Reflections in a Head Mirror

I don't know what your destiny will be, but one thing I do know: the only ones among you who will be really happy are those who have sought and found how to serve.

- Albert Schweitzer


The middle-aged Tanzanian woman lived many hours away and had traveled to the academic medical center in Moshi. She had now waited all day to see the doctor. He would tell her why the neck mass was growing and if there was any treatment.

My host is a teacher at the Kilimanjaro Christian Medical Centre and the only fully trained otolaryngologist in Northern Tanzania. He is one of only six ENT physicians practicing in a country of 40 million people. He described her predicament. “She has had a growing neck mass for about one year,” he told me. “Look here! There is also a mass in her tongue. That is the source of the neck mass, don’t you agree?” I peered over his shoulder as he focused the dim light from his head mirror in the back of her throat. They had taken a piece of the neck mass out at some point and I pointed out the scar in her neck. “Oh, the report from the biopsy shows that the mass is a cancer but the description is unclear. We don’t have a pathologist here very often.”

I looked at the two-sentence pathology report that described a type of cancer that made little sense. Clearly, though, despite the fact that her diagnosis had been made in a way that was not consistent with our standard of care and the fact that I doubted the diagnosis on the pathology report, she had an advanced Stage IV cancer of the throat. Today, she would learn her diagnosis for the first time.

The Tanzanian doctor finished up his brief examination and then spent five minutes discussing her diagnosis and options in Kiswahili. I am quite certain that he shared that her cancer was best treated with radiation therapy.

I watched as they talked. Back home, she would be seen immediately by a medical oncologist and radiation oncologist and be scheduled for treatment. In Tanzania, though, the only radiation therapy was located in Dar es Salaam, 350 difficult miles away. Chemotherapy is rarely available. In addition to the difficulty getting to treatment, most Tanzanians must pay at least 50 percent of the cost of any medical care. As a result, most people put off seeing a doctor for as long as possible and most cancers present very advanced.

The discussion between the Tanzanian doctor and the patient was remarkably brief and I surmised that the doctor told her that she had cancer and that the only option for treatment would be both far away and expensive. She smiled weakly and spent a few moments shaking our hands (“Asante sana, Doctor”), and then left. The doctor jotted a few notes in her chart.

“What did she say?” I asked. “What will happen next?”

“Oh, she is lucky,” the doctor responded. “She has family near Dar es Salaam so she will have a place to stay during treatment. In addition, her family has some cows. They will sell two cows and she should be able to pay for some treatment. Still, without the cows, they might have trouble in the future.”

I had a hundred questions, but did not know where to start. No matter. We were late and it was time to visit the inpatient ward where we would soon find many more patients with very difficult problems, grinding poverty, and no easy solutions.

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The following is feedback received for this blog: Wow. 40 million people and only 6 ENT's. In honor of your work there a donation has been sent to KCMC. It is not much but perhaps it will help in some small way to those not as fortunate. May God continue to guide your hands and bring comfort to those in need. - anonymous

No great artist ever sees things as they are. If he did, he would cease to be an artist.
-Oscar Wilde  


The physical exam of the head and neck is both simple and challenging. Simple, in that even children are familiar with the shape of the face, the sheen of the eye, the curve of the ear, and the texture of the tongue. Challenging, because when complicated, interlacing structures malfunction, they send mixed and subtle messages.

Last month, over 200 second-year medical students descended on the ENT clinic for an afternoon. We supplied lights, ear specula and tongue depressors. They supplied the energy and curiosity as they practiced peeking in each other’s ears and throats. Some brought along their brand new $400 otoscopes. Most will never spend another minute working with me or my colleagues to learn the head and neck examination.

Is the physical exam even important anymore?

A recent story on National Public Radio confirms that some physicians skip the physical exam because they find that the quick 15 minutes allotted to an office visit is better spent engaged in conversation and reviewing test results. They also acknowledge that some of the parts of the examination are so difficult and subjective that an expensive test (for example, a $600 echocardiogram) might be more reliable than using a stethoscope to diagnose a murmur or extra sound.

The modern, technology-savvy doctors are probably correct, but, when it comes to a decent physical exam, I am painfully old-fashioned. I really enjoy the process of discovery that the exam provides by melding physical findings with the patient’s story to arrive at a diagnosis. It is far from a perfect science, but it is important work at which we can only improve with practice. The "laying on of hands" remains a big part of what I do in the office.

A friend of mine told me about returning to see a doctor that was caring for her broken ankle. "I saw the physician three times and he never actually touched my leg! My ankle healed up just fine, but it seemed odd that he examined me only by looking at my X-rays. Is that typical?"

I do not know what is typical anymore.

During my training, we flocked to learn from the gifted diagnosticians — the curious, thorough, patient, and perceptive teachers who could use their hands, ears and sense of smell to arrive at an obscure diagnosis. Even as technology pushes to every corner of Medicine, I am hopeful that we will always have those master clinicians among us.

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The following is feedback received for this blog: Nice Blog!!! Thanks For Great Information . - suvarna bhagwat I recently saw a surgeon about my torn rotator cuff. He asked all sorts of questions, and I pointed out that I had had an MRI. He replied that looking at the MRI first was cheating. Sounded right to me. - Bruce Small http://brucesmallsurveys.typepad.com/

Inside every patient, there’s a poet trying to get out. My ideal doctor would ‘read’ my poetry. my literature.
– Anatole Broyard


"When did you first notice the sore?" I ask the newly diagnosed cancer patient. I was taught in medical school that a thorough history includes information on the "duration of symptoms." Over the years, I have been amazed how often the answer is: "Doc, I first noticed something about six weeks ago." Whether the cancer appeared large or small, completely confined or widely metastatic, barely symptomatic or agonizingly painful, the answer was frequently "six weeks."

Early in my career, I didn’t believe the "six weeks" response from patients with advanced disease, although it made sense when coming from patients with small cancers. However, after I noticed that the response was so common, I began to wonder why. Certainly, cancers can grow at different rates. Not every cancer behaves the same. Still, though, I suspected that denial was delaying evaluation and cancer care.
 
Danielle Ofri, MD, in her wonderful book of medical essays, Singular Intimacies: Becoming a Doctor at Bellevue (Beacon Press, Boston, 2003), tells the story of a prominent psychoanalyst with an unnamed cancer. Over the course of several months, the disease ravages his body and destroys his liver. Even with obvious signs of malignancy, he steadfastly refuses to admit even the possibility that he might have cancer. He is confident that he has a viral infection that will soon resolve. No need for a biopsy! No one can convince him otherwise.

Eventually, he becomes so debilitated that he has to be admitted, very reluctantly, to the hospital where he dies of the cancer and, perhaps, some of the zealous attempts to make a diagnosis. Suddenly, Dr. Ofri realizes that this intelligent psychiatrist had shrewdly used denial to his advantage. He had maintained control for as long as he possibly could. He had delayed the inevitable hospitalization and medical interventions until he was finally completely unable to resist.

There are a host of reasons that people deny things that seem perfectly obvious to others. Perhaps the person has a debilitating fear of medical care, a lack of insight, legitimate concerns about devastating medical costs, or a strongly held system of alternative beliefs.

Until reading Dr. Ofri’s story, though, I had not understood how powerfully denial could also allow the patient to maintain a sense of control over their situation for as long as possible.

For some, the decision to relinquish that control marks the end of denial. They finally admit that their symptoms — the pain, the mass, the bleeding — might represent something bad. They realize that it is time to reach out for help even if they would rather not. Now, six weeks later, they sit unhappily in my office getting ready to find out if their symptoms represent the very thing that they dread the most.

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The following is feedback received for this blog: having worked in ICU for 32 years, denial is huge. It is a good and bad thing. When an alcoholic denies, we know that ruins his life and others around him/her. Denial does keep people from seeking help sooner, probably based in repressed fear and hope that "it will go away". It also does keep people in control and able to function, fight or carry on in difficult situations. - Cheryl Scheuerman