A Second Opinion by Rachel Hines
I have already gone through my rituals with five or six patients this morning. I made conversation, asked the right questions, instinctively re-deepened my drawl, and found a couple new neutral phrases to use after completing the various elements of the patient history and physical exam: “ok,” “thanks,” “alright,” “all done.” Sometimes I would slip up and says something like “sounds good” after auscultating a patient’s heart or lungs. Then I worried Dr. Alston would come in after me and tell the patient that actually, it doesn’t sound good.
Again, I pull a chart from an exam room’s door. Bass. (“Hey there Mrs. Bass!”) 1923. (That makes her 86.) Follow-up. (I bet for some permutation of high cholesterol, diabetes, and/or hypertension.) Blood pressure 150/95. (Bingo.) Weight 178. (“I see you’ve lost a couple pounds – that’s hard to do over the holidays!”) Total cholesterol 198. HDL 53. (“Your cholesterol is doing great!”) Hemoglobin 10.3. (“It looks like you’re still a little anemic.”) Last note dated 10/3/09 from Dr. Alston reads: Mrs. Bass is a well-appearing, pleasant woman who presents today for routine follow up. She has no complaints. Previous labs revealed progressive anemia and stool sample was heme positive. I discussed with her the need for colonoscopy to identify sources of blood loss, including a GI malignancy, but she was not interested in having a colonoscopy at this time. The patient stated that she understood that in not having a colonoscopy, we could not rule out many causes of blood loss, including malignancy.
Mrs. Bass’ patient demographic sheet is tagged with a handwritten sticky note that reads “colonoscopy” and I assume that this is Dr. Alston’s self-reminder to further discuss the issue with her. I knock and, without waiting for a response, open the door to the room. Mrs. Bass has been waiting and I greet her with a smile and my usual introductions as I take a seat to face her. She has white hair and loose wrinkles on her face, beyond the telltale patterning of smiles and squints into the work of gravity and disrupted collagen. Overweight in a way most would not label on account of her age, her lower stomach bulges disproportionately beneath a clean striped shirt. It is tugging her pants up just high enough so that an inch of calf is exposed above her socks. Her socks match her pants which match the stripes.
Mrs. Bass reminds me of my grandmother. She has “no acute complaints” despite being 86. She tells me that she cooks, she cleans, she hosts her children and their families at her home. This is a patient with a “high quality of life.” She diligently opens her plastic pill organizer each morning after breakfast and takes a palmful of requisite drugs, though she would prefer not to. She knows their names and dosages when asked, even if she sometimes forgets what each is for. Simvastatin, Atenolol, vitamin D with calcium. Mrs. Bass is “compliant.” Her chart reveals that her husband died recently, yet she is not taking antidepressants like many other recently widowed patients. I suppose in her case, bereavement did not turn pathologic.
It is easy to speak with Mrs. Bass, and “pleasant” actually seems to be an apt adjective in her case. She understands my questions and provides responses with an appropriately small amount of tangential information. For example, when I ask her if she has noticed any blood in her stool recently, she says:
“Well, I think there might be.”
“How often have you noticed it?”
“Oh, probably most times I go to the bathroom.”
“Can you describe what it looks like? For example, is the blood bright red or dark?”
“Well, that’s the thing. It looks kind of like raspberries. And I eat frozen raspberries at least once a day. I love raspberries.”
“Is the raspberry-looking stuff part of the stool or is it separate?”
“It’s separate, just in the bowl with it, so that’s why I’m just not sure whether it’s actually blood or not.”
I stop for a moment and picture her stool. I consider what I know about bowel movements, one of the more artfully described phenomena in medicine. Common descriptors include “sausage or snake-like,” “fluffy,” and “lumpy.” Stool can include “occult blood.” Doctors refer to “melena” and “steatorrhea” like Inuits describing snow. I am tempted to ask Mrs. Bass if she could draw it for me or at least describe how it would appear on a menu. (A mousse with raspberry drizzle? Or more like an éclair with fresh berries?) Instead, I tell her that it would be hard to tell if it is bloody without more tests and ask her if she has given any more thought to having a colonoscopy.
She has, and she still does not want one. She refers to a recent article that indicated people over 80 don’t need colonoscopies and tells me she mailed a copy to Dr. Alston when it was first suggested that she get one. I know the research to which she is referring – and by “know,” I mean “remember hearing about.” I think it was when we spent a few days before Thanksgiving discussing geriatrics. From what I recall, current guidelines recommend against screening colonoscopies for people over 80 because they are more likely to do harm than help. Everything in old people gets fragile – the tube of colonic muscles, blood vessels, dendrites, skin, their whole bodies. Bowel perforations happen. Insert an endoscope and Pop! goes the intestinal wall.
I imagine that polyps, little cellular seaweeds, are growing into Mrs. Bass’ colon. Their stalks and spherical buds extend into the lumen of the large intestine, bending with the flow of most feces, bleeding if their little bobble heads are hit by something solid. That makes them different from seaweed. You see, Mrs. Bass, we could solve all this with a snip and sizzle, a cut and cautery if you’ll simply let us sedate you and put a camera up your colon. Given time, the polyps can sprout elsewhere, preferring liver and pelvic neighborhoods. Excuse me, ma’am, you may have some colon in your uterus.
I silently quiz myself. Which of the following is most likely responsible for heme positive stool in a geriatric patient?
a) Metastatic colorectal carcinoma
b) Adenomatous polyp
e) Internal hemorrhoids
I rule it down to b) or c) and am feeling pretty satisfied with myself when I hear Mrs. Bass exhale. Surrendering her conviction, she meets my eyes and asks, “What do you think I should do?”
This is not part of my routine. I have had patients ask me questions like, “What do you know about Lipitor?” or “Are these red bumps on my arms normal?” but her question is different. I think she is asking me to evaluate her quality of life as a person, beyond performing activities of daily living and personal maintenance. Is the procedure worth it? Is she worth it? The risk of bowel perforation, chemotherapy, thousands of dollars. She had thought not, but is uncertain. Doctors see uncertainty and order tests to be sure but I am not a doctor and I too am uncertain and that is valuable.
May I please have the question in the form of a brief clinical vignette?
An 86 year old patient with a history of hypercholesterolemia and hypertension presents with heme positive stool and worsening anemia. She is otherwise healthy, is well-educated, maintains an independent lifestyle, and was recently widowed. What is the most appropriate next step in the diagnostic management of this patient and the associated major concern?
a) Colonoscopy; bowel perforation
b) Barium enema; low yield results at high cost to the patient
c) Reassure the patient that colorectal cancer is slow progressing; early metastasis and rapid deterioration
d) Repeat stool sample; no new information gleaned
e) Leave it up to the patient; lose authority
I have never seen this question before in my life. I have little predictive prowess but more instinct on which to base my response to her question. I have less length to my white coat, I am less of a doctor, I still speak in lay person, I am more of a person. I reside in a finite period of privilege in which patients have not yet become patterns. I wonder if this makes me more honest. I am lucky to be in this position but also unlucky because I fear being wrong, as a future doctor and as a human. I fear that my answer will be different from Dr. Alston’s, which will certainly be offered when she comes in after me, and I do not want to be that student who left a mess to clean up, to correct. But I also fear betraying my own preferences, and my preferences for the people I love.
“What do you think I should do?”
How can I think anything when the human and doctor parts of myself are busily hurtling images and so many words that once were organized but lose utility when side by side? Polyp lollipop. What if my grandma was dying now and they could have taken that polyp out if she’d had a colonoscopy and maybe Mrs. Bass’ family needs her to be around even though her husband isn’t but she knows she’s going to die eventually like him and she is more at peace with it and doesn’t want to be sick and dependent getting chemo and maybe if she has cancer she’ll die with it not from it because the polyps don’t grow fast unless they’ve already grown…
I think too many things and fear enough to recognize that I have the option of bowing out. No “should do” appears in my tangle of facts and empathies. I suspect there is not only one correct choice, that this question is short answer, but I am just not there yet.
“What do you think I should do?”
“I think this is a very personal decision and you should talk to your family and Dr. Alston some more about what to do.”
I know that when Dr. Alston comes into the room she will sit to face Mrs. Bass, to face her questions. I will surrender the chart and take my place, leaning against the exam table in a corner. Leave it up to the whole people and the whole doctors and leave me safely out of your decision making process. Dodged. Deadline extended. Done no harm.