221. Sign of the Times

Not an uncommon request: "Can I have [procedure x] done before I lose insurance at the end of the month?"  The frequency (and emotional urgency) of such requests will surely increase.

Last week Maria asked for a hysterectomy.  She had breast cancer several years ago, her treatment including surgery and chemotherapy.  She received a standard 5 year course of tamoxifen, a drug that blocks estrogen receptors in the breast (her cancer was accelerated by estrogen) but paradoxically stimulates estrogen receptors in the uterine lining, increasing the risk of uterine cancer.

So, she asks, why not just take out the uterus, an organ that now serves no health purpose and carries the risk of cancer?  I acknowledged that although a hysterectomy would remove the threat of uterine cancer, the risk of uterine cancer is low even with taxoxifen, and usually easy to detect--bleeding occurs at pre-cancer stage and she has experienced no bleeding. Furthermore, she is now a couple of years beyond the final tamoxifen dose.

Then consider the potential complications of a hysterectomy such as injury to the bladder or bowel, infection life-threatening blood loss.

Maria returns to her original concern:  "I may not have insurance when and if I experience signs of cancer.

We end up planning an ultrasound (assuming it can be performed in the two weeks remaining on her insurance), which can show signs of hyperplasia (the pre-cancer stage).

220: Child's Play

In response to the regular survey that most of our patient's receive, a patient said that she felt like she had been treated like a child. As a brief written note, I couldn't tell whether this comment came out of anger, frustration, humiliation or resignation, but it sure wasn't a compliment. Too much time had elapsed between the encounter and the feedback, and I could't remember the specifics of the visit; I just had to leave it as an unknown.

Unknown until last week when I experienced a very unsatisfactory exchange with my (now ex-) dermatologist. I was at first annoyed, then frustrated, then unhappy but I couldn't pin down exactly what it was that bothered me until after a couple of days I connected the two. I felt treated like a child.

If a 4-5 year old came to me with a scratched arm or broken toy (or more likely, a crashed iPad ap), I would exaggerate my concern and sympathy wanting to make sure that I would be heard through the tears.  "Oh that's just terrible," I might say, or "you must feel really upset; let me make it better"  A knowing parent might want to add a reality check: the scratch is minor, the toy fixable, the pad just has to be rebooted. But I think (wrongly?) my relationship with the child would suffer if I reacted that same way as I would to a friend.

The dermatologist brought her chair close to me, tilted her head just so, maintained steady eye contact, and expressed much concern even though I hadn't really complained--I just came in for a refill. Her manner would have been lauded at a doctor-patient communication workshop. But it didn't work for me any more than my condescending manner worked for my patient a few months ago.