Christmas at the Hospital

I think Christmas is probably my favorite holiday of the year. Despite having to spend it overnight at the hospital this year, for whatever reason, I was still in pretty good spirits. There was Christmas music playing on the radio, people are generally in pretty good moods (although there were definitely some sour faces at the hospital), and it's a relatively quiet night at the hospital - I think I got 6 hours of sleep on call, which is absolutely amazing! I played some poker with some other residents, we ordered some Chinese food (the only thing open on Christmas day), and just hung out.

However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.

Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.

Comfort Zone

One thing I've run across lately are a lot of radiology reports that seem to make statements or recommendations that are a little, well, off. First, let me make clear - my field is radiation oncology, NOT radiology. Another thing that I have to make clear is that in most cases, the radiologist that looks at images from a CT scan, MRI, ultrasound (etc.) never meets the patient, and often doesn't know their clinical history.

So why is it that I often read in radiology reports things like, "fibrosis and scarring consistent with radiation-induced pneumonitis"??? Sometimes the patient hasn't even had radiation! Moreover, pneumonitis is a clinical diagnosis, not just a radiologic one. In a day and age when patients can access their own results, including radiology reports (which I am in favor of), this can be very dangerous to claim. And sometimes downright wrong.

Another thing that happens is that in the report, it reads something like, "5 mm area of enhancement not clearly imaged by CT. Recommend follow-up with CT in 6 months," or "Recommend additional MRI study." I find that it's interesting they can recommend this without even knowing the clinical situation. For example, what if the patient had some clinical condition that easily explained the imaging abnormality, but now because of this report, it's almost necessary to order this additional (and sometimes costly) test. If the reports said something like, "based on clinical scenario and judgment of the ordering physician, a follow-up CT scan may be indicated," I think everyone would be much happier.

Just to give an example - I certainly do not tell a cardiologist how to prescribe or dose anti-hypertensive medications. I expect other specialties to respect the same boundaries.