Thursday, November 02, 2006
Under the Microscope
When Ernie was in town, we saved the system lots of money, and we saved women lots of stress and a little bit of surgery. Damn Ernie anyway: he sometimes took vacations.
Cytopathology -- the microscopic study and interpretation of individual cells -- is tricky business. Looking at the typical tissue sample under the microscope, one looks at patterns formed by large numbers of cells. It's like an aerial photograph: get the lay of the land from 20,000 feet. Looking at only a few cells, spread apart, is like trying to figure out a neighborhood by looking at only a couple of houses. In particular, cancer is most easily recognizable when a goodly swatch of tissue is presented and that "aerial view " is available. Pathologists drive us surgeons crazy in the operating room when we send a sample for intra-operative diagnosis, and they call back asking for more specimen. Damn, we say. The reason you got what you got is because I can't send any more. Can't you make the call? Nope, need more....
So it's not hard to imagine that if some pathologists are reluctant to make a call based on an actual chunk of tissue, even more would shy away from trying to diagnose based on a small sample obtained with a fine needle. Not Ernie. The man had a gift. Over the years, he actually managed to drag me along to the point where when we looked at slides together I could sometimes see what he saw. But never as clearly, or as confidently. And the other pathologists? Forget it!
At the risk of annoying those who already know, let me state that cancer cells are normal cells gone bad: something happens to a cell or cells to unbridle them, to allow them to reproduce more rapidly than necessary, to gain the ability to insinuate themselves into areas in which they don't belong. And in the process they take on appearances that differ from normal. There are characteristics of cancer cells that can be recognized in individual cells, without the need to see giant patterns. Part of the process is that cancer cells can vary quite wildly within a group: cells are way larger -- or smaller -- than normal: the nuclei are very large, take up differently the stains that are used to highlight them under the microscope. Still, sticking your neck out and unequivocally identifying a few cells as malignant is something many pathologists are reluctant to do.
I've said in previous posts that when I'd see a woman with a breast lump, I'd most often take a fine needle sample on the initial visit, and then hand carry it to the lab, sit down with the pathologist and look at the slides with him. When cancer was confirmed I'd call the woman back that day and get together with her at the end of my office hours. It was a great service; in addition to avoiding a prolonged time of misery for the woman as she waited to hear results, it avoided surgical biopsy, saving someone well over a thousand bucks in various costs. Problem is, Ernie was the only guy willing to make the call. Anyone else, I'd get "highly suspicious" as a diagnosis. And that really doesn't help a damn bit, because it means -- even when I was as sure as I could be based on all the evidence: physical exam, mammogram, even the way the needle felt as I passed it into the lump -- that I couldn't tell the woman it was cancer, and had to resort to an open biopsy. (Often, when Ernie came back from wherever he was -- another planet? -- I'd have him secretly look at the slides, just to know what he'd have called. And pretty much without exception, in those cases when it was clear to me, he'd call it cancer.) Nor was Ernie a cowboy: he'd call it only when he was damn sure. If he couldn't make it out as cancer, even when he was highly suspicious, he'd demur.
Just to muddy the waters, and to scare the hell out of everyone, there actually was one time Ernie wrongly diagnosed cancer. It was a sample I took from a young woman with a lump I was certain was innocent, a fibroadenoma; not wanting surgery, she chose the needle aspiration for confirmation that it was ok to leave it alone. The result was so surprising to me that I simply told her the sample was a little questionable and I recommended removing the lump, which I did as a simple ten-minute office procedure, for not a whole lot of money. The report was fibroadenoma. No harm, no foul. No explanation, either.
Once again, I've ambled slowly to the point: variation in the skills and talents of doctors lead to variations in outcome, especially in the area of costs. It takes a pretty bad doctor regularly to affect ultimate outcome: the body is amazingly forgiving, and will heal in the face of wide variation from the Platonic ideal of a given operation, for example. If a bigger incision than necessary is made, if the wound edges are pulled on harder than ideal, you might hurt a little more and a little longer, but you'll be fine. If the operation took substantially longer than it might have in other hands, it'll cost more in OR charges, maybe take a little longer to shake it off, but you'll not know the difference in a while. But that stuff adds up. Would that I could deal only with Ernies. How I'd like not to have certain radiologists read my mammograms -- the ones who always have to say "can't rule out...." and "stereotactic biopsy recommended" [even when the lump is big as a house!] Of COURSE you can't rule it out!!!! No mammogram can absolutely exclude that cancer is present. But can't you give a report with the aim of helping, as opposed to covering your ass???
In an ideal world, guys like Ernie would teach the other pathologists his secrets, and they'd develop the skill and confidence to make the calls he's able to make. Radiologists would become able to say what they see and don't see in ways that streamline rather than complicate care. Anesthesiologists would help each other to gain the ability to have every patient off to sleep within moments of arriving in the OR, staying fully asleep during the operation (Note, once again: moving around during surgery is not a rememberable event for the patient; it just makes it a little harder for the surgeon) and fully awake right at the end of the case. And, of course, every surgeon would make the right judgments about when to operate and when to not; and how to conduct the operation efficiently, cost-effectively and safely; and would see the patient often enough post-operatively in the hospital to see to it that recovery was fast and uneventful. It doesn't happen now, and it's unlikely that it ever will. Not unlike people, doctors vary in skill, knowledge, experience, and committment. In my opinion, analyzing the wide variations in care delivery and finding a way to lessen them would be much more useful in controlling costs than the blood/turnip approach to date. And, assuming such analysis were possible in both meaningful and non-punitive ways (as you'd expect of our government, currently the approaches are nothing but punitive), it would be FAR more useful than the silly and simplistic and generally annoying "performance" measurements being instituted currently. But the complexities are daunting. Not only are the sheer numbers overwhelming, getting doctors to open their practices to such analysis, to look open-mindedly at the results, and to be willing to share their aptitudes with others is a pipe-dream. As is the ability of any agency I know of or could imagine to come up with a workable plan to try. Nor am I so sure I'd be willing, despite having shot off my mouth about it: if for no other reason that I don't trust any bureaucrat with the responsibility.
The good news, as I think I've implied, is that for most patients none of this matters to a really critical degree. Good enough, as I said in my book, is good enough. Most of the time. As it's impossible to imagine that every plumber you might randomly call will do a perfect job, so it's a fact that you can't expect that all doctors are equally perfect or even strive to be. It's just that healthcare is such a high-impact field and costs so damn much. As a guy getting older and approaching the time when I may need a surgeon, or a cardiologist (or a thanatologist) I'd like to think I could roll the dice and come up sevens. But I don't like the trends I'm seeing.