Comfort Zone

Chapter 55

The afternoon started with a patient bearing a newspaper article her friend had given her from the New York Times about the controversies of mammograms.

"Dr. Gotlin, I'm fifty-one, due for a mammogram, but now I'm not sure I should have one this year, or ever! I'm fifty-one. This article says getting one might hurt me more than help me. What should I do?

Miriam smiled, her ethical and statistical training fresh in her mind. This decision wasn't a slam dunk. There were evidence-based guidelines, true, but there was also controversy about them, and they couldn't be rigidly applied anyway. In this situation, the guidelines were to be mixed with shared decision making. Together they made for a perfect system. She would educate without influencing and her patient would decide, based on her own values and preferences.

"Ms. Kozin, years ago your doctor would have told you what to do, but now we give you the facts and help you make a decision, because only you know what's right for you.

"Let me help you make an informed decision. Let's go over the numbers, the information from the study this article is talking about. And keep in mind it's just one study; a new one may come out that draws other conclusions."

Miriam brought up the statistics on her screen.

"One thousand women underwent yearly mammograms for ten years. This prevented up to three women from dying from breast cancer, but about half of the women had a false positive, and about ten were over-diagnosed, leading to unnecessary treatment for cancer that didn't need to be treated, so finding it early didn't prolong their lives." She explained what a false positive was, and even managed to wedge in the concept of the positive predictive value of the mammogram.

"Let me see if I understand," her patient said slowly. "Because of something called the positive predictive value, if I have a mammogram and it's positive, it's most likely false and I don't have cancer. But I'll go through the initial worry of the positive test, and maybe undergo further tests like a biopsy."

"Right."

"Or I might have a cancer that never needed treatment, and I might be harmed by the treatment."

"Right again."

"Or I might have cancer that's found early, but finding it won't make me live longer."

"Exactly."

"But I might be one of the three women whose lives are saved by the screening. And there's no way to know which woman I am."

Miriam knew she didn't need to answer.

"And another medical study might come out disproving this one."

There was silence. Miriam felt proud of herself for taking the time to educate her patient, and even more impressed with her patient's grasp of the situation.

"What do most women do?" Ms. Kozin finally asked.

"It depends. Some people can live with uncertainty. For them, waiting to see if they develop a problem is preferable to undergoing a slew of tests. Others can't bear not knowing, and are willing to go through anything for a definite answer of whether or not they have cancer. It depends what type of person you are."

A few seconds elapsed before Ms. Kozin answered.

"But I don't know which type of person I am!"

And then, there it was.

The Question.

"Oh doctor, what would you do?"

Miriam felt a flutter of panic at the perfect visit gone bad. She forced herself to look into her patient's pleading eyes. It was messy. Ethically and medically messy.