Melanoma gave me a wake-up call

His brush with cancer taught the author a lesson in being a frightened patient—and changed his approach to practicing medicine.

By Andrew Mackey, MD
Family Physician/Williamsburg, MA

My vibrating beeper read, "Call Dr. Brown." I did, and he wasn't in—but his receptionist startled me with the message he'd left: "Dr. Brown asked me to tell you that your biopsy report came back. The lesion is a melanoma." I didn't realize it at the time, but the ordeal I was about to go through would change my personal perspective and the way I practice medicine.

A cold fear washed over me as the receptionist read the report. My lesion was 1.05 mm deep. This large, irregular mole had been on my face for at least 10 years, and though I'd expressed concern on numerous occasions, my dermatologist repeatedly assured me that it wasn't a melanoma. Yet on my most recent visit, he had agreed that I should have it removed.

Stunned by the news I'd just gotten, I headed for the library to read about melanoma. I spent the remainder of the day with patients, trying to keep a lid on my anxiety. No chance. I made appointments with a surgical oncologist, a dermatologist, and a medical oncologist—all for within three weeks.

Those weeks were interminable, as my anxiety grew. A friend gave me a stack of information about melanoma from the Internet. One article quoted a cure rate of only 70 percent for a head and neck melanoma of this depth, which further fed my fears. Finally, I went to a psychiatrist for medication to relieve my anxiety and help me sleep.

Dr. Fine, the surgical oncologist, looked young for a cancer surgeon, but his demeanor was reassuring. He listened sympathetically and conducted a brief but thorough examination. He even massaged my neck and axillae to be sure I had no palpable lymph nodes. We agreed on a sentinel lymph node biopsy, along with excising the mole. He explained the procedure and then introduced me to his colleague, a plastic surgeon who would help close the large gap the excision would leave on the side of my face. Surgery would be done in 10 days.

That was a trying week and half. Everyone from family members to office staffers gave me comfort and support, but despite the reassurances I couldn't stop worrying that the cancer had spread. The day before my surgery I went for my final appointment at the clinic. A fourth-year medical student examined me, and a young dermatologist told me that the pathologist at his institute had reviewed my slides and found that my lesion was only 0.75 mm deep.

It's uncommon to perform a sentinel lymph node biopsy on a 0.75-mm lesion. Even so, the dermatologist and I agreed that because surgery was already set for the following morning, and I was still going to have an excision of the tumor site, we would proceed with the biopsy, as well. The medical oncologist said that for lesions similar to mine the cure rate is approximately 80 percent. For the first time in three weeks, I felt I was going to survive.

The next morning, my wife and I went to the hospital. I spent an hour lying on a table while a radiology fellow injected radioactive dye until he identified the sentinel node at the level of the clavicle. From there I went to the pre-op area, where I met the anesthesiologist. His smooth, competent air relaxed me. The last thing I remember is a third-year medical student starting the intravenous line. The following week I called Dr. Fine for the pathology results, now fully expecting that no melanoma had been found. I was surprised when he placed me on hold to get the report—thinking it should be easy for him to remember that the nodes were negative. That's not what he had to say, however. Although there was no residual tumor at the excision site, or melanoma in the nodes, he said, there was something else—"a small focus of well-differentiated papillary thyroid carcinoma" in one node.

At first, I wondered if there had been a mistake. But then I digested the news. Dr. Fine reassured me that this type of cancer was generally unaggressive and easy to fight. He arranged for an endocrine surgeon to see me when I came back to have the sutures removed.

Despite my dismay about the new finding, I was nevertheless happy to trade a melanoma for a less ominous thyroid cancer. The endocrine surgeon and I agreed that the only reasonable option was to remove the cancer with surgery. This time, I was not panicked. In fact, the anxiety medication sat untouched on my dresser. The surgery went smoothly, and within a couple of days I felt great.

How has this experience affected me? Foremost, the fear of dying helped awaken me to all of the wonderful aspects of my life. It also encouraged me to examine my life, especially my career, and find ways to enjoy myself more. And it made me want to focus on what's truly important to me: family and friends, laughter, relaxation, enjoying simple pleasures, traveling, and helping others. When looking at loved ones, colleagues, and patients who are struggling with chronic illness, cancer, or bereavement, I feel fortunate that my cancers haven't significantly affected my overall health or sense of well-being.

At the same time, the experience has reinvigorated my practice of medicine. I now search for ways to enjoy every day and every patient encounter. Having confronted serious illness, I now take myself less seriously, and find myself using more humor in an attempt to put patients at ease and strengthen the therapeutic alliance.

Certainly I am better able to empathize with patients, especially those who suffer from anxiety. If a patient is worried about a test result, I make every effort to get the result quickly. Furthermore, unlike Dr. Brown, when I have to report bad news, I do it in person, leaving adequate time to address any questions.

In the office, I have made some changes while simultaneously taking steps to reduce my workload. I now focus on the patient's chief complaint and place all other business, such as the overwhelming number of screenings that the health plans have thrust into the exam room, on hold to be addressed at another time. I have learned to accept that I cannot compress 30 minutes worth of work into a 15-minute slot.

In addition, before getting too far into the visit, I try to uncover any hidden patient agendas by asking, "Is there anything else you want to discuss today?" When a patient raises a new concern at the end of a visit, and I can't handle it thoroughly in the time remaining, I have become quite comfortable asking him to make another appointment. I keep my schedule free enough that anybody can arrange a visit within a few days.

I've gotten tough about phone calls, too. Unless an issue can be dealt with in five minutes or less, I want to see the patient in person. Of course there are exceptions, particularly in the area of pediatrics and when discussing adverse reactions to medications. However, I have found that most patients seem to like the fact that I'm willing to devote an office visit to their concerns.

These days, I also give myself more time to do the things that I truly enjoy in primary care, such as injecting joints, suturing lacerations, removing suspicious moles or bothersome skin tags, and diagnosing and treating a wider variety of orthopedic problems. And I no longer do circumcisions and other procedures that I don't enjoy.

For a time, I'd been thinking of a career change, possibly to administration. But I've postponed that. I've decided to see whether I can increase my enjoyment of patients and practice enough to want to stay. So far, it seems to be working.

Though the hassles of private practice continue to increase, the changes I've made have allowed me to regain a tremendous degree of control over my life, my practice, and my income. Primary care—with its long-term patient relationships, the privileged role the physician plays in patients' lives, and the vast array of clinical problems—can be the most satisfying job in medicine. Sometimes it just takes something dramatic to help one appreciate that.

 

Andrew Mackey. Melanoma gave me a wake-up call. Medical Economics 2001;20:58.