Trouble at 6 O’clock

Emily Green knew there was a lump in her right breast. She was a new patient I saw a few weeks ago. Her previous doctor had sent her for a mammogram last year, but she had not come in for a clinical breast exam. She was a busy professional, who admitted she sometimes cut a few corners with her own health care.

I remember signing the order for her annual mammogram even before I met her. At that point in time, she had not made an appointment to see me, but I signed the order anyway.

In years past I used to stick to my guns and not order a mammogram for patients who had no intention to come and see me for a breast exam.

We all know that a mammogram is best done after a clinical breast exam, so that women with abnormalities on their exam can have a more comprehensive, or diagnostic, mammography study with an ultrasound examination to distinguish between solid and cystic masses.

Purist that I was, I insisted on doing the job right, and on my terms – exam first, then mammogram. I don’t know how many patients ended up having nothing at all done because of my stubbornness. After a lot of thought I decided to authorize mammograms for any woman who wanted one, whether she came in for a breast exam or not, since doing something seems better than possibly doing nothing to screen for cancer.

When I finally met Emily Green for her first appointment, she told me she was concerned about a small lump in the lower portion of her right breast. I agreed with her – the lump was a little larger than a pea, nontender and freely movable against the overlying and underlying tissue. Another, larger, irregular cluster of lumps toward her breast­bone in the 3 o’clock position seemed like typical fibrocystic disease.

At the end of her appointment we agreed on getting a diagnostic mammogram followed immediately by an ultrasound. Whether these tests showed anything or not, we also agreed to have her see a breast surgeon in consultation because of the suspicious nature of the lump at 6 o’clock. We also decided to get some updated blood tests and change her blood pressure medication.

I signed off on her normal radiology reports and added “cc: Dr. Fowler” at the bottom of each page.

When I saw Emily Friday to follow up on her blood tests and new medication, she had already seen the breast surgeon the day before. She was quite animated when she said:

“I can’t believe the tests didn’t show anything. I mean, I felt the lump, you felt it, and Dr. Fowler found it instantly. She’s set me up for a biopsy in less than two weeks! I never realized doctors might disagree with an x-ray.”

“A test is only a test” I mused. “Mammograms are probably best at finding little microcalcifications we can’t feel with our hands.”

“I guess so, but I still feel like I had a near miss”, she said. “What if I had just trusted the mammogram and not bothered to come and see you until the lump had grown some more?”

I reminded her that the biopsy may still come out negative, but agreed that it was very good she had taken the time to come in with her concern.

I still wonder, which is the better thing to do, authorizing screening mammograms to any and all or start insisting again on seeing patients for a clinical breast exam first.

2 Responses to “Trouble at 6 O’clock”


  1. 1 isaac September 29, 2009 at 12:38 am

    I guess that depends on what happens with the ol’ reform business going on.

    My sense is that for psychological reasons, a mammogram result is going to motivate a patient more than a palpation result. One’s high tech and the other’s not.

  2. 2 Dee September 29, 2009 at 4:10 am

    Can I ask how many lumps you’ve found doing CBEs that the woman hasn’t already found? Just curious, because my GP said that in 30 years of practice he’s only found one that the woman hadn’t found (he knows I do cancer-related policy work, so we were chatting about it while he was doing my CBE a couple weeks ago). Just a note – he does them thoroughly and correctly.


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s




Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share

Mailbox

contact @ acountrydoctorwrites.com

RSS A Country Doctor Reads:

  • Simple Bedside Test Trumps Mega-Workup
    The Journal of Family Practice just published an illustrative case of a young woman with severe headaches and blurry vision. After a couple of hospitalizations with non-contrast and contrast brain MRIs, lumbar puncture and exhaustive laboratory testing, the diagnosis was made with a no-cost two minute bedside test, promoted by yours truly in a post […]
  • Miracle or Outlier?
    A story in the New York Times about a cancer patient who wanted to live to see her daughter’s wedding caught my attention. Haider Javed Warraich, a resident in internal medicine writes: As a physician, I never liked the word “miracle.” I preferred to think in terms of “medical outliers.” And yet that day of […]
  • Psychotherapy and the Dodo
    In “Alice in Wonderland”, the Dodo claimed everyone a winner. In many people’s view, every form of mental health treatment is equally effective. Not so, according to new research. Bulimia, for example, is said to respond better to CBT, Cognitive Behavioral Therapy, than other modalities. So when it comes to psychotherapy, it seems the dodo […]
  • Why is Ordering X-rays Different from Referring to Other Specialists?
    Peter Elias asks a provocative question: If I diagnose symptomatic gall stones or an incarcerated hernia, I refer the patient to the surgeon. I don’t pick the procedure the surgeon will do. My office and I don’t schedule the operating room time and notify the patient. But if I want a CT scan or an […]
© A Country Doctor Writes 2008-2014. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.