An uncomfortable question

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgWork called last night. (It happens.) Basically, I had two deadlines for two big things (finishing reviewing the grants assigned to me for study section and a major writeup for a project for my job). Unfortunately, both of them were today. I realized as I perused old posts that I hadn’t reposted this one in over five years. So, unless you’re a long time reader, it’s definitely new to you. More importantly, it reminds me that I don’t write about thins like this much anymore. Certainly I rarely do personal anecdotes or straight medical blogging much anymore. Maybe I should do more.

[NOTE: This story is loosely based on a real patient encounter from several years ago, but some details have been changed.]

The patient list for the day had simply the words “abnormal mammogram” next to her name. That used to be the most common reason that of breast patients came to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal. The next thing they know, they’re sitting in one of my examining rooms. However, the patient list is quite brief. It’s just meant to be a quick capsule of what patient has what basic complaint. These days, because at my current institution so many more practitioners order breast biopsies, most of the patients I see are already pre-diagnosed with breast cancer. Be that as it may, nothing on the list prepared me for the woman I greeted when I walked in the examination room.

This woman was enormous, and I do mean enormous. Morbidly obese, she told me she wasn’t sure how much she weighed, but that it was at least 450 lbs. As she sat in a wheelchair massive enough to support her, rolls of fat hung over the armrests, and her breath wheezed like a mortally wounded Darth Vader near the end of Return of the Jedi, right before he took his helmet off and revealed Anakin Skywalker beneath the mask. Indeed, on the same theme, I could not help but be reminded of Jabba the Hutt. Yes, I know that physicians aren’t supposed to think that way about their patients, and, honestly, I tried not to. However, we’re human, just like everyone else, and even our years of professional training can’t entirely suppress our baser thoughts. At least I managed to keep enough self-control to restrain myself from voicing such thoughts to my nurse or any of the clinic staff at all, not just where the patient couldn’t hear. Not all clinicians exercise such self-restraint, and, I’m embarrassed to say, there have been times in the past when I didn’t either. I like to think that experience and maturity have provided me with the self-restraint to reign in my sarcastic tendencies.

Normally, dealing with a patient with suspicious microcalcifications on her mammogram is fairly simple. A biopsy is indicated, and there are basically two techniques to choose from. You can do an image-guided core needle biopsy, either a stereotactic biopsy (in which the image guidance is mammography) or an ultrasound-guided core biopsy (in which the image guidance is from, well, ultrasound). If neither of these are possible, then the patient will require an old-fashioned surgical biopsy, known as a wire localization or needle localization biopsy. This is a technique in which a wire is placed into the breast under local anesthesia such that the wire sits next to the abnormality that needs to be biopsied. In essence, the wire placed under either mammographic guidance or ultrasound guidance, leads the surgeon to the lesion. Given that even the surgical option is usually a same day surgery using local anaesthesia and sedation, even that isn’t so hard. The surgery can sometimes be a little trickier than one might think, but even then it’s usually not all that hard. Oh, sometimes you get patients with multiple abnormalities, and you have to decide if you want to go after them all or if you want to perform a triage and decide that some of them need to be biopsied and some of them don’t, all the while realizing that if you miss a cancer it can be a major disaster for the patient.

Of course, a 450+ lb. patient adds a new level of challenge. For one thing, she was way too heavy for the stereotactic table; so stereotactic biopsy wasn’t even an option. Not surprisingly, her health was horrible. She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians’ Desk Reference. I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it. So I made do and did my best to examine her while she was sitting in her wheelchair. It was a suboptimal examination, but, given the size of the room, it was all I could manage. Morbidly obese patients, because of their size, frequently make it very difficult to provide optimal care to them.

By the time I was done, I felt profoundly sorry for this woman. How on earth does such a person live, given her physical and medical problems? Despite my sympathy, I maintained the professional bedside manner that we’re all trained to keep up and explained what was abnormal about her mammogram, that she would need a biopsy, and how the biopsy would be done. I also explained the risks (which, for her, were much higher than the minuscule risks most patients undergoing this procedure face), and arranged for her to be seen by her pulmonologist and cardiologist in case something more than local anaesthesia were needed.

When finished, I asked if there were any more questions, gave her my card, and made my way past the family members to the door. Although it was near the end of the day, there were still a couple of more patients to see.

There was.

“Do you believe in God?” she said, looking at me expectantly.

I was still standing there, hesitating. To be honest, my first thought was: Why on earth should it matter whether I believe in God or not? Belief in God has nothing whatsoever to do with whether I’m a competent surgeon or not. Personally, if I needed surgery I’d prefer a surgeon who is a flame-throwing “militant” atheist like PZ or Richard Dawkins, as long as he or she is highly competent and has a bedside manner that doesn’t bother me (and, of course, doesn’t push his or her beliefs on me), over an incompetent believer. In the same vein, it wouldn’t matter to me if the surgeon is a Bible thumper, again as long as he or she is highly competent, easy for me to get along with, and doesn’t push fundamentalist beliefs on me. To me, the question of belief in God is utterly irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way. Thinking back on this incident, I can’t help but remember an interview I had heard with Eddie Tabash, an atheist attorney who mentioned during the interview that he sometimes defended prostitutes. During the interview, he went on to mention that it was not infrequent for prostitutes to become very uneasy about having him as their attorney when they found out about his atheism. I had never encountered this phenomenon among my patients, however.

My second thought was: Why on earth would this woman still believe that there was a benevolent God looking down on her? She was a mess. She couldn’t walk more than a few feet without assistance; she could hardly breathe; and she was on enough medications to stock a Walgreens or CVS. Her health was so bad that even a minor surgical procedure such as a breast biopsy could put her life at risk.

Worse, the question brought into sharp focus a question that I myself have been wrestling with myself for the last three years or so, a question whose answer seems to be yes one day and no on others. There’s nothing like being trapped in a small examination room with a 450 lb. woman and three members of her family, with nowhere to run and no way to dodge the question. I was trapped. A believer might have said that the woman’s question was God’s way of making me face my fluctuation between belief and disbelief; an atheist might say that such an assertion is wishful thinking. Whichever was the truth, that didn’t prevent the formation of a little bead of sweat that was slowly enlarging on my brow. I suspect the question would have still been uncomfortable for me to answer even if I were as religious as I was when I was younger, as even then I tended to view religion as a private matter, one I didn’t usually talk about much.

What if I were to tell her that I was an agnostic or an atheist, that I didn’t believe in God? Would she have sought out another surgeon? For a fleeting moment, I was sorely tempted to say just that. It might have been an out, a way of not having to do the case and all the attendant risks of major complications from what is normally a minor operation. On the other hand, this woman had no insurance and had to rely on charity care, which meant that she probably didn’t have the option of going to a different surgeon, at least not at a different institution, and her going to one of my partners would have been perceived as dumping on them. If that were the case and I said I was an agnostic/atheist/whatever, she would then be going into surgery with no confidence in her surgeon, clearly an undesirable situation. A patient needs to have confidence in her surgeon, and anything that undermines that confidence, regardless of the reason or what I think of the reason, is to be avoided if it is possible to do so within reason.

So what did I finally say?

“I’m Catholic,” I said. A pause. “But, to be honest, I don’t go to Mass much anymore.”

This answer was true, of course, but incomplete. I was raised Catholic but long ago drifted away from the Church and, more recently, away from belief itself. It seemed to answer her question, but in reality didn’t. Not really. The truth is much more complicated, but she didn’t need to know that. Fortunately, because the woman was Catholic herself, my answer seemed to satisfy her. “God will guide your hand,” she said.

“I hope so,” I replied. Bullet dodged successfully.

I walked out of the examination room not looking forward to the day when this patient and I would meet again in the operating room–or to contemplating the way I had handled the situation. To this day, I still can’t make up my mind whether my choice was a complete cop out or a clever and diplomatic strategy not to undermine a patient’s confidence in me. It was probably a little of both. Whatever the case, in that situation on that day it worked.