By Linda Wong, MD
I looked at the next patient on my schedule and saw: “Reason for referral: Evaluate for adrenalectomy.”
In the next several minutes, visions of pheochromocytomas and aldosteronomas danced through my head. I thought about all of those algorithms about how to work up an incidental adrenal mass. It had been awhile, but I still remembered something about the urine metanephrines, aldosterone, plasma renin tests and dexamethasone suppression tests. I Googled some things to refresh my memory: The American Associations of Clinical Endocrinologists and Endocrine Surgeons (AACE/AAES) had specific guidelines for this.
I read through her chart, and the MRI report mentioned “a 2.3-cm left adrenal mass of indeterminate characteristics.” Her primary care physician was concerned and thus requested a surgical consult.
So I walked in the room and saw that the patient was in a wheelchair. She was in her late 70s and underwent a recent hip surgery because she had fallen while trying to feed the birds. She lived in a care home, had no relatives and had become a ward of the state. She had an MRI because a very meticulous internist was doing a follow-up of a subcentimeter pancreatic cyst. She had a myriad of medical problems, including a previous breast cancer, but she smiled pleasantly and had not a single complaint. She could not remember many details, and her caregivers took care of everything.
The internist wanted a surgical consult and a workup.
The radiologist conclusion read “needs additional imaging,” “needs clinical correlation” and “needs imaging follow-up.”
I hunted down some old records and found an ultrasound report from six years before that also incidentally mentioned a 2.2-cm left adrenal mass. This meant that this mass had grown 0.1 cm in six years. What were the odds that this was anything malignant? What were the odds that this was something functional when she had normal blood pressure, took no antihypertensives and had normal electrolytes? Would I ever take this frail woman with mild dementia, among other problems, for an adrenalectomy? Wasn’t she more likely to die from something other than this adrenal tumor?
On the other hand, I would be defying the internist’s wishes. I would be ignoring the radiologist’s recommendations. I would be going against all the guidelines for AACE/AAES and all the algorithms from textbooks still burnt into my brain. Is that internist ever going to send me another patient? Am I going to miss something because I did not follow the guidelines? How was I going to explain to a lawyer one day that my medical management here defied all known guidelines, algorithms, recommendations and requests? I just went with a whole new paradigm: common sense.
After interviewing the patient and caregiver and checking her from head to toe, I smiled back at her and said, “Be careful when you feed the birds now.” I did nothing and sent her back to the care home. I tried to explain the situation to her caregiver, who seemed uninterested, and I wrote up her consultation note.
Medicine gets more complicated every day. There are guidelines for the management of everything, which generally involves laboratory studies and imaging with increasingly expensive and sophisticated, but sometimes obscure, testing. Then there are recommendations by radiologists for the continued imaging follow-up of anything greater than 1 mm, no matter how asymptomatic and incidental until the end of time or death do us part.
Looming behind all of this are the threats of lawsuits for not following all these algorithms and meeting the elusive “standard of care.” The continued follow-up of some of these small things has sometimes created neurotic, cancerophobic patients who have increasingly come into the office saying, “Please take out my 3-mm gallbladder polyp because it might become cancer one day.” “What if my 2-mm thyroid nodule is really a small cancer? Shouldn’t we take it out now?” And, “can we get an MRI of my 1.0-cm pancreatic cyst every month just in case it grows bigger?”
I find myself saying to patients, “If I took out everything in your body that might become cancer one day, you would just have hair and teeth left, and they’d probably fall out.”
So, sometimes we need to put down all the guidelines, the apps, WebMD, MD Consult, Medscape and Wikipedia; gather up all of our courage; and make some real-life decisions. Maybe a Karnofsky score, a performance score or a frailty index can help you decide what to do, but in the end, no robot, computer website or scoring system will be able to give the full picture of the human condition of one particular patient. Once in a while, we just need some common sense.
There’s no app for that.