My quest for a second qualified opinion on an abnormal mammogram (microcalcifications) began in October, Breast Cancer Awareness Month. Two days before the end of the year, a sharp surgical resident put an end to the spin. The solution was simple – and not high tech. She got on the phone and spoke to the various physicians involved. She was proactive where the system was flawed or obviously broken. Most important, she listened to me, the patient.
First, she had the radiologists clarify their thinking. The first radiologist agreed there were no significant changes in microcalcifications between the ’07 and ’08 mammograms. Nonetheless, he chose a more conservative BIRAD 3 (indefinite) designation and opted for a closer follow up (six months) – which is fine with me. The second radiologist, more of a “niche” specialist and therefore a “qualified second opinion,” opted for the BIRAD 2 (benign) category with, he said, follow up recommended at one year.
Despite being guaranteed payment for his services, the specialist refused to write an official report downgrading the rating, so the resident had the hospital radiologist read the films. The latter agreed that the calcifications were benign appearing and a biopsy was unwarranted. Unbidden, the resident telephoned my primary care provider and explained the situation. Thus one physician in the system remains guardian of my health.
Having herself witnessed instances of women slipping through the cracks, arriving at the clinic too late for meaningful treatment, the resident did not belittle my concerns or emphasis on early detection. The criterion for the biopsy remained patient comfort, she stressed. Unlike the radiologists, she responded to my question about the chances of malignancy. (More like 1:10 or 1:100?) Was the surgeon humoring me by offering the biopsy option, or was this a science-based decision whereupon we could agree what constituted acceptable risk?
The resident heeded my request for e-mail communication, saving everyone phenomenal amounts of time. The next day, she locked down follow-up appointments at both ends: radiology in six months (three after the quest for clarification), and the surgery clinic for explanation and clarification. At my request, she got me the latest possible appointment at the surgery clinic so I do not miss (yet) another day’s work.
The visit to the surgery clinic cost me 3 1/2 hours plus one day of lost work.
The follow up took minutes to resolve via e-mail.
Despite her obvious smarts and grasp of her job, the resident’s powers were limited. She could not explain why the second radiologist refused to report in writing, but she did back-stop him with their own experts. Nor did she did leave follow-up solely to the office of Radiologist No. 1. When asked which radiology practice was best for my case, she stated that the clinic had never experienced problems with the first office (a deep seated concern given my daughter’s history with this office). As for the expert refusing to put the second opinion in writing, she assured me that the record of the phone conversation in my file would suffice as confirmation of the diagnosis.
I will not see the resident again because she is rotating to the next service. I wish her the best in her career, which, one assumes, will be radically altered through health care reform and new HIT (health information technology). Her actions did nothing to change my opinion of female physicians as being more collegial, less arrogant and more willing to correct error. She had, I felt, a genuine compassion for women’s fears about breast cancer. Nor did it change my opinion of the generation gap in medicine: Younger, she was at ease with the not-so-new technology of e-mail. Plus I admire her courage. She (or her boss) was willing to risk transparency in the interests of efficiency and human decency.
Subsequent research revealed that the second radiology practice has become, as one person said, “the only game in town” by securing a contract with a major hospital; its partners are more than satisfied with remuneration. In contrast, the referring clinic is known as a mill, staffed by part time, uncommitted physicians.
I can not help thinking that the rookie, being the least invested in the medical business, was the one who got things done. Nor can I help noting that the male specialists at opposite ends of the class spectrum in medicine – the public clinic and the lucrative radiology practice – were equally intolerant, indifferent to best practices. Tell me that gender dynamics are not defining in medicine, that gender bias is not a part of the health care system that the Obama administration should pledge to fix. Tell me that women are not experiencing a higher toll from cancer due to this intolerance.
One has to wonder what would have happened if the physicians in question had heeded my request at the outset. There is no billing code for communication, at least one lucrative enough to make communication worthwhile. Therefore physicians’ anger and resentment at “special requests” – or best practices, even.
Coincidentally, the county hospital in this rural agricultural area has one of the top-ranked surgical residency programs in the country, even as the hospital bleeds red ink. Someone, somewhere, is doing something right, and it is not because of high tech.