Thursday, February 18, 2010

Tracking Patients

This morning, I dropped my kids off to school early at 6:30 a.m. Luckily, there is a teacher available to help me out when I have to go to a more rural hospital or cover early frozens or a conference. Fortunately, I only have to do it about once or twice a month.

I was covering breast conference for my partner, who is on vacation. The last time I covered it for her was a year ago, when she went to the Rio Carnival on a cruise (jealous!) for her honeymoon. I love covering this monthly conference because it reminds me, in an attenuated version, of the hardcore weekly breast conference I covered at my training university during my fellowship year. Geneticists, medical oncologists, radiation oncologists, radiologists, mammographers, case coordinators, surgical oncologists, PET experts and oh yeah, pathologists -- all gathering in one room to pow-wow about the patients. Going over cases. Discussing new treatments. Asking questions. Challenging each other (hopefully in a tame fashion - it doesn't always work out this way depending in personalities involved).

Today we began by discussing an incredibly rare breast cancer, and I was happily surprised that only two years out of residency I had the same experience with this type of cancer as surgeons and medical oncologists ten and twenty years my senior. So my contribution to the discussion, based on my reading, was substantial. We presented one other case, a sad one about a young girl that was just diagnosed with a high grade breast cancer - after she finished lactating she noticed a lump that didn't go away. Lactational change, to a pathologist, is usually a sight that generates a big sigh of relief when peering in the scope, because 99.9% of the time it means the lesion is benign. Then there are the exceptions. They make your gut twist. They generate nausea. Even though you know what you are looking at, you show it to a partner because you are staring at the age, and thinking about the young nursing mother and what she is about to go through, and you desperately want your partner to tell you that you are hallucinating.

I remember when I was a nursing mother I read nursing texts obsessively in attempt to prevent stories I heard from my friend who attended La Leche League. She would call me and tell me somewhat comical ones, like the girl who brought to the table her issue of being unable to find a bikini because her baby would only nurse on one side and therefore one breast was a G (do those really exist?) and the other was a C. As a new nursing mother, despite my symmetrical breasts, I was impressed (thinking of my flabby stomach) that she was even considering going out in a bikini at all that summer. Then my friend would tell me horror stories, like the girl that ignored a lump and developed an abscess and sepsis and had to have surgery and quit nursing. I went to my OB/GYN once, obsessed over something I felt in my breast that in retrospect was probably fibrocystic changes. I was convinced it was the seed of the abscess that was plotting to doom my nursing efforts. When my OB palpated my breast, she looked at me quizzically. "Um, Gizabeth, I'm not sure I really feel anything? But if you want me to pull out the ultrasound, I'll be happy too." I smiled and blushed with relief and embarrassment. "No Cindy. If you think I'm crazy, that makes me happy. I'd rather be crazy about this, than right."

There were two other patients to present in breast conference, but the radiation oncologist generated a lively discussion about a new treatment, and everyone joined in, burning up the rest of the hour. Back in fellowship when I was doing weekly conferences, I was annoyed when this happened, because I had usually spent an extra couple of hours the night before taking pictures of cases to put in a power point - other pathologist's cases (I was doing a cytology fellowship) -while my own breasts swelled up like melons, aching for the relief of going home to my nursing son. All my work seemed like such a wasted effort. But now I was the relief pathologist, no longer nursing, and the discussion meant a lot more to me with my own experience of signing out breast cases. Of course we always strive for accuracy and perfection in our reports, but it is nice to sit in the room with treating physicians and learn the direct implications of your words. The all powerful ones that you put on the patient's permanent record. Grade III. 2.5 cm. Posterior/superior margin positive for malignancy. Micrometastasis to the sentinel lymph node. Estrogen receptor positive. Progesterone receptor negative. Her-2-neu positive.

So I sat back contentedly and listened, so I might learn something. At one point, the radiation oncologist and a breast surgeon (one that I have always admired tremendously) got into a discussion about a particular patient. The radiation oncologist began discussing her, and how she treated her. She turned to the breast surgeon.

"That was your patient, right? I'm surprised she is still alive. She made it longer that I would have expected."

The breast surgeon reached into a tiny notebook in front of her and pulled out a square of newspaper, showing it to the radiation oncologist. An obituary. Everyone remained stoic.

The radiation oncologist said, "Oh. When did that happen?"

"February 3rd."

"Not that long ago, then."

The discussion moved on, and everyone slowly began to gather up their breakfast trash to throw away and head to their respective clinics, OR's, radiology caves, and lab offices. As a pathologist I have so many cases, and bounce around on so many different rotations, that I don't get follow-up unless I serendipitously come across a patient for a second time on a new case. Then I get to catch up on what has happened between then and now. I can't imagine being a treating cancer surgeon or oncologist, and keeping up with my patients by scanning the obits. Cutting them out meticulously, and keeping them in a notebook, as a reminder of how that patient ended up. Maybe to affect how you might treat a similar case differently, next time. Or maybe just to remember your patient.


7 comments:

  1. Reading your posts is such a treat - like sitting by the fire, curled up with a book.

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  2. Thanks, KC! Reading your last post was like diving into a moment in time and getting swallowed by it. I want more!

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  3. Gave me chills Gizabeth. Heartbreaking to read, as I watch my MIL struggle in her battle with metastatic breast cancer. Thank you for your beautiful writing.

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  4. Indeed, G's do exist, unfortunately!

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  5. My mother-in-law has metastatic breast cancer, too. She has done well for the last few years, but being a patient (vertebroplasty, hip replacements, etc.) is a full time job for her, in addition to picking up my kids a couple of times a week for sewing/library/ice cream afternoons. She is an inspiration.

    Good to know about the G's. I was so worried about that possibility, but I never went beyond a DD, and happily returned to my not so opposite-sex entrancing large B/small C's (I like to pretend about the C's, anyway).

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  6. This particular post really hit home with me today. A dear friend (and wife of another medical professional) is one of those early 30's lactating moms that had a "case of mastitis" that wouldn't go away. Months and chemo and a double mastectomy and radiation treatment later, she was declared free from her stage 4 inflammatory breast cancer. Until this week when we were devastated to learn that she has multiple tumors in her brain. To us, she is our precious and much loved Julie. I hope her doctors feel at least a little bit the same way.

    When we have patients die on our unit, particularly ones that were there for a while or made a significant impression on the staff, their obituaries hang for a while, taped to the edge of the countertop. It's a somber reminder of the finality of what we do. Make it or break it.

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  7. Wow, Nurse Heidi. Thanks so much for your comment. I'll keep Julie in my thoughts. You are right - what we deal with on a day-to-day basis is so final.

    I sometimes feel like a grim reaper - passing out cancer like candy. But I was reminded recently, that sometimes early diagnosis can lead to cure. Made me feel better, about what I do.

    I'm so glad that there are a lot of people out there, remembering their patients.

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