Monday, March 29, 2010

Comfort Zone

One thing I've run across lately are a lot of radiology reports that seem to make statements or recommendations that are a little, well, off. First, let me make clear - my field is radiation oncology, NOT radiology. Another thing that I have to make clear is that in most cases, the radiologist that looks at images from a CT scan, MRI, ultrasound (etc.) never meets the patient, and often doesn't know their clinical history.

So why is it that I often read in radiology reports things like, "fibrosis and scarring consistent with radiation-induced pneumonitis"??? Sometimes the patient hasn't even had radiation! Moreover, pneumonitis is a clinical diagnosis, not just a radiologic one. In a day and age when patients can access their own results, including radiology reports (which I am in favor of), this can be very dangerous to claim. And sometimes downright wrong.

Another thing that happens is that in the report, it reads something like, "5 mm area of enhancement not clearly imaged by CT. Recommend follow-up with CT in 6 months," or "Recommend additional MRI study." I find that it's interesting they can recommend this without even knowing the clinical situation. For example, what if the patient had some clinical condition that easily explained the imaging abnormality, but now because of this report, it's almost necessary to order this additional (and sometimes costly) test. If the reports said something like, "based on clinical scenario and judgment of the ordering physician, a follow-up CT scan may be indicated," I think everyone would be much happier.

Just to give an example - I certainly do not tell a cardiologist how to prescribe or dose anti-hypertensive medications. I expect other specialties to respect the same boundaries.

Tuesday, March 2, 2010

Heavy thoughts

Well, I don't know if I'm back for good, but I've been thinking about things sufficiently to write again... the world of lung cancer is not the most uplifting of worlds.

For example. I was talking to a patient that I like very much - one I empathize with, one I like personally, and one I even identify with. She's a hard worker, in a demanding career, still working through radiation we had given her previously, and chemotherapy, funny, witty, smart, had 3 children relatively late in life. We had a great conversation about how her daughter just went off the pill and was hoping she would get pregnant soon. I shared my story about how I got pregnant only a few months after stopping the pill, and the patient had the same experience. So she was hoping she would have a grandson or granddaughter soon. Her time is limited - she has metastatic lung cancer. In the world of lung cancer, her average survival would probably be about a year. And that's with chemotherapy, which, let's be honest now, will make her feel lousy half the time.

She started coughing up blood lately, and so we are going to give her radiation to her lungs at a low dose to shrink her tumor and hopefully stop her from losing blood. It's not serious. Not yet. I was doing what I do with a million other patients, I was explaining the side effects of radiation:
"You'll feel tired. But fortunately, that will pass."
"You might get a sore throat. But that will eventually go away too."
"You might develop a cough, fever, or shortness of breath, but that's not common."

One of the last things I say is something like "Very rarely, radiation can cause a second cancer in the area we are treating you, but this doesn't happen for 5-10-20-sometimes 30 years."

She snorted and said "if I get another cancer in 10 years, I'll be very happy. Right?" And I nodded my head in understanding and made an mm-hm sound. Then she started crying. I gave her some tissue, she coughed up some blood, and I put my hand on her back. Nothing to say. She pulled herself together, and said, "okay, let's get on with this." And she thanked me for being honest with her.

Here I am, feeling horrible about mentioning a side effect that realistically, she will never ever have the chance to feel, and she thanks me for it. Maybe this is a lesson that I should stop mentioning this particular side effect to certain patients. Or maybe it's not that deep, it's just a manisfestation of a really sad situation, one that I will have to get used to.