“. . . for the secret of the care of the patient is in caring for the patient.”
Jim was raised on a tobacco farm in the Deep South, volunteered for military service, and attended optometry school on the GI Bill. His intelligence, demeanor, and work ethic landed him a job at a prestigious university eye clinic. He tells people that I twice saved his life. The first time, he came under my care with pulmonary edema and a rapid life-threatening heart rhythm. An implanted pacemaker-defibrillator and medications got him back to work. The second time occurred years later, when I cared for him during an episode of near-fatal bilateral pulmonary emboli.
After the prostate-specific antigen (PSA) blood test was developed and administered at reasonable cost, Jim underwent testing, and his level was mildly elevated. A urologist was consulted. Prostate biopsies revealed a low-grade cancer. Surgical removal was recommended, but Jim opted for watchful waiting. The decision had merit, for his occasional PSA blood tests remained stable for the next 12 years. During the last 3 of those years, the prostate enlarged and partially obstructed urinary outflow from the bladder. Finasteride was prescribed to shrink the prostate. Jim was pleased with the result.
Then, a controversial U.S. Preventive Services Task Force guideline was published. It discouraged the performance of PSA blood tests on the asymptomatic elderly. Doctors were advised to be circumspect in proposing procedures to eliminate prostate cancer, because asymptomatic patients who underwent procedures and treatments on the basis of elevated PSA test results often had adverse sequelae and did not live longer than patients with elevated PSA levels who remained asymptomatic on a program of “benign neglect” of their unbiopsied (and untreated) cancers. Many doctors disagreed, but Jim's doctors followed the guideline. He had no PSA tests for 3 years. The next test result revealed a dramatic elevation that was almost “off the charts.” Even though the PSA level had rocketed up, Jim remained unconcerned and without symptoms. However, when the urologist found a rock-hard area on the prostate, Jim reluctantly agreed to further studies. A bone scan revealed multiple areas of likely cancer that had spread from the prostate to bone. A prostate biopsy revealed the highest grade of cancer.
A scientific study in 2013 concluded that patients taking finasteride were more likely to develop high-grade prostate cancer than were those who did not take it.
When there is a troublesome outcome, most doctors review the patient's course and the actions of the medical establishment. In this case, they might ask, “Would Jim's health-and-wellness scale still be in balance if annual PSA studies had been performed? Would the spread of cancer have been prevented with earlier diagnosis and treatment?”
When tumor-shrinking chemotherapy was proposed, Jim did not want to undergo treatment if side effects would immediately make him ill. He was content to enjoy his asymptomatic state and delay any consideration of treatment until the cancer caused pain or suffering. If such occurred, he would face that challenge and prevail. Jim is resilient—he has overcome serious medical illness and personal troubles in the past, without falling apart.
After I retired from clinical practice, we stayed in touch. When asked to accompany Jim to a meeting with his urologist, I agreed to do so as a friend. Time and space do not alter the strong bonds of long-term patient–doctor relationships.
The urologist's apparently prepared sermon ended with a request for Jim to start a relatively benign oral medication that should delay symptoms, should be well tolerated, and should have the potential to substantially shrink the tumors. During the monologue we listened, and we nodded our approval when Jim agreed to be treated.
At this writing, Jim remains asymptomatic and shows evidence of tumor regression. We shall await the outcome together.
Submissions for Peabody's Corner should 1) focus on the interpersonal aspects of a specific patient–doctor experience; 2) be written in storybook fashion; 3) contain no references; and 4) not exceed 5 double-spaced typescript pages.
From: Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215