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.


scalpel said...

This segues nicely with your last post, in the sense that the best medical care is accomplished when physicians (and associates) work together seamlessly.

Empress Bee (of the high sea) said...

gosh if YOU feel this way, what must the rest of us feel like? when i had my lung surgery i had no idea who to get. my dr. was in another state and i knew no one to ask. sigh. i actually went to the yellow pages to start. then of course, i went online to check him out all i could, but you never really know. i was blessed with the best.

and a funny side note, i asked his receptionist how he was and she told me he was wonderful and i later found out she was his WIFE! she has also been wonderful by the way... bee

scalpel said...

Oh, and thank you for giving your patients biopsy results the same day. Nothing frustrates me more than to see some frightened patient in the ER who had a test (biopsy, CT scan, stress test) on Thursday and comes in Sunday or Monday night with the same concern.

Of course their physician is not on call, and their partner doesn't know the test results.

It happens so often it is apparently the standard of care around here, and it makes me sick.

Anonymous said...

Thanatologist -- LOL! Complimentary parking validation and coins for the boat crossing... (quid pro quo Greek reference :P )

And lookie lookie...without reading this post, you already addressed the comment I made in the previous post just a few minutes ago about "indecisive" radiologists.

Speaking seriously (*cough*) I really can't see how physicians, ostensibly "enlightened" individuals wouldn't want to expand their knowledge, etc. at the expense of a little ego to say, "perhaps I do have something to learn here." I have always wanted to teach no matter what I did with medicine, so the idea of mentoring and being mentored is for me just as natural as breathing. Like breathing, it should be seamless and integral unless a toxic individual/relationship comes into play, at which point you're better off going elsewhere before you cough up more lung cookies.

Anonymous said...

Thank you for being sensitive to the fact that waiting on a pathology report, even for a few days, is like walking on the glass shards of hell. But if you can't figure out who the competent ologists are how is anyone else expected to do so?

Anonymous said...

Not that it matters much but I have woken up during 2 different surgeries and remember it. In both cases nothing hurt, I could hear the Dr's talking and knew they weren't done yet and and I must have moved because I heard them ask the anesthesiologist to up the dosage.

I never mentioned it to them because I didn't think it was a big deal.

Sarge Charlie said...

Attention, friends of Miss Bee, November 4, 2006 is a special day for Miss Bee. There is a party going on at my blog, “sarge charlie”, which is on Miss Bee’s sidebar. Everyone is going to be there, stop on by and join the party.

Anonymous said...

I don't have a primary doc, haven't for over ten years, am in perfect health at age 66, but tripped and broke the hip. By the time I got to the emergency room I was doped to the gills with morphine but managed to answer all the questions. I don't know how I got the ortho surgeon who pinned the bones together, but I really liked him. My recovery is great.

The point is, should I begin checking out different specialists, so that should another accident happen I can give a name, my preference, in OR? Not that I plan to make another such trip again, ever! I don't like hospitals, though my stay this time convinced me this one is very good!

beajerry said...

A doc personally confering with a pathologist or radiologist? Why, that's crazy talk!

Unknown said...

I had a surgery to remove a tumor from my kidney. The surgery started at 2:00 P.M. on a Friday. A frozen section was supposed to be tested by a pathologist during surgery, but that never happened. Looking back, I think that my surgery lasted an extra 2 hours because the surgeon was trying to find a pathologist after 5:00 on a Friday and couldn't find one.

After the surgery, the doctor told my family he did not think it was cancer and even hugged my sister. Five days later, right before I checked out of the hospital, he gave me the results of the Pathology report and told me it was cancer, but he had got it all.

Two weeks later when I went to remove the staples, he tells me that I had positive margins. His followup plan was to wait three months and have a scan to see if the cancer came back.

About one month after my surgery, I joined a kidney cancer email group on ACOR and told me story. They were alarmed and said to post the exact information from my pathology report to the list. After several attempts of having the report faxed to me, I finally received it and posted the information to the list.

Everyone was dismayed at what my doctor had advised me for follow up. The report said I had a Fuhrman Grade 3 of 4 indicating an aggressive cancer. They recommended I get another opinion right away as they believed my entire kidney should be removed.

Two Oncologists and the Chairman of the Glickman Urological Institute, Dr. Novick from the Cleveland Clinc all said my kidney should be removed right away.

Thank God for the internet!!

Mark Wick said...

As a pathologist, I actually agree with you that too many of my colleagues give "cloaked" diagnoses that are too general, out of a desire to avoid being "wrong." As I near retirement, I see this as a generational thing... medical students and residents are not being taught or encouraged to use their knowledge and common sense to reach an actual conclusion. As a result our world of medical care becomes increasingly nebulous... and expensive... as more data are accrued to get to the "answer."

As you might imagine, I choose doctors VERY carefully for my family!



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