Not Everybody Can See What You Can

     Today's blog post is about people.  Specifically, what in the world are people thinking?  Something that may seem so obvious to you might not register to somebody else.  For example, half the country may think Donald Trump is compromised by Russian influence, while others may think that he is getting framed by corrupt Hillary acolytes within the Deep State.  Because talk radio, cable news, big media, Twitter, and the blogosphere have all written extensively on these 2 diverging viewpoints, I'll discuss other, more tangible examples.

     I once saw a patient who was in her early 70's.  I think she came to the office for a sinus infection or something.  Just before the visit ended, she asked me to look at a spot on her shoulder that she said her daughter was concerned about.  I said okay, and asked how long had it been present?  She said it had been there for around a year and a half, and it was starting to get a bit tender.  She then pulled the neckline of her sweater to the side to expose her shoulder, and there was a huge weeping ulceration, the diameter of a golf ball, that was inflamed, and necrotic.  This lady obviously had a skin cancer that had been present for some time.  What I wanted to ask was "How in the world do you think this is okay to have on your shoulder for over a year? Why haven't you shown this to a doctor until today?!"  However, at that point in time, it didn't matter.  What was necessary was getting her to a surgeon to perform an extensional biopsy.

     So what prevented her from seeking medical care?  She had insurance.  Sure, finances could be an issue.  Denial is a possibility.  Fear of a bad diagnosis may be a reason, which could transform into denial.   All these reasons make sense to me.  I may not understand the denial, but it is a plausible explanation.

     What scares the living daylights out of me is the possibility that perhaps this patient was too stupid to recognize a significant medical problem.  Can one be that oblivious?  Could she see this cancer forming on her body, day in and day out, and be completely incognizant of potential danger?  I mean, she had to see it every time she put on or took off her shirt.  Did she think it is normal?  What if she truly lacked the ability to KNOW that there was a major problem going on right in front of her face?  I mean, she didn't go to medical school.  Are my expectations of what people should know that much different than others?

     You see, common sense is not so common.  We humans think that everybody should think like we do.  But that simply isn't the case.    My common sense may be different than that of a lawyer, or a farmer, or an Egyptian for that matter.

     While I understand that people might not have my common sense, I still have a hard time getting my mind around people who fail to promote their self interests, especially when it is at their own personal expense. 
     I have a patient who is in his late 50's.  I see him for high blood pressure and high cholesterol.  At his visit last week he said he thought perhaps he should have me take a look at his toenails, because he thinks something might need to be done about them.  This patient said his toenail got stuck in some carpet, and he almost tripped and his nail almost got ripped out.  So, he takes off his shoe and sock, and this is what greets me:

     What you are looking at is at least 1 year of untrimmed toenail growth.  In addition to being dystrophic (misshapen) there is a fungal infection (onychomycosis) which likely is the cause of the nail curvature.  I told the gentleman that I was going to go to into my office to get my chainsaw for him.  But seriously, I had to refer him to the podiatrist.  At least the patient was able to realize something was wrong, better late than never.
     My last story for this blog post involves a 70 year old man who always comes with his wife.  He initially came to see me for uncontrolled hypertension.  We got that under control after a few visits, along with his cholesterol, and I was working on his likely alcoholism, when one day he told me that he was having bloody stools.  He described bright red blood when he had a BM, and at times when he didn't.  I asked how long that had been occurring.  He replied for around 8 months.  I had seen this guy at least three times during this period for other medical issues, and he never mentioned this bleeding.
     I arranged for a colonoscopy, which revealed an adenocarcinoma (cancer) of the colon, confirmed on biopsy.  The gastroenterologist and I discussed the patient.  He asked which oncologist and surgeon I preferred to send the patient to for treatment.  He was then going to call the patient to his office to discuss the diagnosis and treatment plan.
     Fortunately, given the location and size of the tumor, the prognosis seemed very good.  He would need a colon resection, likely chemotherapy, and careful monitoring.  A few days later, shortly after the meeting, the GI doctor called me.  The patient was declining all treatment.  The doctor explained that without treating this, it would form a larger obstruction, there would be pain, he would bleed more, and ultimately would die.  The patient still refused.  So I called the patient, and asked that he and his wife come see me to discuss.
     So the patient and his wife came to see me.  I brought up how the GI doctor thought that he'd do great with a surgery and some chemo.  The patient refused.  He wife was crying.  He smelled sour and soiled.  The rectal mass was making it different for him to pass stool, so loose stool was leaking past the obstructed part.  I asked why he wouldn't want to be treated.  He was unable to give an explanation.  He just didn't want it.  I explained the natural progression of the cancer:  the obstruction would get worse, he'd have worsening pain and discomfort, he could have continued bleeding, the cancer could spread, he could then form blood clots and possibly die from them.  Despite all of this, he didn't wish to be treated.  I offered to have him see a radiation oncologist for palliative radiation to the mass to make it easier to pass stool.  He refused.
     I can not understand why he wouldn't want to be treated when he was so symptomatic and it could improve his quality of life, and his longevity.  I think about his poor wife, who was sobbing, obviously hoping he would change his mind.  Yet she supported him.  I told them to think about it; and to let me know anytime if he changes his mind.  He didn't change his mind;  he currently has a hospice service helping him with his symptoms.
     Not everybody can see a given situation the same way I do; but I am not so arrogant to think that I can see all the variables that go into other peoples' decisions.  So while I can not always understand, I try my best not to judge, because I do not have the other person's perspective.  I think it is vitally important for doctors and patients to be able to make choices together based on each individual's wants and needs.  It would be hypocritical for me to rally against an insurer wanting to limit care to a patient based on something like age, but be against an individual patient who wants to exhibit his autonomy by declining medical treatment.
     Whether or not I understand another perspective, my job is to educate my patients so they can make an informed decision, even if that choice isn't the choice I would make or recommend.  Some people see the dress as blue, others as gold.  While opposite sides don't even necessarily need to come to an understanding (although it would be nice), we must strive to respect autonomy while maintaining compassion.  And add a bit of humor whenever possible.

     Thanks for reading my blog!  I have posted a number of healthcare topics recently, so my next one likely will be about alcohol / cocktails.  To my knowledge, this is the only blog dedicated to the twin topics of medicine and cocktails.  So that means you've come to a special place on the internet.  Congratulations.  Please follow me on Twitter by clicking here!