If it ain't broke, don't fix it

Over dinner with friends the other night, the conversation turned to medical matters, and Peter, a 65-year-old playwright and businessman, said he had never had a comprehensive physical. “Do you mean you don't know your cholesterol?” I asked.

“No, I don't,” he said.

“And you don't know your blood sugar?” I asked.

“No,” he said, “but I don't eat sweets.”

“What about your blood pressure?” I pushed on.

“Nope,” he said.

“Ever had a stool check for blood?” I asked.

“Never seen any blood in my stool,” he replied.

“No one has ever taken a detailed medical history and done a complete hands-on exam of you?” I asked.

“Not that I can recall,” Peter said.

I was incredulous. “How do you know if you're healthy?” I asked.

“Well,” Peter held, “I assume I am because I feel OK. And just today I played tennis with a fellow 20 years my junior and beat him soundly. I believe if it's not broken, don't fix it.”

Peter is an intelligent man, but that didn't mean he had any common sense as far as his health was concerned. I wanted to trap him in his own specious reasoning (i.e., “I feel well so I must be well”), but I had to be careful; Peter is competitive and hates to be bested in a debate.

“Peter,” I began with a salvo, “You take the ostrich approach to your health. You stick your head in the sand. I have lots of patients like that.”

Peter let that one go by.

“Let me ask you something,” I said. “Do you change the oil in your car?”

“Every 3,000 miles,” he said.

“And do you tune it up?” I asked.

“Every 30,000,” he replied.

Peter could see where this was going. “Is your car broken?” I asked triumphantly.

“No,” he replied, not bothering to add that it was because he took care of it and did preventive maintenance.

“I'm always surprised at how much better people take care of their cars than their bodies,” I said. “Are you really going to wait until your body breaks down before you fix it?”

“Well,” he said sheepishly, “maybe only until it squeaks.”

Lost to follow up

“I've had this lump in my neck for two weeks,” Stephanie, a 57-year-old patient, complained. “It doesn't hurt, and I feel fine otherwise, but it doesn't seem to be going away.”

A lump in the neck is not a rare complaint in my practice. Everyone worries that it's a lymphoma, but most of the time it just disappears. I reassured Stephanie that it was most likely an enlarged lymph node due to something viral and set her up for a two week follow-up appointment. Two weeks later she thought the lump was smaller and she had no new nodes, so we decided to watch and wait. Another two weeks later, the lump was still there, a 1 cm by 2 cm soft mass under her right mandible, and it was time to do some lab tests. The results yielded nothing to hang a diagnosis on, so we were left with getting the darned thing out.

From the get-go, I had prepared Stephanie for the possibility of a biopsy, and now we were there. I offered to set her up with my ENT consultant, but she preferred going to an ENT she had used before. I let her make her own referral and waited for a report. In truth, I had assumed I would get a note from her attending, and I forgot about her – until three months later when she left a message on my answering machine. “Call me if you'd like to know what happened with that lymph node,” she said.

Now that jogged my memory.

“Guess what? I had thyroid cancer!” Stephanie said when I called her back. Apparently, an MRI of her neck and a needle biopsy of the mass were inconclusive, so the ENT recommended that the node be removed. It turned out to be a cystic metastasis from a papillary cancer, and she underwent a total thyroidectomy. There was a 5 mm tumor in the right lobe and a 1 mm tumor in the left. One lymph node was positive. She received radioactive iodine to obliterate what little remaining thyroid tissue she had left and was told she wouldn't need any chemotherapy or radiation.

Stephanie said her surgeon wanted her to be under the care of an internist for a while, and it was hard to read whether that was indeed the case or whether she was just upset with me for not following up. If it was her way of changing physicians, I really couldn't blame her. For someone who usually phones back patients the same hour they call, I really blew it. I lost Stephanie to follow up because I was non-compliant about her continuing care.