Too risky to remain silent

Regular Wizbang readers know I’m a melanoma survivor and am fighting stage IV disease at present. Today one of the subcribers to the Mel-l mailiing list sent out an article from the NY Times. It was about a physician who sees a woman at a book shop who isn’t their patient but thinks they may have one of the deadly skin cancers. Should the doctor bring it to their attention? The article is below the fold but I’ll relate a personal experience of mine.

For two years in the 1990’s I worked part-time for Wally world. A clerk in the electronics dept had a large mole on his neck. One day I said hi and mentioned I saw the mole and that I was a skin cancer survivor.

“Did you ever have it checked by a doctor?” I asked.

“Yes, it was fine.” The clerk said or something like that.

If you think someone is sick or has cancer, what’s the harm in telling them your concern? A cancer diagnosis is scary, and no one wants to hear it. I remember my first diagnosis in 1993 vividly still to this date, as I do with the news I received late last year and early this year that I first had a recurrence and then was told it had been spread.

If you say nothing and it is cancer, the man or woman may not get treated till too late. This isn’t some when growing up when we’d snicker at some kid’s fashion mistake. Here’s the story of a young man who died from melanoma barely a month after his HS graduation. I prefer to speak up. No one wants to see more Joel Harmons. God bless the melanoma warriors.

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It was bigger than a pencil eraser and irregular in shape. That put the odds against her. But it had smooth edges; that was in her favor. From four seats away, in the diffuse light of the bookshop, it looked black. But I couldn’t be sure.

I wanted to be concentrating on the fledgling poet who was courageously reading aloud. But the poetry faded into the backdrop of my internal debate. The mole on the left shin of that woman in my row: was it a malignant melanoma?

She was perhaps 45 years old and wearing pedal pushers. When her right leg was crossed over her left, the mole was obscured; I was free to listen. When she rearranged herself, crossing her left over her right, I was thrown into conflict.

Should I say something to her in spite of my uncertainty? It felt like arrogance to intrude into the life of this stranger. I imagined myself, a doctor-bull barging into her china shop, shattering her peace of mind. Or was that the overempathic psychiatrist in me speaking?

It is common medical knowledge that if a melanoma is discovered while still very thin, it can be surgically removed and the patient cured. But left to grow to the thickness of just three stacked CDs, it is the deadliest of skin cancers — indeed, one of the deadliest of all cancers. If this mole was really a melanoma, how could I keep silent?

Doctors are trained to be observant. During my psychiatric residency we performed five-minute interviews as a learning exercise. What could one discover in five minutes? Quite a lot. Patients tell their life stories through nuances of tone and cadence, flashes of suspicion in the eyes, postures of arrogance, shame or pain. Now, even from a distance, clues leap out at me unbidden.

A doctor is often in the position of perceiving evidence of medical or psychiatric disease in an unsuspecting patient. But clues are always shadowed by uncertainty. How sure is the diagnosis? How grave? Is there a cure? A treatment? Would the person want to know?

The regret of another physician (a former patient) crossed my mind. It had been obvious to her that a hospital receptionist had a thyroid disorder; she had assumed that the woman was being treated. Countless physicians had passed this woman at the information desk until one day it was whispered around the hospital that one of their own had shown up in the emergency room. There the receptionist received the help she needed, but only after her condition had led to a medical crisis.

Why not risk some awkwardness to alert the woman down my aisle? What would be the harm in speaking up?

There’s defensive anger, for one. At a reunion with his old college roommate, Dr. Robert Marion, a clinical geneticist, realized that the roommate’s daughter probably had a rare inherited syndrome. His article in The American Journal of Medical Genetics in 1996 describes what happened when he decided to tell. The friend was not grateful and “nearly shouted” at him, “You spend a couple of minutes with my kid and you think you know more than the doctor who’s been seeing her since she was a newborn.”

Beyond the pain of hearing that one might have a serious disease (with visible pathology, no less), I knew that other harm could follow: terror, sleepless nights, doctors’ visits, costly and even painful medical workups that, in the end, might turn up nothing.

A century-old autobiography articulated the value of restraint. Dr. Leonard Mark had been crossing Cavendish Square in London when it came to him that he had acromegaly, a disorder in which a tumor leads to excess growth hormone and gradual changes in physical appearance. Soon he learned that his colleagues and his own physician had been aware of this for some time. Though initially resentful, his feelings turned to gratitude. Their silence had allowed him extra years of believing he was a healthy man. Acromegaly was untreatable in 1905; but this was 2007.

The poetry reading ended. When she stood up, the woman’s pant leg covered that spot on her shin. There was applause, and then, during the chitchat that followed, someone introduced me to the woman with the mole.

I apologized in advance for being intrusive and said that as a physician, I was concerned about the mole on her shin. Conveying only the barest of information, she related that a dermatologist had thought her mole was benign.

She thanked me for my concern and moved on quickly. The five-minute interviews had taught me to be aware of the contradictory message in her abrupt departure. I felt awkward, bumbling. I had embarrassed her. My diagnosis had probably been wrong. Even so, it had been too risky to keep silent.

Barbara Schildkrout is a psychiatrist in Boston.

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