Opinion

A PIECE OF MY MIND Khanjan Baxi Shah, MD Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio.

Corresponding Author: Khanjan Baxi Shah, MD (khanjan.shah @uhhospitals.org). Section Editor: Roxanne K. Young, Associate Senior Editor.

Adverbs He sits on the side of his hospital bed each morning, his body hunched in desperation. He is but a shadow of his previous self, broken by months spent in a drab hospital gown. I dread rounding on him now—his hopeless eyes leave me perpetually wounded. I met him four weeks prior, two months into the journey of his diagnosis. He initially presented complaining of weakness: “Caught something from the grandbabies,” he surmised. His confidence nearly had me convinced. Further questioning uncovered important revelations: unintentional weight loss, nightly sweats, and overwhelming fatigue. I listened carefully and detailed the need for further testing. “It’s a lung infection, right, Doc?” he asked. “Perhaps,” I replied, “but it could possibly be something more serious.” One chest film later, we first met our elusive lung mass. I called him to return for a CT scan of his chest. “Why do I need another test? Can’t this one tell you what I have?” “We need a more detailed picture, which will likely reveal the diagnosis.” The CT scan further delineated the large right upperlobe mass with clear invasion into the bronchi. “We need to proceed with a bronchoscopy and biopsy,” I explained. “Only when we have a sample can we tell you what it is.” “But do you have any idea, Doc?” he replied fearfully. “It is potentially a cancer but too early to tell. It could still be a more benign condition.” The biopsy was completed during an outpatient visit: nondiagnostic sample of necrotic tissue. The pulmonologist was optimistic for a second trial. “We will probably get it this time around,” I pleaded. He conceded after modest debate. Unfortunately, the second bronchoscopy remained nondiagnostic. Six weeks had now passed since I first met him, and he had progressively become weaker. The decision was made to admit him for expedited diagnosis. “We are usually more successful in the hospital by incorporating a multidisciplinary approach,” I explained. He wearily agreed. The PET scan redemonstrated the mass as hypermetabolic—an interventional radiologist attempted CT-guided biopsy: nondiagnostic. Mediastinal lymphadenopathy was also noted—a thoracic surgeon attempted mediastinoscopy with biopsy: nondiagnostic.

So here we were, three months later with no definitive diagnosis despite several teams of physicians involved in his care. And each day he deteriorated further. His severe malnourishment left him with anasarca and resulting painful stasis dermatitis. He developed an intense leukemoid reaction and was started on broadspectrum antibiotics after which he developed profuse diarrhea. “So you think I have an infection, right, since you started the antibiotics?” he asked. “Well, cell counts this high usually represent a cancer-mediated reaction, but we cannot be certain,” I slowly replied. His elusive mass continued to grow rapidly with eventual invasion of his chest wall. In addition to hopelessness, he now suffered from excruciating pain. “We almost got it last time,” I stated. “We need to now pursue a surgical biopsy. It’s most likely to be successful given the chest wall invasion.” “Almost? Why almost, why probably, why likely? Why don’t you just know?” he yelled. It was a logical and fair question for which I had no answer. Thankfully, the surgical biopsy was successful— stage IIIb squamous cell lung cancer. Concomitant chemotherapy and radiation therapy was initiated on the same day as diagnosis. Several days later, he was stable for discharge to a skilled nursing facility. His granddaughter was practicing her multiplication tables as I entered the room. “Four times five is 20!” she exclaimed. “It certainly is,” he said lovingly. I explained the need for close follow-up and continued medical therapy. As I turned to leave the room, he stopped me. “I’m sorry I yelled at you, Doc. It’s just that … I thought you doctors knew everything.” “Well now you know the truth,” I replied and left him for the final time. I realize now that I dreaded rounding on him not because he was difficult, but rather because I could not definitively give him the answer that he craved—that he deserved. Perhaps one day he will understand the forgotten insight into my practice: That medicine is not mathematics. That uncertainty is in fact truth. That logic is often unbound to reality. That humility lies in the adverbs.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.

jama.com

JAMA February 26, 2014 Volume 311, Number 8

Copyright 2014 American Medical Association. All rights reserved.

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A piece of my mind. Adverbs.

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