The big C and the art of medicine

February 23, 2012
by Nishani

Today’s theme in the ambulatory internal medicine clinic was focused on the art of medicine.  In particular, we saw two patients who had very different experiences with cancer.   The first patient, let’s call her Ms. X, was told she had cancer before further investigations confirmed that she did not have it.  The other, Ms. Y, worried that “something was wrong”, but instead was told not to worry about it.  Later investigations revealed that she did have cancer, and in fact, it had already spread to distant regions.  Both patients experienced significantly different outcomes.  However, they both continue to wish that things could have been done differently.  

Ms. X reiterated the need for doctors to be cautious and mindful of the patient’s feelings when delivering bad news.  Her doctor had told her that she had cancer after seeing a suspicious lesion on imaging.  In actuality, this lesion did have a very high likelihood of representing a malignancy.  She explained that she would have preferred if the doctor had said something to the effect of: “It looks like there’s something on the imaging that’s not quite right, but we will have to do further investigations to sort it out.”  I wondered, when there is a 90% chance that a lesion could be malignant, do you try to prepare a patient for the worst?  Or, do you withhold that information until you are sure?  According to Ms. X, it is better to let patients direct how much information is delivered.  If Ms. X had probed further to inquire whether there is a chance that the lesion could be malignant, perhaps then her doctor could have offered this information.  Of course, each case and each patient interaction is different.

Ms. Y emphasized the importance of listening to patients and addressing their concerns.  She had been worried about her symptoms for quite some time, and asked repeatedly for further workup and investigations only to be told not to worry.  She said, she “knew [her] body best,” and wishes that her doctor had listened to her requests.  Perhaps her cancer might have been caught earlier and she might have been offered a chance for cure.  Again, I was reminded that even though doctors may have their own agenda of tasks to complete, addressing patient concerns should take precedence.  However, as managers of health care system resources, is it practically feasible to offer investigations to patients every time they ask for them especially when these investigations may not actually be clinically indicated? 

In both of these scenarios, it would be easy to look back on what was done and direct blame.  However, I see that the doctors involved did what they did according to the information they had at the time.  The patient perspectives serve to illustrate that doctors don’t always know what’s best and they really need to be mindful of their patients’ wishes and concerns while carefully balancing the multiple duties of their role.