Indexing Title:

RJOSON’s Medical Anecdotal Report [05-4]

 MAR Title:

How to deal with patients who prefer outright radical treatment

 Date of Medical Observation: May 21, 2005

 Narration:

 A 45-year-old female previous patient of mine came to my clinic with a recurrent right breast mass.  She had three previous operations on her right breast and one on her left.  All the three operations (excisions) on her right breast showed benign mastopathy, specifically, fibroadenomas.  The operation on her left breast which was a wide excision done a year ago showed medullary carcinoma.  There was no palpable left breast mass at this time of the examination.

 What struck me was her initial statement right after she entered my clinic.  “Doc, please remove my entire right breast already so that there will not be any recurrence anymore.”   At the end of her visit, I was able to convince her to undergo a needle biopsy first for on my physical examination, the mass could still be benign.  If the mass turns out to be malignant, then I will do the total mastectomy.

 Insights (Discovery, Stimulus, REINFORCEMENT) / (Physical, PSYCHOSOCIAL, ETHICAL):

 I have encountered a few patients in the past who would rather have an operation rather than a repeat aspiration of macrocysts and who would rather have a total mastectomy rather than a repeat excision of what I think is a benign breast mass. Fortunately, the number of such patients is small.  However, the challenge exists on how to advice and how to convince them of the non-necessity of the more radical procedure.  Up to now, I have successfully held my ground and follow the rational and indicated processes of patient management as well as the dictate of my conscience.  I usually document my advices to them particularly specifying the degree of certainty and bases of my clinical diagnosis, the indications and need for a paraclinical diagnostic procedure, and why I think a radical approach should not be done.  The documented advices would turn out to be either an informed consent or informed refusal.  There are patients who subsequently don’t come back to me.  They most probably have consulted other physicians, which I don’t mind.