Take My Time…Please

"There is nothing so easy to learn as experience and nothing so hard to apply."
-- Josh Billings

A long-term cancer survivor returns for a regularly scheduled follow-up visit. These routine appointments usually focus on problem solving. It is quickly apparent, however, that she is in significant pain and has lost weight.

"How long have you had this lump in your neck?" I ask.

"It appeared a month after my last visit and has been growing ever since. It hurts."

My heart sinks and I fear that an opportunity might have been lost. We will order scans and probably schedule surgery. The visit takes on a new sense of urgency. Why hadn't she called for an appointment when she first noticed the mass? She shrugs. "I'm not sure."

A recent study confirms that this scenario is all too common. A team of head and neck cancer specialists at Ohio State University collected information on 3,600 follow-up clinic encounters and found that a new or recurrent cancer was identified at 5% of the visits. Almost all of the patients with cancer already knew something was wrong before the visit; physicians rarely found non-symptomatic cancers.

Oddly, the confirmation of the cancer usually occurred at a regularly scheduled visit. Symptomatic patients rarely called to schedule an earlier appointment. (Agrawal A, Laryngoscope Feb 2004; 114:232) This suggests that the "routine" check-up might not be the best way to provide cancer surveillance for survivors. In any case, it appears that we haven't found simple and non-threatening ways for patients to return as soon as they are alerted to a problem.

Why don't worried patients with symptoms call immediately for an appointment? There are lots of reasons, I suspect. In my experience, worried patients usually apologize for "taking up my time" after I tell them everything is fine. I, on the other hand, am relieved when the symptom has a benign, treatable explanation. I reassure them, set up another visit, take a breath, and knock on the next door.

Bruce H. Campbell, MD, FACS
Professor of Otolaryngology and Communication Sciences
Chief, Division of Head and Neck Oncology
Interim Director, Froedtert & The Medical College of Wisconsin Cancer Center

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.