The Value of Sputum Cytology BRENDAN MACDOUGALL,MD, BRIAN W-CINERMAN,MD Objective: To a s s e s s the value o f cytologic e x a m i n a t i o n o f expectorated s p u t u m in the d i a g n o s i s a n d m a n a g e m e n t o f p a t i e n t s with suspected lung cancer. Design: Retrospective c h a r t review. Setting: I n p a t i e n t wards, tertiary care university h o s p i t a l M e a s u r e m e n t s a n d m a i n results: The charts o f 357 p a tients were reviewed. Two h u n d r e d eighty-eight o f the 3 5 7 p a t i e n t s h a d h a d initial s p u t u m cytologic e x a m i n a t i o n p r i o r to o t h e r diagnostic procedures, o f w h i c h 41 (1596) h a d p o s i t i v e cytologic results. Thirty-six o f the 41 were conf i r m e d histologically o r s h o w n to have metastatic s p r e a d by n o n i n v a s i v e tests. O f the 222 p a t i e n t s with negative o r unsatisfactory s p u t u m tests, 9 7 w e n t o n to b r o n c h o s c o p y a n d 3 5 h a d needle-aspiration biopsies. I n the p o ~ o f p a t i e n t s w h o s e c h e s t x-rays were highly suggestive o f p r i m a r y o r metastatic lung cancer, the p o s i t i v e rate f o r cytologic e x a m i n a t i o n was 3 8 / 9 4 (40%). There w a s n o faise-positive test in this study. O f the 5 0 p a t i e n t s with positive cytologic re~dts, f i v e (10%) h a d diseases that were o f a d i f f e r e n t cell type; t w o o f these f l v e (40%) h a d diseases t h a t involved small-cell cancer. There was a n u n s a t i s f a c t o r y delay in o b t a i n i n g these samples f o r analysis. Conclusions: s p u t u m cytology w a s f o u n d to be too insenst. tire a n d i ~ y accurate to be i n c l u d e d in the rou. tine w o r k u p o f a p a t i e n t suspected o f h a v i n g l u n g cancer. The results o f the test d i d n o t influence f u r t h e r diagnostic p r o c e d u r e s . This test should, therefore, be reserved f o r p a tients c o n s i d e r e d o n initial assessment to be too sick f o r f u r t h e r investigations a n d treatmen& Key w o r d s : s p u t u m cytology; diagnostic tests; l u n g cancer. J GEN INTERN MED 1992;7:11 - 13.
IT IS OFTEN routine practice to obtain several sputum samples for cytologic examination for any patient when either the clinical history or the chest x-ray findings suggest the possibility of lung cancer. This is considered to be an inexpensive and reasonably accurate diagnostic test. This study attempted to analyze the clinical usefulness of this test and whether the results influence further diagnostic testing on patients admitted to the wards of a tertiary care university hospital. In addition, the sensitivity and the accuracy of this test were assessed.
METHODS A hospital-based retrospective chart review was performed for 357 patients known to have had sputum cytology testing, who had been admitted between Received from the Sections of General Internal Medicine (BMacD) and Oncology (BW), St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada. Supported by a grant from the Department of Health, Government of Manitoba, Canada. Address correspondence and reprint requests to Dr. MacDougall: Room C5114, Department of Medicine, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba, Canada R2H 2A6.
1985 and 1988 to the wards of St. Boniface General Hospital, a tertiary care university-affiliated hospital.
RESULTS Of the 357 patients, 288 had sputum cytology ordered prior to any other investigation. There were 620 samples analyzed for these 288 patients (average of 2.2 per patient). Of the 288 patients, there were 41 (15%) with positive cytologic results. Twenty-five of these 41 positive results (61%) were confirmed histologically, either by bronchial biopsy, mediastinoscopy, or thoracotomy. Six of the 41 patients (15%) had positive needie-aspiration biopsies or pleural fluid analyses. Five had chest computed tomography (CT) scans showing widespread disease and five were too sick for further testing. Thus, 88% were conformed as having lung cancer. Of the 222 patients with negative results or unsatisfactory sputum samples, 97 went on to bronchoscopy and 28 (29%) were positive. Forty had mediastinoscopy and 20 (50%) were positive. Thirty-five had needle-aspiration biopsies and 25 (70%) were positive. Of the ten patients who had "suggestive but not diagnostic" reports, nine eventually had carcinoma proven. Of the 12 reported as showing "atypical cells," five were diagnosed as having cancer. Table 1 shows the correlation between the chest x-ray findings and the positive cytology results. We were unable to categorize the chest x-ray as showing a proximal or a distal lesion, since we relied on the x-ray reports. For the high-probability chest x-rays (> 2-cm nodules or several nodules), the positive rate was 38/94 (40%). Of the three patients with pulmonary infiltrates only and positive and positive cytology, one had hemoptysis, weight loss, and a hard supraclavicular lymph node positive for squamous-cell cancer; one had fatigue hemoptysis and the Eaton-Lambert syndrome; and one had a mass seen on chest CT scanning. The positive rate of initial expectorated sputum analysis was compared with the positive rate obtained with bronchoscopy and postbronchoscopy sputa analyses in patients with high-probability chest x-rays. As noted above, the positive rate for initial sputum testing was 38/94 (40%). Bronchoscopy was positive in 31/91 (34%) of the patients; postbronchoscopy sputa analysis was positive in 24/66 (36%) of the patients. There was no statistical difference among these three methods (p = 0.4). The diagnostic accuracy of sputum cytology (preor postbronchoscopy specimens) was assessed by com11
1~.
MacDougal/, Weinerrnan, SPUTUM CYTOLOGYVALUE TABLE 1
The Relationship between the Chest X-ray Results and the Sputum Cytology Results Chest X-rays Result (n = 288) > 2-cm nodules Several nodules < 2-cm nodule Pulmonary infiltrates Other Normal
n 75 19 8 110 37 39
Positive Cytology 30 8 0 3 0 0
(40%) (42%) (0%) (2.7%) (0%) (0%)
paring the results with those of individuals w h o had tissue confirmation. Of the 50 patients in this category, five (10%) had diseases that were of a different cell type and two of the five (40%) had diseases that involved small-cell cancer. The time delay was assessed from test ordering to being s t a m p e d " r e c e i v e d " by the pathology laboratory. Ten percent of the samples were received the same day; 37%, the following day; 41%, from day 2 to day 4; and 12% took longer than four days to reach the pathology laboratory. This did not take into account delays in analyzing, reporting, sending the reports to the wards, and time for the physicians to see these reports.
DISCUSSION In this retrospective review, sputum cytology analysis lacked sufficient sensitivity. Only 15% of the 288 patients had positive sputum results, and of the patients with chest x-rays highly suggestive of cancer, the positively rate was only 40%. Furthermore, the results of this test did not influence further test ordering. Twenty-five of the 41 patients with positive sputum results went on to have these confirmed histologically. In addition, of the 222 with negative or unsatisfactory sputum samples, 97 w e n t on to bronchoscopy. Savage, in an analysis of 190 charts of patients w h o had lung cancer, also c o n c l u d e d that in those cases diagnosed by sputum cytology, additional invasive or diagnostic procedures w e r e not avoided, as they were often necessary to stage the disease process. Table 2 outlines other studies w h e r e the lung cancers were histologically diagnosed. These studies demonstrated variable sensitivity of sputum cytology (13 - 77%), w h i c h is likely to be due to different techniques in collecting and preparing the samples. Postbronchoscopy sputum analyses have not b e e n shown to be statistically better than analyses of p r e b r o n c h o s c o p y samples. Although there was a high specificity in our series, there were two concerning cases w h e r e the sputum test misdiagnosed small-cell lung cancer with potentially serious therapeutic implications. Overall, there were five of 20 (25%) w h e r e a different cell type was diagnosed. Suprun 9 reviewed his own data about 232 cases, of w h i c h 173 (75%) had b e e n correctly typed. In this
study, 34 of the 35 small-cell cancers were correctly diagnosed. He reviewed 13 other studies, indicating that the overall accuracies varied from 74.8 to 100% for squamous-cell cancer, from 63.6 to 93.3% for smallcell cancer, from 31.7 to 100% for adenocarcinoma, and from 20 to 62.5% for large-cell carcinoma. Jay 3 found that among 155 with nonmalignant lung disease, 16 (10%) had false-positive specimens, and this finding was significantly related to necrotizing p n e u m o n i a in 13 of these 16 patients. Rosa 8 found a 94.7% ( 1 8 / 1 9 ) concordance between analysis of sputum samples and tissue confirmation. Pilotti 5 described 27 cases of small-cell cancer and only two of these were misclassified. In the Ng series, 7 5 5 / 5 7 of small-cell cancers diagnosed by analyzing sputum samples were confirmed by histologic methods. Therefore, this study has demonstrated that cytologic analyses of initial sputum samples were insufficiently sensitive and accurate to be used in patients suspected of having lung cancer. Further testing was not avoided and the positive cytologic results added little to the information obtained from the chest x-rays. In addition, a negative or low-probability chest x-ray was seldom associated with positive s p u t u m cytologic results. Even if one accepts the small rating misclassification, a positive cytologic report will not stop further diagnostic measures if the patient is considered resectable (if n o n - s m a l l - c e l l carcinoma). If the patient is considered nonresectable on clinical grounds, then a tissue biopsy, usually from a skin lymph node or the liver, is usually done. A positive sputum sample in this setting adds little useful information. The treatment implications are so critical for small-cell carcinoma that we believe a tissue sample needs to be obtained to verify the sputum cytologic result. Also, the time delay in obtaining and analyzing these specimens made it an e x t r e m e l y inefficient test. Therefore, this test should be abandoned, e x c e p t in those cases w h e r e a diagnosis is n e e d e d and where the patient is considered too sick for more invasive investigations leading to definitive treatment. TABLE Z Percentage of Positive Results Obtained by Three Methods of Diagnosing Lung Cancer (All Cases Histologically Confirmed)
R~emn~ Chopra et al. 2. Jay et al.3 Beclrossian and Rybk# Pilotti et al. s Tanaka et al.6 Ng and Horak7 Savage et al.1 Rosa et al.8
Initial PostbronchosNo. of Sputa Bronchos- copy Sputa Patients Analysis copy Analysis 52 69 50 400 154 666 190 381
18% 50% 56% 57% 77% 75% 13% 51%
67% 63% 76% -80% --43%
*For references 1 - 8 , see the reference list.
47% 72% m 54%
JOURNALOF GENERALINTERNALMEDICINE.Volume 7 (Januao//February), 1992
REFERENCES 5. 1. Savage PJ, Donovan WN, Dellinger RP. Sputum cytology in the management of patients with lung cancer. South Med J. 1984;77:840-2. 2. Chopra SK, Genovesi MG, Simmons DA, Gothe B. Fiberoptic bronchoscopy in the diagnosis of lung cancer: comparison of pre and post-bronchoscopy sputa, washings, brushings and biopsies. Acta Cytol. 1977;21:524-7. 3. Jay SJ, Wehr K, Nicholson DP, Smith AL. Diagnostic sensitivity and specificity of pulmonary cytology. Acta Cytol. 1980; 24:304-11. 4. Bedrossian CW, Rybka DL. Bronchial brushings during fiberoptic bronchoscopy for the cytodiagnosis of lung cancer: comparison
6. 7. 8. 9.
with sputum and bronchial washings. Acta Cytol. 1976; 20:446-52. Pilotti S, Rilke F, Gribavdi G, Ravasi GL. Sputum cytology for the diagnosis of carcinoma of the lung. Acta Cytol. 1982;26:649-54. Tanaka T, Yamamoto M, Tamura T, et al. Cytologic and histologic correlation in primary lung cancer. Acta Cytol. 1985;29:49-56. Ng AB, Horak GC. Factors significant in the diagnostic accuracy of lung cytology in bronchial washing and sputum samples. Acta Cytol. 1983;27:397-402. Rosa VW, Prolla JC, Gastal E. Cytology in diagnosis of cancer affecting the lung. Chest. 1973;63:203-7. Suprun H, Pedio G, Rutmer JR. The diagnostic reliability of cytologic typing in primary lung cancer with a review of the literature. Acta Cytol. 1980;24:494-500.
REFLECTIONS Growing Up in General Practice ABOUT20 years ago I went to my father's home town to find the farm where he was born and raised. I stopped at a produce stand and asked the older gentleman w h o was minding the stand how to get to the Carpenter place. He said, "Oh, the Carpenters don't live there any more. 'Course Lockwood, he passed on some time ago. Margaret, she lives out West some place. Raymond, he lives down in town. And Leonard, well you know Leonard became a doctor!" It was a big deal to become a doctor in Stephentown, New York. And many people benefited from the fact that Dad became a doctor. Dad's patients remember the things he did for them as a physician. Like them, our memories as a family are shaped by the fact that Dad was a doctor. We remember that we grew up in a house with two phones and we had to learn the proper etiquette for answering the office phone at home. We remember going down to the office on Sunday afternoons to help answer the phone. Or going to Memorial Hospital and waiting in the lobby while he made rounds. And, of course, we remember house calls. Many people told us they remember Dad coming to see them at home, but what they didn't realize is that sometimes there was someone waiting in the car. We remember that family and old friends often went with Dad on house calls. It was a way to have some time alone with him. We remember that it was particularly hard to be a doctor's kid the one time a year that Dad and the other physicians in town would go to school to do physicals. We worried about whether that might jeopardize some of our best friendships. That always proved to be a needless worry. We remember when Congress passed the Medicare bill and we hid the newspaper from Dad. We thought it wo u l d ruin his day. But several years later, when he turned 65, we had a ceremony to sign him up for Medicare and he just laughed. And, of course, we remember the stories. Every physi-
13
cian's practice generates a lot of funny stories. Like the patient w h o didn't want to be treated because he said Doc Carpenter said his condition was ridiculous. Actually, what Dad had said was that he had diverticulitis. Or the story from Dad's first days in practice about a woman w ho delivered twins at home and named them after Dad and his n u r s e - Leonard and Edna. Perhaps most important, we remember what Dad was proud of about being a physician. First and foremost on that list was that Dad was proud of caring for families. He liked caring for everyone in the family, watching the kids grow and have families of their own. Sometimes he cared for them too. He liked knowing h o w one person's health was affected by another's. And whenever Dad w o u l d come to visit us, he would bring us up to date on his families. Most of the time he was talking about p e o p l e we didn't know, and that seemed to surprise him. We finally figured out this week that he was surprised because Dad thought of his patients as family and he couldn't imagine that one part of his family didn't know another. Dad was like any physician, he enjoyed the challenge of m e d i c i n e - - f i g u r i n g out a tough problem, making a good diagnosis. But we thought it was quite wonderful that Dad was also proud of making a good r e f e r r a l - - o f knowing his patients well enough to know w h o m they'd like and of knowing that his patients trusted him to send them to someone good. Dad was still making house calls w h e n he retired after 50 years of practice. One of his favorite things to do in retirement was to look through a book that had the names of all of his patients. He wanted to r e m e m b e r them all. Many people have said that they don't make doctors like that anymore. We don't know if that's true. If it is, that's sad. And yet maybe it's OK too, because it's a lot to ask. But Dad didn't know any other way to be a doctor; he didn't want to practice any other kind of medicine. So that's the way we will remember him. CARYLE. CARPENTER, PhD Health a n d Medical Services Administration Widener University Chester, PA
IT IS OFTEN routine practice to obtain several sputum samples for cytologic examination for any patient when either the clinical history or the chest x-ray findings suggest the possibility of lung cancer. This is considered to be an inexpensive and reasonably accurate diagnostic test. This study attempted to analyze the clinical usefulness of this test and whether the results influence further diagnostic testing on patients admitted to the wards of a tertiary care university hospital. In addition, the sensitivity and the accuracy of this test were assessed.
METHODS A hospital-based retrospective chart review was performed for 357 patients known to have had sputum cytology testing, who had been admitted between Received from the Sections of General Internal Medicine (BMacD) and Oncology (BW), St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada. Supported by a grant from the Department of Health, Government of Manitoba, Canada. Address correspondence and reprint requests to Dr. MacDougall: Room C5114, Department of Medicine, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba, Canada R2H 2A6.
1985 and 1988 to the wards of St. Boniface General Hospital, a tertiary care university-affiliated hospital.
RESULTS Of the 357 patients, 288 had sputum cytology ordered prior to any other investigation. There were 620 samples analyzed for these 288 patients (average of 2.2 per patient). Of the 288 patients, there were 41 (15%) with positive cytologic results. Twenty-five of these 41 positive results (61%) were confirmed histologically, either by bronchial biopsy, mediastinoscopy, or thoracotomy. Six of the 41 patients (15%) had positive needie-aspiration biopsies or pleural fluid analyses. Five had chest computed tomography (CT) scans showing widespread disease and five were too sick for further testing. Thus, 88% were conformed as having lung cancer. Of the 222 patients with negative results or unsatisfactory sputum samples, 97 went on to bronchoscopy and 28 (29%) were positive. Forty had mediastinoscopy and 20 (50%) were positive. Thirty-five had needle-aspiration biopsies and 25 (70%) were positive. Of the ten patients who had "suggestive but not diagnostic" reports, nine eventually had carcinoma proven. Of the 12 reported as showing "atypical cells," five were diagnosed as having cancer. Table 1 shows the correlation between the chest x-ray findings and the positive cytology results. We were unable to categorize the chest x-ray as showing a proximal or a distal lesion, since we relied on the x-ray reports. For the high-probability chest x-rays (> 2-cm nodules or several nodules), the positive rate was 38/94 (40%). Of the three patients with pulmonary infiltrates only and positive and positive cytology, one had hemoptysis, weight loss, and a hard supraclavicular lymph node positive for squamous-cell cancer; one had fatigue hemoptysis and the Eaton-Lambert syndrome; and one had a mass seen on chest CT scanning. The positive rate of initial expectorated sputum analysis was compared with the positive rate obtained with bronchoscopy and postbronchoscopy sputa analyses in patients with high-probability chest x-rays. As noted above, the positive rate for initial sputum testing was 38/94 (40%). Bronchoscopy was positive in 31/91 (34%) of the patients; postbronchoscopy sputa analysis was positive in 24/66 (36%) of the patients. There was no statistical difference among these three methods (p = 0.4). The diagnostic accuracy of sputum cytology (preor postbronchoscopy specimens) was assessed by com11
1~.
MacDougal/, Weinerrnan, SPUTUM CYTOLOGYVALUE TABLE 1
The Relationship between the Chest X-ray Results and the Sputum Cytology Results Chest X-rays Result (n = 288) > 2-cm nodules Several nodules < 2-cm nodule Pulmonary infiltrates Other Normal
n 75 19 8 110 37 39
Positive Cytology 30 8 0 3 0 0
(40%) (42%) (0%) (2.7%) (0%) (0%)
paring the results with those of individuals w h o had tissue confirmation. Of the 50 patients in this category, five (10%) had diseases that were of a different cell type and two of the five (40%) had diseases that involved small-cell cancer. The time delay was assessed from test ordering to being s t a m p e d " r e c e i v e d " by the pathology laboratory. Ten percent of the samples were received the same day; 37%, the following day; 41%, from day 2 to day 4; and 12% took longer than four days to reach the pathology laboratory. This did not take into account delays in analyzing, reporting, sending the reports to the wards, and time for the physicians to see these reports.
DISCUSSION In this retrospective review, sputum cytology analysis lacked sufficient sensitivity. Only 15% of the 288 patients had positive sputum results, and of the patients with chest x-rays highly suggestive of cancer, the positively rate was only 40%. Furthermore, the results of this test did not influence further test ordering. Twenty-five of the 41 patients with positive sputum results went on to have these confirmed histologically. In addition, of the 222 with negative or unsatisfactory sputum samples, 97 w e n t on to bronchoscopy. Savage, in an analysis of 190 charts of patients w h o had lung cancer, also c o n c l u d e d that in those cases diagnosed by sputum cytology, additional invasive or diagnostic procedures w e r e not avoided, as they were often necessary to stage the disease process. Table 2 outlines other studies w h e r e the lung cancers were histologically diagnosed. These studies demonstrated variable sensitivity of sputum cytology (13 - 77%), w h i c h is likely to be due to different techniques in collecting and preparing the samples. Postbronchoscopy sputum analyses have not b e e n shown to be statistically better than analyses of p r e b r o n c h o s c o p y samples. Although there was a high specificity in our series, there were two concerning cases w h e r e the sputum test misdiagnosed small-cell lung cancer with potentially serious therapeutic implications. Overall, there were five of 20 (25%) w h e r e a different cell type was diagnosed. Suprun 9 reviewed his own data about 232 cases, of w h i c h 173 (75%) had b e e n correctly typed. In this
study, 34 of the 35 small-cell cancers were correctly diagnosed. He reviewed 13 other studies, indicating that the overall accuracies varied from 74.8 to 100% for squamous-cell cancer, from 63.6 to 93.3% for smallcell cancer, from 31.7 to 100% for adenocarcinoma, and from 20 to 62.5% for large-cell carcinoma. Jay 3 found that among 155 with nonmalignant lung disease, 16 (10%) had false-positive specimens, and this finding was significantly related to necrotizing p n e u m o n i a in 13 of these 16 patients. Rosa 8 found a 94.7% ( 1 8 / 1 9 ) concordance between analysis of sputum samples and tissue confirmation. Pilotti 5 described 27 cases of small-cell cancer and only two of these were misclassified. In the Ng series, 7 5 5 / 5 7 of small-cell cancers diagnosed by analyzing sputum samples were confirmed by histologic methods. Therefore, this study has demonstrated that cytologic analyses of initial sputum samples were insufficiently sensitive and accurate to be used in patients suspected of having lung cancer. Further testing was not avoided and the positive cytologic results added little to the information obtained from the chest x-rays. In addition, a negative or low-probability chest x-ray was seldom associated with positive s p u t u m cytologic results. Even if one accepts the small rating misclassification, a positive cytologic report will not stop further diagnostic measures if the patient is considered resectable (if n o n - s m a l l - c e l l carcinoma). If the patient is considered nonresectable on clinical grounds, then a tissue biopsy, usually from a skin lymph node or the liver, is usually done. A positive sputum sample in this setting adds little useful information. The treatment implications are so critical for small-cell carcinoma that we believe a tissue sample needs to be obtained to verify the sputum cytologic result. Also, the time delay in obtaining and analyzing these specimens made it an e x t r e m e l y inefficient test. Therefore, this test should be abandoned, e x c e p t in those cases w h e r e a diagnosis is n e e d e d and where the patient is considered too sick for more invasive investigations leading to definitive treatment. TABLE Z Percentage of Positive Results Obtained by Three Methods of Diagnosing Lung Cancer (All Cases Histologically Confirmed)
R~emn~ Chopra et al. 2. Jay et al.3 Beclrossian and Rybk# Pilotti et al. s Tanaka et al.6 Ng and Horak7 Savage et al.1 Rosa et al.8
Initial PostbronchosNo. of Sputa Bronchos- copy Sputa Patients Analysis copy Analysis 52 69 50 400 154 666 190 381
18% 50% 56% 57% 77% 75% 13% 51%
67% 63% 76% -80% --43%
*For references 1 - 8 , see the reference list.
47% 72% m 54%
JOURNALOF GENERALINTERNALMEDICINE.Volume 7 (Januao//February), 1992
REFERENCES 5. 1. Savage PJ, Donovan WN, Dellinger RP. Sputum cytology in the management of patients with lung cancer. South Med J. 1984;77:840-2. 2. Chopra SK, Genovesi MG, Simmons DA, Gothe B. Fiberoptic bronchoscopy in the diagnosis of lung cancer: comparison of pre and post-bronchoscopy sputa, washings, brushings and biopsies. Acta Cytol. 1977;21:524-7. 3. Jay SJ, Wehr K, Nicholson DP, Smith AL. Diagnostic sensitivity and specificity of pulmonary cytology. Acta Cytol. 1980; 24:304-11. 4. Bedrossian CW, Rybka DL. Bronchial brushings during fiberoptic bronchoscopy for the cytodiagnosis of lung cancer: comparison
6. 7. 8. 9.
with sputum and bronchial washings. Acta Cytol. 1976; 20:446-52. Pilotti S, Rilke F, Gribavdi G, Ravasi GL. Sputum cytology for the diagnosis of carcinoma of the lung. Acta Cytol. 1982;26:649-54. Tanaka T, Yamamoto M, Tamura T, et al. Cytologic and histologic correlation in primary lung cancer. Acta Cytol. 1985;29:49-56. Ng AB, Horak GC. Factors significant in the diagnostic accuracy of lung cytology in bronchial washing and sputum samples. Acta Cytol. 1983;27:397-402. Rosa VW, Prolla JC, Gastal E. Cytology in diagnosis of cancer affecting the lung. Chest. 1973;63:203-7. Suprun H, Pedio G, Rutmer JR. The diagnostic reliability of cytologic typing in primary lung cancer with a review of the literature. Acta Cytol. 1980;24:494-500.
REFLECTIONS Growing Up in General Practice ABOUT20 years ago I went to my father's home town to find the farm where he was born and raised. I stopped at a produce stand and asked the older gentleman w h o was minding the stand how to get to the Carpenter place. He said, "Oh, the Carpenters don't live there any more. 'Course Lockwood, he passed on some time ago. Margaret, she lives out West some place. Raymond, he lives down in town. And Leonard, well you know Leonard became a doctor!" It was a big deal to become a doctor in Stephentown, New York. And many people benefited from the fact that Dad became a doctor. Dad's patients remember the things he did for them as a physician. Like them, our memories as a family are shaped by the fact that Dad was a doctor. We remember that we grew up in a house with two phones and we had to learn the proper etiquette for answering the office phone at home. We remember going down to the office on Sunday afternoons to help answer the phone. Or going to Memorial Hospital and waiting in the lobby while he made rounds. And, of course, we remember house calls. Many people told us they remember Dad coming to see them at home, but what they didn't realize is that sometimes there was someone waiting in the car. We remember that family and old friends often went with Dad on house calls. It was a way to have some time alone with him. We remember that it was particularly hard to be a doctor's kid the one time a year that Dad and the other physicians in town would go to school to do physicals. We worried about whether that might jeopardize some of our best friendships. That always proved to be a needless worry. We remember when Congress passed the Medicare bill and we hid the newspaper from Dad. We thought it wo u l d ruin his day. But several years later, when he turned 65, we had a ceremony to sign him up for Medicare and he just laughed. And, of course, we remember the stories. Every physi-
13
cian's practice generates a lot of funny stories. Like the patient w h o didn't want to be treated because he said Doc Carpenter said his condition was ridiculous. Actually, what Dad had said was that he had diverticulitis. Or the story from Dad's first days in practice about a woman w ho delivered twins at home and named them after Dad and his n u r s e - Leonard and Edna. Perhaps most important, we remember what Dad was proud of about being a physician. First and foremost on that list was that Dad was proud of caring for families. He liked caring for everyone in the family, watching the kids grow and have families of their own. Sometimes he cared for them too. He liked knowing h o w one person's health was affected by another's. And whenever Dad w o u l d come to visit us, he would bring us up to date on his families. Most of the time he was talking about p e o p l e we didn't know, and that seemed to surprise him. We finally figured out this week that he was surprised because Dad thought of his patients as family and he couldn't imagine that one part of his family didn't know another. Dad was like any physician, he enjoyed the challenge of m e d i c i n e - - f i g u r i n g out a tough problem, making a good diagnosis. But we thought it was quite wonderful that Dad was also proud of making a good r e f e r r a l - - o f knowing his patients well enough to know w h o m they'd like and of knowing that his patients trusted him to send them to someone good. Dad was still making house calls w h e n he retired after 50 years of practice. One of his favorite things to do in retirement was to look through a book that had the names of all of his patients. He wanted to r e m e m b e r them all. Many people have said that they don't make doctors like that anymore. We don't know if that's true. If it is, that's sad. And yet maybe it's OK too, because it's a lot to ask. But Dad didn't know any other way to be a doctor; he didn't want to practice any other kind of medicine. So that's the way we will remember him. CARYLE. CARPENTER, PhD Health a n d Medical Services Administration Widener University Chester, PA
