Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [37]
Two weeks before, Matt had seen a urologist because he’d started to feel the need to urinate so urgently that he sometimes had to break away from business meetings to get to the men’s room. But by the time he arrived for his appointment, the symptom had subsided. After examining Matt, the urologist said, “I’m not sure why you had such frequent urination. You have the prostate of a young man.” The urologist looked over the blood tests that had been done by his internist. He noted that Matt’s prostate-specific antigen, or PSA, had risen slightly, from 2.8 to 3.0. “I really think that small bump in the PSA is nothing,” the urologist had said, “but the only way to be absolutely sure is to do an ultrasound with a biopsy.” He went on to say, “We don’t have to do this now. We could wait another few months, repeat the PSA, and then decide.”
“In my world, information is power,” replied Matt. “Let’s do it now.” The biopsy took less than fifteen minutes and was not particularly painful. The urologist told Matt that on the ultrasound study his prostate gland looked entirely normal. “I really don’t think you have anything to worry about.”
Matt put away his BlackBerry. He had another meeting in ten minutes. A computer software company in India was seeking more capital to expand its operations. Ten minutes should be long enough to return the urologist’s call.
“I’m really surprised,” the doctor said, “but it turns out that there is some cancer in the gland. I didn’t expect this.” The doctor tried to reassure him, saying that only three of the twelve biopsies contained small amounts of tumor, all on the left side of his prostate gland. He gave Matt a number—6—a Gleason score, a measure of the tumor’s aggressiveness. “It’s in the midrange, not the worst at all.”
“I was unnerved by that call from the urologist,” Matt told us. “It was bad enough to hear that I had cancer, but the shock was much greater after being reassured by the doctor that my prostate felt normal, that the ultrasound study was normal, too, and that the rise in PSA was nothing. This was not supposed to happen. My trust and confidence in this physician were completely shaken.”
As physicians, we recognize that we often walk a fine line with our patients, trying to allay their anxiety and concern by giving reassurances that are based largely on probabilities. We spoke with other patients whose doctors had initially assured them that their symptoms or physical examination didn’t suggest a serious underlying disease, only to have those assurances proven wrong. A forty-five-year-old teacher had been told by two specialists based on physical examination and an ultrasound study that a small nodule in her neck was “almost certainly” benign; however, a biopsy showed thyroid cancer. A sixty-two-year-old physician and marathon runner developed indigestion. His internist performed a complete physical examination, told him everything was fine, and prescribed an acid blocker. A month later, he was rushed to the hospital and underwent open heart surgery to bypass four blocked coronary arteries; the “indigestion” was really a symptom of heart disease. A twenty-six-year-old writer was found to have a minimal elevation in one of her liver function tests at her yearly checkup. Her doctor told her, “Don’t worry about it. One glass of wine can do that.” Although there is a long list of trivial causes of slightly elevated liver tests, in her case, follow-up and an eventual liver biopsy showed extensive inflammation from hepatitis C infection.
No physician is right all the time. Every physician is wrong sometime. Perfection is impossible. How does the patient react to that reality? When we as physicians were wrong in the past, some of our patients left us. They could no longer trust our judgment. Doubt clouded every conversation. Uncertainty shadowed every subsequent recommendation. Confidence in the physician helps a patient cope with the vicissitudes of his illness; trust in the doctor reduces fear and allays the sense of vulnerability. These