What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Thursday, July 13, 2006

A Nose For Cancer

Today I attended the funeral of a previous patient and friend. This isn’t the first such occasion since my retirement and I’m sure it won’t be the last. One never gets “used to” losing friends and former patients, so the event is a downer in its own right; but the thing that gets me are the tragic stories leading up to the event.
In this particular case, I had last seen this friend at Christmas/04. He had obviously lost weight and looked somewhat lackluster to me and I mentioned this to him. He chided me since I had always pushed him to keep his weight down (he was a diabetic), and related to me that he was merely being more attentive to his diet since his blood sugars had been somewhat more difficult to control. I had suggested he see his new physician and have a thorough work up none the less. Apparently he saw his physician as I had suggested---several times up to a month ago---- at which time he was taken to the emergency department and properly investigated-----inoperable and terminal cancer was his diagnosis.
I have been told by a number of specialists in the past that I have a peculiar “nose” for cancer. On many occasions I have insisted on certain investigations by them which yielded that diagnosis. But what really is a “nose” for anything? In medicine the primary prerequisite is know the patient. On one occasion many years ago before fancy CTs and such, a patient had the usual work up for abdominal pain, which revealed nothing. On strenuous urging from me the surgeon did exploratory abdominal surgery-----and found cancer. The surgeon wondered how I had known. It really wasn’t difficult. This particular patient hardly ever saw me, and when he did, he usually downplayed his symptoms. On this occasion he had seen me three times in three weeks with complaints of unwellness and persistent abdominal discomfort. At the age of 60 with no other findings to explain his symptomatology, the diagnosis was not surprising.
My friend that we buried today, that seemed to have lost that spark, that glow of health that he usually exuded, apparently continued to slowly lose weight. At first his physician bought into the “diet” thing’ and after many months and visits, it was suggested that he may have been depressed. His appetite slowly decreased, and finally when he reached 130 pounds of body weight, his family took him to the emergency department.
This man was 74 years of age, six feet one inch tall, and had a stable weight of 190 pounds for most of the years I knew him. Why suddenly would his attitude to diet and weight control change? Why suddenly would his blood sugars start to become unstable? And then there was that distinct lack of “spark”, that loss of the glow of good health. It is true that people who become depressed can have that “dull” appearance, but I often wonder how many people, who become depressed in later life, have an underlying cancer. Has anyone done a study on this? I recall seeing a patient from Saskatchewan who was diagnosed with depression. He had been losing weight and strength. His final diagnosis was wide-spread metastatic cancer. Sometimes I wonder if the patient, at some level of their subconscious, knows they have cancer, are in some kind of denial, and express themselves by being depressed. To most everyone, cancer is certainly a depressing disease.
The family of my friend today related to me that little investigation was done until he was taken to the emergency department. In the emergency department, the appropriate testing made the appropriate diagnosis, and an attempt was made at doing the appropriate surgery. Unfortunately, the cancer involved some major structures and nothing could be done. Had the diagnosis been made one year ago, would the results have been different? Very likely!
Is it really that some physicians have a “nose” for cancer (like apparently dogs can now be trained to have), or is it simply knowing the patient as a living, breathing, feeling human being, and being tuned in to him/her as a person. Perhaps not having the “nose” is from fatigue, apathy, too much to do in too little time, or simply an ongoing erosion of basic principles of medicine such as listening to and giving the patient every benefit of the doubt. Whatever it is, I don’t like it! I’m tired of going to friends and previous patient’s funerals.

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