Throughout fellowship, my experiences working with patients in clinic have taught me many lessons. In particular, I’ve learned the true value of a physical exam. While working in a continuity clinic alongside my program director, who has a special interest in breast cancer, I’ve had a special opportunity to observe and learn from him the proper way to conduct a breast exam. Working with this program director has also taught me to be mindful of certain important considerations in patients with metastatic disease.

In this article, I present the case of a woman with widespread disease in the bone, lung, and colon. Initially, she was thought to have colon cancer based on imaging results. However, a simple physical breast exam revealed something very different.

Our patient is a 66-year-old woman with an unremarkable past medical history. In fact, this patient reported no history of ever being seen by any healthcare provider. She presented to the emergency department with worsening neck pain and right-sided chest pain, which had been bothering her for weeks. She denied symptoms of weakness, tingling, numbness, and urinary or fecal incontinence. When she was seen by our team, her initial physical exam was normal.

Upon meeting with this patient, our team ordered a CT scan of her neck. Results revealed multiple lytic lesions, with C5 cord compression. Because these findings raised suspicion of malignancy, a CT scan of the patient’s chest and abdomen was conducted as well. Results of the second scan revealed diffuse osseous metastatic disease. Extraosseous soft-tissue components were noted at numerous levels in the cervical, thoracic, and lumbar areas of her back. The scan further revealed several bilateral pulmonary nodules with mediastinal adenopathy and indeterminate mural-based soft tissue that involved a short segment of the ascending colon. An MRI scan of the woman’s spine also revealed diffuse osseous metastatic disease throughout her spine, with cord compression at C5 and epidural disease at L1 and L2.

In light of this information, an oncology service at an outside hospital was consulted. The patient’s physical examination, which included a neurological exam, was normal. It was after this that she received a recommendation to be transferred to our facility for a neurosurgical and radiation oncology evaluation, as metastatic colon cancer had been suggested as a diagnosis based on imaging results. She was transferred to our hospital and examined by the neurosurgery service, who (since she had no neurological deficit), preferred to wait to make a treatment decision until receiving an actual tissue diagnosis. However, she was started on high-dose steroids and our service was consulted.

When I reviewed her chart, I really did not feel that this patient had metastatic colon cancer. I considered her amount of bone disease and her intact liver. I also considered the basic principles of medicine and noticed that despite being seen by several doctors, not one had performed a simple breast exam. After getting up to speed on this patient’s medical history, I asked her if she had noticed any changes in her breasts or other symptoms, such as discharge. She said she had felt something in her right breast 8 months earlier that she thought was a painless cyst and showed no concern about it.

I conducted my own physical exam and, as it turned out, she had a 5-cm mass in the middle of her right breast. The mass was firm and nontender to palpation. The patient had nipple inversion, but no signs of rash or erythema. Her axillary exam was normal. This right-breast mass was not previously detected during any of this woman’s imaging scans.

The results of an ultrasound-guided biopsy of her right breast were consistent with estrogen-receptor/progesterone-receptor—positive and human epidermal growth factor receptor 2–negative invasive ductal carcinoma. Neurosurgery deferred surgery, and radiation oncology started treating her C5 disease since there was no neurological defect.

I communicated these findings to the initial oncologist who had seen this woman, and he was very appreciative of my attentiveness and willingness to dig deeper into this patient’s case. He explained to me that, “We, as oncologists, sometimes forget to do a breast physical exam because of all of the imaging technology available. But this patient serves as an excellent example of why it is important to conduct a complete physical exam, especially during an initial patient encounter.”

Cases such as this one highlight an important principle in oncology. We frequently talk about pathology and imaging results, but we rarely talk about physical exam findings, even in tumor boards. This case clearly demonstrates the importance of the physical examination in oncology, as it can play a huge role in a patient’s diagnosis and treatment.

Articles

Throughout fellowship, my experiences working with patients in clinic have taught me many lessons.

Do We Still Need Physical Exams in the Era of Advanced Imaging Technologies?

It is 4:45 AM on a Saturday in June. My alarm has just gone off. Additional sleep threatens to pull me under again as I grope for the snooze button. “Just 5 more minutes,” I beg. Ten minutes and 2 alarms later, I finally pull myself from my bed. I throw on a pair of scrubs, down a cup of coffee, and rush to the hospital to start my morning rounds.

I only have 3 short teams to round on this morning and, I am ashamed to admit this, I am eager to “get them over with.” It is a feeling I regret, but it is also, unfortunately, shared among many of my colleagues.

Many recent articles and forums have described the unhappiness and feelings of burnout among current physicians. The never-ending paperwork, increasing regulation, and enforcement of ill-advised quality-assessment measures detract from actual patient care. The practice of medicine now resembles something very different from what we initially envisioned it to be when we were bright-eyed, eager medical students.

Complicating my feelings even further is the fact that patience has never been my strong suit. Rather, I’d consider patience as my eternal weakness. I often explain this challenge to others during self-evaluations and interviews. I walk fast, I talk fast, and I even eat fast. As a general surgery resident, I have little time for inefficiency.

My plan on this Saturday morning is to proceed quickly—move in, move out&mdash;so that I can return home quickly to enjoy my Saturday … and maybe take a nap. However, my plans are soon thwarted by a late and unprepared intern. It is clear that he has not read up on our patients, which creates more work for me. My mood immediately turns sour.

I rush through visits with my first 2 patients in the Intensive Care Unit as the intern trails behind. Things are running smoothly, and as we head upstairs to see our floor patients, I feel as though everything is back on track. Then, we reach our next patient. She is in her 40s and has just undergone a bilateral mastectomy with reconstruction, having recently been diagnosed with early-stage breast cancer. She is visibly anxious and upset this morning. Despite my attempts to reassure her that everything is going well, she bursts into tears. I hold her hand and reassure her that it is okay to cry and momentarily feel fear, and even pity. I stop and instantly forget about the other 20 patients on my list. I forget my desire to round quickly. Instead, I take the time to focus and listen to this woman as she opens up to me about her concerns and fears. It takes a little while, but she eventually relaxes a bit, her tears dry up, and I am able to move on.

My next patient, who has metastatic colon cancer, is an amazing woman. She is in her mid-40s and has the support of a husband and 2 children. She is about to undergo her fifth operation in less than 3 years. I enter this patient’s room and note that although it is just 6:30 AM, somehow she is perky and full of energy as she relaxes in her green, plaid pajamas. She immediately asks me how I am doing and tells me that she feels bad that I have to work this weekend. She is amazing. Again, I instantly stop rushing around and forget about my list of patients and the passing time. We talk about the milkshake her brother may bring for her from the ice cream shop down the street. We talk about her son’s cello recital scheduled for later this afternoon that she likely won’t attend. And we talk about the 2 miles in laps around the hospital floor she’ll walk by the end of the day. I tell you—she’s amazing! I don’t want to leave this patient, but when I do, I leave with a smile on my face and tears in my eyes, in awe of her resilience.

I quickly continue on to visit with my next patient who is a similar ball of energy. He has been doing barre exercises in the hallways using the side railing for support, although he has 5 liters of stoma output every day after extensive surgery for metastatic colorectal cancer. He has even been teaching the nurses how to do the exercises! As I enter his room, he beats me to the punch and asks me about my day. We begin to talk and once again, I relax a bit. This trend of rushing to the next patient, then relaxing, continues until my rounds are finished. Then it is time to run down the list with the attending and go home. As I finish on this Saturday morning, I reflect back and realize that I’ve gained more from my interactions than my patients have. My experiences this morning have helped to teach me to slow down and listen. For me, this is part of overcoming burnout and exhaustion. Connecting to patients is one of the things that initially attracted me to medicine and, specifically, surgical oncology.

Every patient has a story and a journey, which often get lost in the mundane ritual of charting and checking off boxes on my to-do list. My patients and these visits have given me a different perspective. “How can I feel tired and rushed when these patients are so positive and thoughtful in the face of such adversity?” I try and hold on to this memory so that I’ll continue to stop and listen. Maybe I’ll finally learn some patience after all.

Patients Are a Virtue

There is no such thing as a typical day for a breast surgical oncologist. Every day is different because each patient is unique—with her own disease, beliefs, fears, and hopes. Each patient has her own story.

It’s easy for us to become overwhelmed by the complexities of caring for our patients. Working every day with women who have cancer can be a challenge, but also a non-negligible privilege. Since I began my breast surgical oncology fellowship, many of my friends and relatives have questioned my abilities to handle the various associated roles and responsibilities. Many of them told me that they would never have the strength and would be too affected to pursue this type of medical practice. It is true that surgical oncology is not an easy profession. It is a tremendously demanding job that often makes one feel as though they are on an emotional roller coaster; but on the other hand, it is a job that is life-changing and abundantly rewarding.

How do we cope with the pressures we face daily at work? How do we help our patients through this journey they have been thrown into unwillingly? Throughout residency and thus far in fellowship, I’ve had opportunities to learn how to manage so many different roles from incredible staff members and my patients.

Courage is defined as the choice and willingness to confront fear, pain, danger, or uncertainty. Courage sits in your clinic every day. It resides in the lovely lady you are faced with telling that she will have to receive chemotherapy and thus lose all of her hair. It lives in the young mother, who, while you are explaining to her the uncertainties of her future, smiles back and tells you she will do everything possible to achieve cure. Or in this sweet lady with hair white as snow who is learning that she will have to be put to sleep and have her left breast removed. Our patients are great examples of courage, determination, and perseverance. They are strong fighters, ready to give all they have in the battle against their cancer. Yes, it is sometimes really hard to see your patients suffering or not doing well, but we also use treatments that help lead to cure in many patients.

During residency, I had the opportunity to pursue elective rotations at some of the best cancer centers in Canada. I met one of the most inspiring surgeons I have encountered thus far at one of these centers. On top of all of the medical knowledge he provided, he taught me some of the most powerful life lessons so far in my career.

Oncology is always evolving, with new concepts and new data frequently emerging. For this reason, patient care has to be adaptable to the new information. Our job necessitates a constant learning process, where we must incorporate the most recent studies and developments into the day-to-day care we provide. It requires passion and the ability to think outside the box, always in the best interest of our patients.

I will never forget the discussion we had on day 1 in the ward after leaving the room of a patient with a peritoneal carcinomatosis. “Give them hope.’’ Despite the stress and demands of our job, I have learned an important key to success: “Always put your heart to the patients you are taking care of.” And always instill hope in them. Facing cancer brings misunderstandings and can lead patients to feel helpless. Remind them that there are better days coming. If we lose hope, they lose hope, and then we all lose the battle.

We are very lucky to play our parts in our patients’ treatments. Let us not underestimate this. When you have a 53-year-old patient entering the operating room for her mastectomy and you realize she is frightened by the unknown, hold her hand silently because she needs comfort. Give her hope. When your 43-year-old metastatic patient, who has 3 young children at home, comes to you with disease progression, be courageous and transparent to her because that is what she wants and needs. Give her hope and remind her that you and the team are there to take care of her. She needs support, and this is where your multidisciplinary team comes in. Always remind your patient that she is not alone and yourself that you are not alone in taking care of her. Help your patient and her family to face the illness. Relieve their suffering, and listen to them. And when your lovely 65-year-old patient comes into your office for her follow-up 5 years after the completion of her surgery and chemotherapy, celebrate with her that she is disease-free. She has hope.

Unfortunately, doctors and medicine have limits. When those limits are reached, we feel like we have failed. We feel powerless and useless. Discussing those feelings of failure is often taboo in the medical profession. If we experience these feelings, we have to remind ourselves to seek help and advice, however. Talking to a colleague or our family is important.

Being a breast surgical oncology fellow offers me the privilege to help so many women. Treating patients every day has helped me realize how fragile and precious life is. One out of every 9 women will have breast cancer; breast cancer affects all women, young and old, rich and poor. Our physical health cannot be taken for granted, so let’s embrace life!

I may be helping women to change the course of their disease daily, but at the end of the day, the one who has changed the most is me.

There is no such thing as a typical day for a breast surgical oncologist.

December 2016 | Oncology Fellows

Do We Still Need Physical Exams in the Era of Advanced Imaging Technologies?

Patients Are a Virtue

Those Women Who Changed My Life: Lessons Learned During a Surgical Oncology Fellowship