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Opinion and Commentary from TMA

Becoming a Better Physician ”Thanks” to Cancer

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The last thing a nonsmoking asymptomatic female physician expects during her usual hourly aerobic exercise is a phone call from her internist about a “spiculated lung nodule.” There was no need for the rest of the radiologist’s sentence: “suspicious for malignancy.”

Kang_BlogShock. Denial: Can’t be! Wrong patient? Perhaps it’s benign. It has to be. I have never been a tobacco smoker; I maintain a healthy lifestyle, exercise, take my medications, eat right, (try to) sleep enough. I do all the “right” things. Anger: God! I cannot possibly have lung cancer! So UNFAIR!

Jumping onto “Dr.” Google Scholar, I found a reputable book chapter summarizing lung cancer in never-smokers. Lung cancer is the leading cause of cancer-related mortality in the world. Of 1.37 million annual deaths or 18% of all cancer deaths, 71% of lung cancers are caused by smoking. However, approximately 15% of men and 53% of women are never-smokers, or have smoked fewer than 100 cigarettes in their life. Aside from this remarkable gender bias, lung cancer incidence rates are higher and more variable among East Asian women. East Asian females who do not smoke tend to have adenocarcinoma on the periphery of the right upper lung. A nagging cough or shoulder pain that develops gradually is shrugged away – until the primary lung cancer rears its ugly presence by way of hemoptysis or seizures.

Rationally accepting that lung cancer can occur even in nonsmokers, I wanted action: Cut out that cancer pronto before it metastasizes!

As an academic physician, I have the privilege and responsibility to help train future physicians. How often do patients have the luxury to watch the surgical and anesthesiology resident physicians develop into capable attending-level physicians? I knew and trusted both my personal anesthesiologist and my thoracic surgeon.

Within 18 days of learning of that spiculated lung mass, I underwent video-assisted thoracoscopy (VAT). (Mercifully gone is that painful long slash between the ribs of an open thoracotomy.) I was still bargaining with God that the pathologist would diagnose a benign tumor or some noncancerous, infectious “-oma.” I still have so many things I want to do on this Earth, places to travel, young people to see grow up. Please, God, spare me the bitter cup of cancer!

I remember a jumble of activities, of being moved, people’s faces, then darkness. Awakening, I found myself in the ICU. Smacking my right chest and chest tube, I grinned: no pain – for now.

I gained new perspective and empathy for asthmatics and emphysema patients. Losing the entire right upper lung to adenocarcinoma left me starved for air-despite “normal” pulse oximetry readings off my finger. Catch-22: I felt short of breath but couldn’t inspire deeply due to a dull internal stabbing sensation. (Note to self: Visceral pain still hurts.) My unwillingness to cough warred against the relentless bodily reflexes to clear out bronchial secretions. How can COPD or cystic fibrosis patients with their preoperative air hunger tolerate the post-thoracotomy feeling of oxygen deprivation?

I understand better now why patients become delirious in the ICU: sleep deprivation. The compression stockings alternately squeezed my legs all night long. The noninvasive blood pressure monitor throttled the life out of my left ulnar nerve every hour. Demonically timed as I drifted asleep were the temperature probes under the tongue and monitor alarms (which never brought any human monitors to bedside). The chest tube preventing my usual right lateral sleeping position, I tried the left lateral position only to have my Foley and the chest tube tugging from the opposite side of the bed. Flattening out the bed increased my air hunger. Taking a sip of air triggered violent coughing. At 3 am (why?), the nurse drew blood out of my peripheral IV for lab work. Since the door to my illuminated ICU room did not close appropriately, I listened all night long to Fiesta celebrations at the nurses’ station.

Medical practice has changed. Instead of seeing the surgeon at the end of a long day of surgeries, I saw the surgical team the following day. I was prepared to be scrutinized on Postop Day 1 at the crack of dawn – before operating rooms start. The surgical residents stuck their heads in, said hello but did not examine. So I examined my chest tube drainage (minimal), my Foley (excellent diuresis), and my chest dressings (dry). The nurse practitioner (NP) made her rounds midmorning. I was freed of my Foley to walk two laps around the ICU with the physical therapist with only the chest tube to drag around. Observing the intubated comatose patients, I felt grateful to be alert and talking.

Still starving for food and sleep, and wishing to avoid hospital-acquired infections, I begged for day-one discharge from the surgeon. He wanted more observation time after the painless removal of the chest tube.

As I nestled under the clean sheets, after a blissful hot shower, ready to fall asleep to the muted television, at 10:15 pm, another very young nurse entered, flicking on the concentration camp room lights. She began undressing the clean IV infusion pump, announcing that she needed to give me my IV antibiotic. Was this another facet of the new medicine: patients receiving IV antibiotic the night before discharge in the morning? I asked the name of this miracle antibiotic as she scanned my arm band prior to hanging the medication. “Zosyn” was the reply, followed by a pregnant pause, then the slow utterance of “Oh, you’re not the one to get the Zosyn.” I was internally spastic. Did that near adverse event get self-reported? Maybe another entry about obnoxious physician/patient?

The problem of being a physician/patient is awareness of unintended consequences. Hence my thought: “Thank you, God, for the requisite zapping of my name band!” I could have received an unnecessary medication. I could have developed anaphylactic shock. Another patient would not have received the necessary antibiotic to ward off infection.

I was ready to fly the coop by 7 am on post-op day two. Midmorning the NP wrote the discharge orders and instructions. The paperwork stated breast cancer. Again, aware of unintended consequences of incorrect medical information living in perpetuity inside electronic medical records, I refused discharge until the inaccuracies were corrected. I have faced patients who adamantly denied medical diagnoses listed on their EMR. Mine was going to be accurate: lobectomy, not mastectomy!

The outpouring of love and affection after cancer surgery is heartwarming. Having cancer makes one feel vulnerable. Mortality becomes more palpable. Nurses, scrub techs, anesthesia techs, my administrative assistant, anesthesia resident physicians, medical students, even my elementary school to university classmates covered me with warm emotional support. The flowers, cards, notes, even groceries with flannel pajamas were wonderful to counter my depression. I attribute to these lovely people my recovery to return to work after six weeks.

The nagging fear of cancer recurrence stays constant. I literally and figuratively hold my breath for a low dose CT of the chest every three months awaiting the radiologist’s verdict. Negative. A sigh of relief. Another CT … Wait! What do you mean the insurance company refuses to authorize the sixth-month CT? My internist appealed the denial. I tried, equally unsuccessful. My sixth-month CT finally occurred in the seventh month. Not looking forward to the next battle with the insurance company.

An authorization for medically necessary procedures or tests is not a guarantee of payment of insurance benefits. The letter from the insurance company says that. I can undergo the tests or procedures, but surprise, it determines how much it wants to pay. I have to suck up the rest of the bill. Balance billing become more personal as a patient. It is more of a shock than a surprise. The physician part of me also gets shocked from the arbitrary low value assessment of our services. How can the typical patient pay? A secretary friend who also has suffered a bad health year answered that question. She can’t. Her paycheck barely covers essential necessities. She stopped opening the latest bills. Our health care system and insurance coverage need massive overhauls. What’s the right answer?

The practice of medicine has changed since I started in 1980. I have benefitted from my personal compassionate and competent physicians. As a physician/patient I have knowledge to protect myself from the cookbook practice of medicine and potential medical errors. Most of our patients do not. Having undergone the trials of being a patient and sharing with you my experiences, I pray that we physicians remain vigilant in protecting our patients. But first, please, get your CXR!

Wendy Kang, MD, is a clinical professor in the Department of Anesthesiology at UT Health San Antonio Long School of Medicine.