I once had a patient in whom I found a small breast lump. She was only thirty-two, and the lump was soft, non-tender, and mobile. But it was new. She examined her breasts monthly and was definitive that she hadn't felt it the month before. And she had a family history of breast cancer.
So, I asked myself, what to do? Her age—as well as the lump's characteristics on exam—made the likelihood that it was cancer quite low. She had a lot of fibrocystic changes in her breasts (meaning they were lumpy to start with), and this was most likely a benign lump that had enlarged from a smaller one that had been present before but that had simply gone noticed in a field of lumps. But the family history of breast cancer was in a first degree relative.
I was midway through my deliberations about how to proceed when I realized I'd failed to include her in the dialogue I was having with myself. Which made me think about how often doctors fail not only to make their reasoning transparent to patients but also to reason at all. Often, doctors, like everyone else, work out of habit. If you go to a surgeon, for example, you're far more likely to end up having surgery than if you go first to an internist simply because—to state the obvious—surgeons perform surgery. What's not obvious, however, is how easy it is for doctors to offer what lies in their own armametarium without bothering to ask themselves if they should. You have a cough? Fine, take these antibiotics. You have a lump? Great, let's take it out. But these answers aren't always correct.
Luckily, patients have a recourse. They can force their doctors to reason through problems by asking them questions. Here, then, are five questions every patient should ask when a doctor offers them a treatment of any kind:
And most breast lumps turn out to be benign. But though my patient lacked most of the risk factors that would have made me suspect her lump was malignant (i.e., it wasn't firm, fixed, or large), she did have that family history. So I raised and answered the five questions above for her, and we discussed the answers. And she decided to have the biopsy. And it was, in fact, benign. Unfortunately, she developed a rare complication from the biopsy, an infection. Which we treated with antibiotics. Which she turned out to be allergic to. In the end she was fine, but she ended up illustrating the very point I made to her: outcomes are often in doubt and which course is best is often difficult to say. If you have a suboptimal outcome from a treatment, at least if you and your doctor thought through all the risks and benefits you can content yourself you made the best decision with the data you had available at the time.
Check out Dr. Lickerman's book, The Undefeated Mind, which will be published in late 2012.