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Other Features: Teaching and Learning Moments


Klein, Joshua U. MD

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doi: 10.1097/ACM.0b013e3182082ede
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“If people knew about the risks of all these tests, they would think twice before pressuring their doctors into ordering them.”

I nodded my head in firm agreement and commiseration; now here was a patient whom I could really talk to. I was seeing Jessica for a routine annual exam in the resident clinic, and, in more ways than one, she stood out right away.

Most clinic patients spoke little English; their grasp of the nuances of modern medicine, let alone the perils of false-positive screen results and needless diagnostic interventions, was typically not very sophisticated, to say the least.

Jessica didn't quite fit the “clinic” mold in other ways either. A thin woman in her 50s, she was dressed, coiffed, and made-up immaculately; she carried a lavish designer handbag that looked a lot more expensive than the usual knock-offs I was accustomed to seeing. Suddenly I was acutely aware of the coffee stain on my white coat.

I took a complete medical history; Jessica seemed to be in excellent health. Next I rattled off the questions I routinely ask at an annual physical: Do you exercise regularly? Religiously, she answered. Do you wear seatbelts? Always. Do you feel safe in your home environment? Yes, absolutely. Do you perform a monthly breast self-examination? Every month, especially because I don't get mammograms. Do you have any concerns about …. Excuse me? No mammograms?

Jessica calmly explained that she felt mammograms were more dangerous than they were helpful; a mammogram killed her mother, she said, and she wasn't about to let one kill her too. I quickly scanned through the records of previous visits in her chart: “Mammo declined ….” “Refuses mammogram today; plan to readdress next visit ….” Apparently, this was not a new issue.

She went on to tell me that her mother died several years prior from complications of breast surgery for what was ultimately found to be a benign tumor, and, since that time, she had become a nationally recognized patient advocate working to reduce unnecessary medical interventions. I expressed my sincere admiration for her work and made a mental note to later Google the name of the organization she founded.

We then moved on to the physical exam.

Somehow I was not surprised when I found the mass. Hard. Fixed. Irregular. How could this intelligent and educated woman not have noticed it before? She told me she was sure it was nothing. I said I wasn't so sure.

Arranging an appointment for a biopsy with a breast surgeon was easy, but actually convincing Jessica to go was not. The more we spoke, the more suspicious I became that something wasn't quite right about the impressive stories she told about her activism and national recognition. Needless to say, even Google couldn't validate her reputation. Eventually, government conspiracy theories and other blatant paranoia crept into her diatribes. All of a sudden, Jessica's lavish grooming didn't seem stylish and elegant; it was flamboyant, bordering on flirtatious and inappropriate. Only weeks later did she finally agree to a formal psychiatric evaluation, and the depths of her psychiatric disorder were plumbed.

Ultimately, my pleading did prevail. Jessica had her tumor surgically removed. It was malignant, but fortunately, it hadn't yet spread.

As it turned out, Jessica was right after all; a mammogram was not really what she needed. She needed someone to listen, someone to understand who she was. Learning to be a good doctor can sometimes seem endlessly complicated; but every once in a while, it really isn't that complicated at all.

Joshua U. Klein, MD

© 2011 Association of American Medical Colleges