Wednesday, December 9, 2009

Relativity

I walk into the FNA (fine needle aspiration biopsy) room, to perform a procedure. A 53 year old woman is sitting in the clinic chair - my patient. Her husband sits to the left of me, and I introduce myself to both of them. I run through the procedure, and then listen to her talk.

"It's been here for a couple of years. I wasn't that worried about it, but my mom recently was diagnosed with breast cancer, and thyroid cancer, and I decided to get it checked out."

She had a mass below the ear, a parotid mass. Slow growing parotid masses are usually one of two things - pleomorphic adenoma, if you aren't a smoker. Warthin tumor, if you are. Both benign entities. She wasn't a smoker.

I steadied my needle and performed one pass. I was confident that I got good material, so let her apply pressure and take a break while I waited for the tech to stain the slides. We chatted about her life.

"My husband and I are going to D.C. tomorrow, for a vacation. So we won't know about the diagnosis until we return. I'm going to be anxious thinking about it, the whole time."

I learned about her children, what they were doing. The slides were ready, so I looked in the scope. It was a great pass. Photo worthy. One to stash away in the files, for the cytotech students. Beautiful magenta metachromatic stroma surrounding football-shaped myoepithelial cells. A pleomorphic adenoma. We were done.

As the tech lowered the clinic chair so she could step down onto the floor, I looked her in the eye. "Have a great trip in D.C. You've got nothing to worry about."

Back in my office, I called the ENT doctor, and told him the diagnosis. "Wonderful. Thanks."

A week and a half later, I received a phone call in my office. It was a transcriptionist. "I've got a lady on the phone, and she wants to talk to you. A patient. She is really upset, and thinks you may have gotten her slides mixed up with someone else. Do you want me to take a message?"

I quickly looked her up on CoPath, saw the name and diagnosis, and remembered her. "No, I'll be happy to talk to her. What line is she on?"

I don't often get phone calls, from patients. The transcriptionist was trying to protect me. We usually leave all the interaction to the clinicians. But having a patient worried and doubtful about my diagnosis alarmed me.

"Hello, Dr. Shyder? Do you remember me?" Her voice was laced with hysteria.

"Of course. How was your trip?"

"Great, but I just went to the doctor. He told me I would have to have surgery, to remove the mass. You told me I had nothing to worry about, you thought. Are you sure you didn't get my slides mixed up?"

Pleomorphic adenomas are, by rule, benign. One in a million can be cancerous, so they have to be removed surgically. I have seen pictures in books, but never run across a malignant one. I'm a young pathologist, but I'd be willing to wager that none of my 13 partners have ever seen a malignant one, either. I'm guessing at these stats, but malignancy, in a PA, is a true anomaly. As pathologists, we don't discuss diagnosis or treatment with our patients, when performing FNA's. But on the precipice of her vacation, and with her mother's history in my head, I felt moved to console her.

"Yes, they have to be removed. But the vast majority are benign. When I saw the slides, I was thinking of your anxiety about your mother's two cancer diagnoses, and was attempting to reassure you on that point. I apologize for any miscommunication. I realize that having surgery is a big deal, and I am sorry to have misled you. I will be happy to have the slides pulled, and will review them today, since you are worried. If there is any change in diagnosis, I will notify your clinician immediately."

Lesson learned. I won't be so quick to pacify a patient, in the future. My idea of "no big deal," isn't every one's. I'm not the one going under the knife - this week, anyway.


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