but missed others; the second had a list of differential diagnoses pertinent to his own field, and when my diagnosis did not match his list, I knew it was time to move on; the third doctor put two and two together and came up with four, but the answer was really five, as I learned today from the next doctor in my tour of specialists in the Bay Area. Fortunately, "5" is benign and treatable.
The message to my readers is that medicine is a blend of art and science. The scope of knowledge and experience required for the diagnosis and treatment for a complex patient may go beyond what we can reasonably expect of a single physician or single system. Patients must some times be willing to put aside their confidence and implicit trust in their physicians or health systems to seek more complete and appropriate answers elsewhere. It isn't that their physicians or health systems are incompetent: it is that they represent humans who are limited in their capacities to solve all problems, even when they practice within the standards of their professions. Sometimes a second or third opinion is needed. Sometimes two plus two equals five.
Sunday, May 3, 2009
Wilson Disease and Abnormal Copper Metabolism
I spent yesterday at a high-level Wilson Disease symposium sponsored by the Wilson Disease Association (I had served on the board for many years), California Pacific Medical Center and the American Liver Foundation which was attended by patients and their families, scientists, physicians and other health care personnel. Michael Schilsky,M.D., a national Wilson Disease expert from Yale, described diagnosis and clinical aspects of this condition, including elevations of liver, blood serum and urinary copper, decreased ceruloplasmin (a protein which moves copper throughout the body), abnormal liver function tests such as elevated bilirubin and INR (a measure of clotting), psychiatric symptoms, movement disorder and hemolytic anemia. Then Sihoun Han,M.D., Ph.D. now of Children's Hospital in Seattle Washington, provided a tour de force of the genetic changes which are found in Wilson Disease and the use of these mutations in diagnosis. Giuseppe Inesi, M.D., Ph.D. of California Pacific described his elegant research into the Copper ATPas Molecule and its mutations and Robert Wong, M.D., a transplant hepatologist at California Pacific described clinical research involving transplanted Wilson Disease patients. Catherine Frenette, M.D. of California Pacific discussed curative liver transplant for Wilson Disease and provided encouraging statistics for all hepatic transplants and finally, in a fast-paced and helpful talk, Mary Pasquali, R.D., M.S. of California Pacific described nutritional support for cirrhotic patients, including those for Wilson Disease, and post-transplant patients.
While Wilson Disease is rare (a speaker cited 30 patients per million), it is a disease which - if diagnosed early - can be treated so that the patient has a normal life and normal life expectancy. If diagnosed late, severe crippling neurologic disorders may develop, or fulminant or chronic liver failure may require liver transplant or the patient may die. A timely on-target diagnosis requires well-trained phsicians and teams and the use of sophisticated technology which has only recently become available.
Good medical care saves money. Early diagnosis and treatment will cost a few thousand dollars; late diagnosis with disability and a liver transplant will have costs approaching a million dollars.
Symposia, such as the one I attended yesterday, will be held by the Wilson Disease Association this year in various regions of the United States and will bring important education and competence to the field.
While Wilson Disease is rare (a speaker cited 30 patients per million), it is a disease which - if diagnosed early - can be treated so that the patient has a normal life and normal life expectancy. If diagnosed late, severe crippling neurologic disorders may develop, or fulminant or chronic liver failure may require liver transplant or the patient may die. A timely on-target diagnosis requires well-trained phsicians and teams and the use of sophisticated technology which has only recently become available.
Good medical care saves money. Early diagnosis and treatment will cost a few thousand dollars; late diagnosis with disability and a liver transplant will have costs approaching a million dollars.
Symposia, such as the one I attended yesterday, will be held by the Wilson Disease Association this year in various regions of the United States and will bring important education and competence to the field.
Sunday, April 27, 2008
What If Your Electronic Medical Record Is Wrong?
The Perspective column, by Robert Steinbrook, M.D. (pp. 1653-6) in The New England Journal of Medicine (N Engl J Med 358:16, April 17, 2008) describes social and medical complexities of computerized online medical records. Steinbrook describes the push towards online records provided by Dossia ("a nonprofit consortium of major employers"), "Google Health, Microsoft HealthVault and other Web services that are seeking expanded roles in the $2.1 trillion U.S. health care system." In other words, there is a lot of entrepreneurial money at stake (consider advertising revenues) pushing this project, which means that profit and return on investment may come first and patient health and well-being may move to lower priority. Since money buys political influence, beware when current Presidential candidates, Senators and Representatives talk about "health reform" and describe electronic medical records as the salvation to our health care systems' ills.
Based on my past experience as an attorney negotiating related issues, I am concerned about the risk that our medical records will become another commodity. After all, as I have described in earlier blogs, HMOs and PPOs have commoditized health care during the last fifteen years: why should our private medical records be different? Who will own the vital facts contained in your medical record? Will it be you, your doctor, your clinic, your hospital, Microsoft, Google, your employer, an HMO, PPOs, insurance companies or venture capitalists? Who will have the right to sell medical records if, for instance, a major repository goes bankrupt and the court system must dispose of the asset for the benefit of creditors to the highest bidder? What happens if a foreign company acquires the records?
The second April 17, 2008 article, "Off the Record - Avoiding the Pitfalls of Going Electronic," by Drs. Hartzband and Groopman (pp1656-8) takes a seasoned and cautious view of the electronic medical record. It describes the mindless repetition of information: "Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family yhistory, social history and review of systems." The authors warn that important new data may be obscured. Even the relationship between a physician and patient may be warped as the physician stands at the computer, focused on the screen, providing an impersonal detached experience for the patient.
My experience as a hematologist, taking care of very sick patients, highlights another issue which is scarcely mentioned. Previous physicians may be absolutely wrong in their diagnoses but the momentum developed in the electronic record may make it difficult to understand whether, how or why they went wrong. I saw patients with voluminous paper records from respected instutitions that diagnosed cancer when there was no cancer, that diagnosed essentially untreatable cancer when the disease was relatively benign, that made patients uninsurable because a doctor did not understand the difference between an adenomatous polyp in the colon and familial adenomatous polyposis of the colon and wrote a note which echoed through the chart for years.
Even competent physicians will, from time to time, look at a familiar patient with blinders of past experience, chart entries and sterotyped interactions. Sometimes, the safest record for the patient is no record (except for the list of medications taken and drug allergies provided by the patient) - which requires the physician to start from the beginning, as if he or she had never seen the patient before, with an open mind and challenges to every sacred diagnosis, treatment and prejudice which has affected their relationship and patient care.
Based on my past experience as an attorney negotiating related issues, I am concerned about the risk that our medical records will become another commodity. After all, as I have described in earlier blogs, HMOs and PPOs have commoditized health care during the last fifteen years: why should our private medical records be different? Who will own the vital facts contained in your medical record? Will it be you, your doctor, your clinic, your hospital, Microsoft, Google, your employer, an HMO, PPOs, insurance companies or venture capitalists? Who will have the right to sell medical records if, for instance, a major repository goes bankrupt and the court system must dispose of the asset for the benefit of creditors to the highest bidder? What happens if a foreign company acquires the records?
The second April 17, 2008 article, "Off the Record - Avoiding the Pitfalls of Going Electronic," by Drs. Hartzband and Groopman (pp1656-8) takes a seasoned and cautious view of the electronic medical record. It describes the mindless repetition of information: "Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family yhistory, social history and review of systems." The authors warn that important new data may be obscured. Even the relationship between a physician and patient may be warped as the physician stands at the computer, focused on the screen, providing an impersonal detached experience for the patient.
My experience as a hematologist, taking care of very sick patients, highlights another issue which is scarcely mentioned. Previous physicians may be absolutely wrong in their diagnoses but the momentum developed in the electronic record may make it difficult to understand whether, how or why they went wrong. I saw patients with voluminous paper records from respected instutitions that diagnosed cancer when there was no cancer, that diagnosed essentially untreatable cancer when the disease was relatively benign, that made patients uninsurable because a doctor did not understand the difference between an adenomatous polyp in the colon and familial adenomatous polyposis of the colon and wrote a note which echoed through the chart for years.
Even competent physicians will, from time to time, look at a familiar patient with blinders of past experience, chart entries and sterotyped interactions. Sometimes, the safest record for the patient is no record (except for the list of medications taken and drug allergies provided by the patient) - which requires the physician to start from the beginning, as if he or she had never seen the patient before, with an open mind and challenges to every sacred diagnosis, treatment and prejudice which has affected their relationship and patient care.
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