Trouble at 6 O’clock

Emily Green knew there was a lump in her right breast. She was a new patient I saw a few weeks ago. Her previous doctor had sent her for a mammogram last year, but she had not come in for a clinical breast exam. She was a busy professional, who admitted she sometimes cut a few corners with her own health care.

I remember signing the order for her annual mammogram even before I met her. At that point in time, she had not made an appointment to see me, but I signed the order anyway.

In years past I used to stick to my guns and not order a mammogram for patients who had no intention to come and see me for a breast exam.

We all know that a mammogram is best done after a clinical breast exam, so that women with abnormalities on their exam can have a more comprehensive, or diagnostic, mammography study with an ultrasound examination to distinguish between solid and cystic masses.

Purist that I was, I insisted on doing the job right, and on my terms – exam first, then mammogram. I don’t know how many patients ended up having nothing at all done because of my stubbornness. After a lot of thought I decided to authorize mammograms for any woman who wanted one, whether she came in for a breast exam or not, since doing something seems better than possibly doing nothing to screen for cancer.

When I finally met Emily Green for her first appointment, she told me she was concerned about a small lump in the lower portion of her right breast. I agreed with her – the lump was a little larger than a pea, nontender and freely movable against the overlying and underlying tissue. Another, larger, irregular cluster of lumps toward her breast­bone in the 3 o’clock position seemed like typical fibrocystic disease.

At the end of her appointment we agreed on getting a diagnostic mammogram followed immediately by an ultrasound. Whether these tests showed anything or not, we also agreed to have her see a breast surgeon in consultation because of the suspicious nature of the lump at 6 o’clock. We also decided to get some updated blood tests and change her blood pressure medication.

I signed off on her normal radiology reports and added “cc: Dr. Fowler” at the bottom of each page.

When I saw Emily Friday to follow up on her blood tests and new medication, she had already seen the breast surgeon the day before. She was quite animated when she said:

“I can’t believe the tests didn’t show anything. I mean, I felt the lump, you felt it, and Dr. Fowler found it instantly. She’s set me up for a biopsy in less than two weeks! I never realized doctors might disagree with an x-ray.”

“A test is only a test” I mused. “Mammograms are probably best at finding little microcalcifications we can’t feel with our hands.”

“I guess so, but I still feel like I had a near miss”, she said. “What if I had just trusted the mammogram and not bothered to come and see you until the lump had grown some more?”

I reminded her that the biopsy may still come out negative, but agreed that it was very good she had taken the time to come in with her concern.

I still wonder, which is the better thing to do, authorizing screening mammograms to any and all or start insisting again on seeing patients for a clinical breast exam first.

2 Responses to “Trouble at 6 O’clock”

  1. 1 isaac September 29, 2009 at 12:38 am

    I guess that depends on what happens with the ol’ reform business going on.

    My sense is that for psychological reasons, a mammogram result is going to motivate a patient more than a palpation result. One’s high tech and the other’s not.

  2. 2 Dee September 29, 2009 at 4:10 am

    Can I ask how many lumps you’ve found doing CBEs that the woman hasn’t already found? Just curious, because my GP said that in 30 years of practice he’s only found one that the woman hadn’t found (he knows I do cancer-related policy work, so we were chatting about it while he was doing my CBE a couple weeks ago). Just a note – he does them thoroughly and correctly.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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