Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

What Happens When WE Are The Patient?

Educational opportunities exist everywhere – it’s just a matter of realizing it. Sometimes these opportunities hit you whether you like it or not. Under normal circumstances, we are the doctors, the providers of medical care, administering to the sick and scared. We’re in control of the medical care our patients receive. But what happens when WE are the patients?

Then it’s not business; it’s personal…

Ok, to be honest, this story is not about me but rather my father. About two weeks ago, my 67 year-old type-2 diabetic father, who lives in Phoenix, presented to the ED with two hours of worsening right lower quadrant abdominal pain. Suspecting acute appendicitis, the doctors ordered a CT scan which showed a 2.5 cm mass on his ascending colon. An investigative colonoscopy the next day revealed what the doctors said was a 99% chance of colon cancer (colonic adenocarcinoma to be precise). My wife, son, and I immediately cleared our schedules and flew to Phoenix.

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What lessons are embedded in my father’s plight?

First, we must remember that our patients float in a sea of the unknown. Most of them are not associated in any way with the medical profession and generally have no clue what’s happening to them or why. Second, medical care is invasive, scary, difficult to understand, often uncomfortable, sometimes delayed for any number of reasons, and destroys patient dignity. They’re scared and require reassurance. Third, accelerated care is best. My father’s gastroenterologist performed the colonoscopy on a Saturday, after my father was admitted. By no means was this convenient for the doctor. He could conceivably have waited until Monday for the procedure, but he cared enough to be proactive and give my family information quickly without waiting in limbo. Sometimes medicine is inconvenient to the doctor. If you don’t like this fact, get out of medicine. One of my mentors once said, “Pus doesn’t take holidays.” You can’t say it better than that!
Back to the story…

My father successfully underwent a laparoscopic-assisted right hemicolectomy (removal of most of the ascending colon) two days later. My family impatiently waited for the biopsy report to determine the stage (determined primarily by lymph node involvement and depth of colon wall penetration by the tumor) and how much chemotherapy he would need. Three days later we received the results: not only were there no lymph nodes involved, there was no cancer! My father’s surgeon walked in the next day shaking his head, explaining my father had ischemic colitis (an interruption to the blood flow to a section of his colon leading to an infarct). With great relief, my father was discharged home.

Yet more lessons demand to be examined.

The doctors missed the diagnosis! Remember, doctors, to keep your mind open to all possibilities. This is the reason we’re all taught lists of differential diagnoses. If you search for cancer, you’ll find cancer. The doctors were so sure it was colon cancer, they didn’t wait for the colonoscopy biopsy. If they had, most likely my father wouldn’t have required surgery. Ischemic colitis usually responds to supportive care and IV antibiotics. The surgeons, though, were honest and up front with my father. They admitted their error immediately and did not try to obfuscate or hide the truth. It was a human error committed under the best intentions. This also argues for the importance of two other issues: the importance of a good biopsy and looking at the patient as a whole. Even when you’re sure, consider a biopsy. In hindsight, my father has significant predisposing factors to ischemic colitis: history of diabetes, coronary disease, and symptoms after eating (think of it as abdominal claudication – as a bolus enters the colon a greater but unavailable amount of oxygen is required causing pain). Granted there were confounding variables (rapid onset of pain and ischemic colitis being rare in the right colon), but perhaps a more holistic view of my father’s medical history would have raised the surgeons’ index of suspicion.

There were Complications

All was well in the Shapiro household. My father went home, and I returned back to Oregon. Everything was progressing as planned… Until one week postop when my father ended up the ED again, this time with an abscess of the larger incision used to remove his colon.

I stayed in Oregon, keeping close tabs via telephone about my father’s progress, while back at the hospital two issues came up. First, a repeat CT scan (this time with contrast to delineate the abscess) showed a mass on one of his kidneys. An MRI was scheduled the next day to investigate the mass. My family then called to inform me about the second issue: the MRI was canceled in place of a renal ultrasound because my father’s kidney function had declined. When I found this out, I made an immediate phone call to my father’s caregivers to inform them of the congenital cystic mass on the kidney that had been there since my father was 15 years-old! After an I&D, IV antibiotics, and negative pressure wound therapy, my father was again discharged home. He’s currently recovering well with follow-up appointments scheduled for a wound clinic (at my demand), his doctors, and a nephrologist (also at my demand) to investigate his renal insufficiency (likely diabetic nephropathy). Patients must also advocate for themselves.

More lessons. It turns out my father failed to discuss the congenital renal mass with his doctors during the second admission. Yep, your patients won’t tell you everything. If you think patients will tell you all the important facts, then I have some cheap swamp land to sell you! Being a physician is like being a detective. Sometimes you have to dig up the information. It’s also useful to investigate those old charts. There’s usually a wealth of prior medical tests and treatments, but it’s only useful if you actually read them.

The lessons abound! If you do the surgery, be sure to follow-up on your patients. Don’t leave it all up to your associate. YOU do the surgery; YOU do the follow-up. Be there for your patients. Five minute morning rounds once a day may not be enough. Be accessible to your patients and their families. Your patient is more than their foot wound or that bunion. There’s a human attached to that extremity. Look up from the foot into their eyes and treat them like human beings. One day you WILL be the patient. It’s inevitable….

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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