During the past week I have diagnosed 2 patients with cancer. Sometimes I feel like these diagnoses come in waves, I may not see a new cancer patient for weeks or even months and all of the sudden 2 walk in my door within a few days. But, as I ponder this I wonder about how close they came to having a missed or delayed diagnosis, for we are in very strange times.
My speciality is to this day stumped as to how and whether we should be treating patients. There is the personal concern that doctors will be exposed unnecessarily and the treatment concern that a patient might be infected by entering a room previously occupied by a positive asymptomatic patient. Many of you are aware of the closures in March and April of medical offices. In addition, many physicians modified their treatment and exam regimens withholding certain procedures they felt might cause added risk to themselves, their staff, or patients.
I recall discussing this with my wife, Cynthia. Should I stop seeing patients, or maybe only do telemedicine like many of my colleagues? If I would see patients should I change what I do? I remembering looking at Cynthia and saying that I can't provide what I feel is substandard care and I fear that all of these doctors staying home is going to result in severe disease such as cancer either being delayed or missed.
I made the conscious decision to continue practicing, yes, I put on the N95 mask, spaced out patients, increased cleansing of the office and the exam rooms, screened patients for symptoms. But, I also made the decision to take on the added risk of seeing people and giving them the best care I could. I argued with my partners over this. The prevailing opinion locally and nationally was to only see emergencies in the office.
But what is an emergency? I argued that a senior citizen sheltering in their home with no ability to leave, reliant on their hearing for telephone calls and news broadcasts, with hearing loss due to wax in their ears or a broken hearing aid constituted an emergency just as important as a nose bleed, severe pain, or tonsillitis. I also argued that how can I or my staff really know what an emergency is, that has to be determined by the patient.
My arguments were accepted and we never closed the office. We offered and even encouraged telemedicine but we kept the doors open. I know for a fact that we were more available to our community than any other ENT practice in the Bay area. I know this because a patient from San Jose called 20 other medical practices before she found me to take care of her ear infection.
So earlier today I was thinking about the 16 year old boy who had a bad respiratory and tonsil infection in January. He developed swollen lymph nodes and they never went down. I don't know what exactly happened between then and early April but by the time I saw him in the office he looked like he was growing a grapefruit on his neck. I did my standard work up and placed a needle in the swollen glands to remove fluid and sent it off. Unfortunately, the pathologist was unable to make a diagnosis. Fortunately, my determination to keep the office open was the same determination to keep my surgery center open, which I administer. I got him in the OR within a week and sent a biopsy off to the lab. The pathology was delayed and then had to be sent to Stanford but now we have the diagnosis of Hodgkin' s lymphoma and I can direct him to treatment.
A second gentleman came in to see me about 10 days ago. He had a swollen gland on his neck for the past 6 weeks. He felt guilty about coming in, nervous about Covid-19, and didn't want to take up my time. Once again I followed my standard routine, I wasn't going to allow this virus to impede good care. Another needle biopsy, this time positive for a metastatic cancer, I plan to take him to the OR next week to do biopsies looking for a source. I already have an oncologist ready to see him.
As I was talking to Cynthia tonight I realized that if I didn't demand of myself to provide the right care, if I reduced my exposure by closing the office or modified my treatment algorithm or screened for only "emergencies" like the vast majority of my colleagues have for the past 10 weeks, in all likelihood these two men would not be on their way to treatment.
This is not an attempt to pat myself on the back. No, I am ashamed by how the medical community including the health officers in our community and our country have handled this crisis. Frankly, they should be ashamed of themselves. Cancer isn't going to wait for a vaccine. People still have health problems and a lot don't look like emergencies. In fact, most emergencies start as little problems that are pretty easy to manage. But, when we collectively forget our duty and our oath we turn those little problems into major ones.
I remember vividly, going to medical school in the 80's during the AID's crisis. We had poor testing, no treatment and 100% mortality. At first we thought it was easy to catch from respiratory droplets. Healthcare workers were terrified and many left the profession. I had family and friends encourage me to choose a different path. But, in medicine, you don't really choose the path, the path chooses you. And I accepted the risks. And the risks weren't limited to AID's, there was hepatitis, TB, and a myriad of other infectious diseases that physicians have risked exposure to since before the time of Galen. We accept that risk and society has rewarded us with respect and a very comfortable lifestyle.
So, I am stumped, what has happened to my profession? Where did all this fear come from? And what happened to science? We have taken individual case reports and completely modified the entire structure of our profession. We have abdicated our role as the expert, we have allowed politicians to tell us what to do and how to do it. And the result inevitably will be bad medicine. Patients will have delayed care, poorer outcomes and minor issues will become major issues, because cancer can't wait for a vaccine.
