Terrifying your patients for their own good.....

In the late 1980s, I was in private practice as a radiologist. Until that became personally unsatisfying to me and I returned to academia. Just a personal choice. Nothing wrong with private practice intrinsically, though it is essentially disappearing under the consumption of megacorporations, buying up practices to be run as short-term profit rendering businesses.  Not that academic centers are any better at this point, having become some of the biggest buyers.

Late one afternoon at about 5:30, I was in my office getting ready to go home but brushing up on my Nerf basketball skills. I always had a Nerf basket in my office for such purposes. My favorite pulmonologist, Paul, came in carrying a film jacket filled with some patient’s x-rays. Don't worry if you don't know what a film jacket or hard copy X-rays are. Most physicians today have never seen them either. Different era. He put it aside and we played a game of horse for a dollar. I can't remember who won. 

“ Remember Mr. G? The guy with the pulmonary nodule?,” he said. 

“Nope. I see too many nodules everyday to remember them by name.”

“ Well this was a good call you made. It was hard to see but you called it on the chest x-ray and we got a follow-up CT scan and it really is there.”

“ So are you coming to compliment me?”

“ No, I'm coming to schedule a biopsy of it.”

“ Can't we follow it for a while?” In those days, one strategy for incidentally noted lung nodules was to get sequential chest x-rays every 3 months or so for a year and then a few more for another year and if it didn't change you would just call it a benign nodule and that was that. I believe some patients are still handled that way even today. If it increases in size a little at any time, then you proceed to biopsy. Nowadays, you can spend around $5,000 for a CT/PET scan, to realistically determine if it needs a biopsy. At least that's the increasingly common strategy if you want to maximize income. It's not clear if it saves any lives. Normally I would go into a rant on spending that kind of money. But when I got my lung nodule years later, I said screw that waiting around for 2 years and got a CT/PET scan which fortunately sealed the deal for me quickly for the better. I had good insurance. Another example of physician hypocrisy on my part.

“Nah, he's freaking out and doesn't want to sit around for 2 years wondering if he has lung cancer growing inside him.”

I was concentrating on a 15-footer from across my office and replied, “No old films?” Because the best friend of a lung nodule in any patient is an old film from several years before showing that it hasn't changed for at least 2 or 3 years whereupon you can declare it benign and of no significance. 

“He says he thinks he got one in Michigan 8 or 9 years ago but can't actually remember exactly where it was. He was on vacation somewhere. Says he can't get it.” 

“Okay, let's take a look.” Whereupon, Paul took out a bunch of CT scan films and we reviewed them and I said “Okay, I'll get him on the schedule.” And I punctuated that with a terrific skyhook from about 12 ft. 

I told Paul to get the usual blood work and to have him explain to the guy what was going to happen and got it all set up for the following week. This was a pretty routine thing.

At 9:00 a.m. the following Tuesday, Mr G showed up and I sat down with him to go over what we were going to do. He was sweating bullets and scared shitless. Now, lung biopsy turns out to not be very painful at all and while there are occasional complications, it's a fairly common procedure and having trained specifically as a chest radiologist and performed probably my first 1000 biopsies by that time, I had a fairly low complication rate. But nobody has a zero complication rate.

The first thing I said to him was what I said to all patients in his situation. And that was, “I hear you had an old chest x-ray in Michigan way back when. Is that true? It would be extremely helpful if we could get that x-ray. If the nodule was there 8 years ago and hasn't changed, you won't have to do anything. We would be done and I could tell you that you are fine. No tumor.”

He said he had the report and showed it to me which said simply that it was a normal chest x-ray and did not mention the nodule. 

I explained to him that it was a very difficult nodule to see due to its location and I wasn't even sure it was real on his chest x-ray until we got the CT scan. And I again emphasized how important it was to try to get a copy of those old films that could save him a lot of headache. It was a nodule that could be easily missed by anyone, including me.

Despite his angst, he did not show a lot of enthusiasm toward trying to get the old films. He just said it would be really hard to do. 

I said to him, “Well, we know you got the x-rays done, presumably they exist, and I'm telling you, you really ought to do everything you can to get them because it could potentially save you a lot of problems.”

He shrugged and said he didn't think he could get them. He clearly needed additional motivation.

I told him to stay seated and that I would be back in a minute. I went into our procedure room and asked my technologist to get me the largest, thickest and longest needle that we had, called a trocar and give it to me. It was about 2 ft long and almost the thickness of a pencil. It was not anything you would stick into the middle of somebody's lung for a biopsy and was used for other purposes. But it was going to serve my purpose that day. I believe it was invented by the Grand Inquisitor, Tomas de Torquemada, during the Spanish Inquisition. 

I returned to Mr. G and showed him the trocar needle.  “Look. I'm not saying this procedure is going to be particularly painful, but do you really want me to stick this thing all the way through your chest? If you don't, and I sure wouldn't, I'd bust my ass to get those chest x-rays.”

His eyes bugged out of his head looking at it. He nervously said, “Uh, give me a week or so and maybe my wife and I can figure out about getting them.”

“Good idea.”

About 10 days later, he returned with a large film envelope and lo and behold there were his films from 8 years previously. I went back and compared them to the current films and sure enough the nodule was there on the 8-year-old films, again, extremely hard to see, low in his chest behind his liver, only visible on one of the two views as it was now. But exactly the same and completely unchanged in size and configuration. It was certainly benign and likely a small focus of old infection.

I came back smiling and gave him the good news that he did not need a lung biopsy, that his nodule was absolutely benign and that he was done. And could go home with no further follow-up or other studies. A clean bill of health.

He started crying a bit and gave me a big hug and a big ‘thanks doc’. “I won't forget this and I got a big surprise for you.”

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I told him to forget about it and simply remarked that it was good he made that extra effort. But I was curious about my big surprise. I did fantasize a bit and hoped he was a multi-millionaire. When I was a resident at UCSF, there was an apocryphal story about a neurosurgeon who did a procedure on the daughter of Mr. Maserati, the same Maserati of automobile fame, who returned home after operating on her to see a brand new red Maserati wrapped in a bow in his driveway. I felt like giving this guy my home address, but realized that might be a bit over the top. Up to that point, the best gift I ever received from any patient was a home-baked banana bread. Admittedly, a mighty fine banana bread.

It turned out that this guy was a bit more proletarian and owned a delicatessen. And a week later, huge platters of delicatessen food were delivered to our department at lunch time to feed our entire department, which admittedly was a small community hospital department. Nevertheless a nice big party that he threw us. Simply because I scared the shit out of him to get some old films for his own benefit. 

It was a very nice gesture on his part, but I would have preferred a Maserati.