The public wants to believe in the profession of medicine. These beliefs are often justified. But not always.
For example, one day, a 60-year-old woman came to the ED for abdominal pain. A refugee from El Salvador, she was admitted to a team of doctors and medical students at a county hospital. The supervising attending physician on that team was an oncologist. He held a high position at the medical school that was affiliated with this hospital.
The members of that team examined this woman and ordered a CT scan of her abdomen. In their notes, they wrote that the CT showed a "mass" in her liver, a biopsy of which was obtained and sent to the pathology department. It was put on slides and an expert pathologist, who also worked at the medical school, looked at it, as did residents who were studying to be pathologists. They saw abnormal cells. They said that those cells were cells of liver cancer, and the official report from the pathology department was liver cancer. There is a blood test for liver cancer. It is called alpha-fetoprotein (AFP), as AFP is generally elevated in those who have liver cancer. The doctors ordered an AFP test in this patient. It was not elevated.
Nevertheless, since the biopsy showed cancer, they assumed she had cancer. They told her that she needed chemotherapy. However, this woman didn't believe that she had cancer.
This was an interesting position for her to take. She was uneducated and was from the countryside of El Salvador. She was raised on a farm in a hut with no electricity and no running water. She was, as they say in El Salvador, a campesina.
She told the doctors that she didn't have cancer. The doctors told her that she did. She told them she wanted to leave. They told her she would die if she did that. She said that she would take her chances. They made her sign out against medical advice (AMA).
I reviewed all these records when I saw this woman a year later. She returned to the ED at that time because she still had abdominal pain and was losing weight.
In addition to reviewing her records, I looked at the CT that was done the year before. What I saw surprised me. It was not a "mass" that looked like cancer. Rather, it was a mass that was primarily a cyst. This cyst brought a diagnosis to my mind -- amebiasis.
As I reviewed her record, I saw that she had no risk factors for liver cancer. Those risk factors are anything that chronically damages the liver, such as chronic hepatitis or alcohol abuse. This patient did not have chronic hepatitis, and she did not abuse alcohol. Therefore, there was no reason why she would have primary liver cancer, a.k.a. hepatocellular carcinoma.
A test of this woman's stool showed that she indeed had amebiasis. Amoeba is a parasite that can be found in contaminated water. This woman drank from ponds and streams in El Salvador. Amoeba can migrate from the intestine to the liver, where it forms a cyst. I treated the amebiasis; she improved.
This woman never had cancer. Had she gotten chemotherapy she probably would have died. Treating a patient with chemo when they have a serious underlying infection would likely cause that infection to kill. But had she died in that manner, the doctors would have said that she died from liver cancer. No one would have known the truth.
I have seen this sort of mistake more than once. They happen, to a large extent, because of a naive belief in the power of medical technology. They happen because doctors and the public are led to believe that the CT scan or MRI give definitive answers all the time. But that is not how it is. Sometimes they give those answers, sometimes they don't.
Also, there are cultural factors at work that affect how this technology is used. For example, threats of lawsuits affect the culture of medicine. If a radiologist misses a diagnosis of cancer, then he or she can easily be sued. Therefore, there is a tendency, among radiologists who fear lawsuits, to over-call a mass seen on CT as cancer.
Once the CT, in this case, was read as "consistent with hepatocellular carcinoma." Then a bias is introduced into the paperwork that makes its way to the pathologist.
The tissue taken for biopsy was sent to the pathology department with a requisition which described where and how the biopsy was taken. There was also a "summary of the case" on that requisition. It said, "60-year-old with liver mass, suspect hepatocellular carcinoma." When the pathologist read this, she assumed that she was looking for liver cancer.
Most pathologists do not review clinical records. Rather, they read the summaries of the case on the requisitions. This summary seemed straightforward -- i.e., "suspect hepatocellular carcinoma."
The pathologist took the biopsy sample, put it on slides, and looked at those slides with the bias of hepatocellular carcinoma in mind. When she saw cells that looked abnormal, she assumed that they were cells of hepatocellular carcinoma. When I saw this patient a year after the biopsy was taken, I went over those slides with the pathologist. Once the correct diagnosis of amebiasis was known, the abnormal cells were seen differently. They were seeing degenerative inflammatory cells from the amoeba infection.
The mistakes made with this patient also happened because of the culture of medical education.
Doctors get promoted in academic medicine for doing research and publishing papers. Excellent teaching and good care of patients are not reliable ways to get promoted.
Hence, neglectful attitudes can develop when it comes to teaching and caring for patients. This neglect is often subtle, but it doesn't take much neglect to mess up education or get on the wrong track when caring for a patient.
This case is probably an example. The supervising physician did not take the time to look at the CT scan. He took the resident's word for what it showed.
The resident told him that the patient had a mass in the liver, and that sounded good to him. He didn't take the time to give the patient or the data much thought. The culture of medical education has allowed this to happen for years. And what makes it worse is that some doctors who do this are held up as heroes. It doesn't take much to dazzle medical students and residents, particularly when those who dazzle control the future of those medical students and residents through diplomas and such. Under these conditions, subtle negligence can be passed on as standard practice.
That this patient had the strength to stand against the doctors is remarkable. I gained insight into why and how she was able to do this as I talked with her about her life. She grew up very poor. Her family eked out a living farming and raising a few animals. She was forced to marry an older man when she was 15. They had a few babies, then he left her.
Other men came and went. Some abused her. Her acceleration into adulthood at a young age, and the abuse, left her with a tough and skeptical attitude toward people and toward life. The way the doctors approached her, and what they had to say, triggered her skeptical side.
She told them they were wrong, and she signed out AMA. She was right.
This case illustrates that the real world of medicine can be tricky. It illustrates the need for clear and critical thinking. This case also illustrates how one false assumption can lead to another. And it demonstrates how fallible medical technology can be. It illustrates problems with medical education.
A simplistic approach to medicine and a simplistic approach to medical technology can lead to false beliefs about health and illness, to incorrect diagnoses, and to harm in some cases.
That a campesina was able to outthink the doctors is also a lesson about the importance of skepticism in our world today.
There is a great deal of misinformation that is spread about health and illness. Naivete seems on the rise. There is a doctor on television who spreads misinformation and encourages naivete 5 days a week. That naivete may seem innocent, but as this case illustrates, if such thinking becomes too established in the profession of medicine, it can have serious consequences. We need to do a better job teaching clear and critical thinking in the profession of medicine. Forces that discourage such thinking should be recognized and countered.
W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. Graham received a National Institutes of Health fellowship at the Salk Institute for oncogene research in 1985. He was a professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.