Today Mrs. Bryan (not her real name) came in for the results of her biopsy. The results were a little surprising to me. I had thought she was going to have a run-of-the-mill skin cancer, but the pathologist called me on the phone to say it looked like she had a rare kind of lymphoma, or cancer of the white blood cells, that presents in the skin. I had to get repeat biopsies with larger tissue samples to nail down the diagnosis, but before I did that, I had to explain to Mrs. Bryan what these results might mean.
This was not an easy task. Mrs. Bryan is country with a “k,” as we say down here. She actually has a beehive hairdo, and she was wearing a bandanna print shirt and orange polyester pants with piping down the front of the legs. She’s the kind of person who’s prone to saying, “Oooh-eee,” as she hoists herself up onto the examining table. She insisted that the rash on her skin is poison ivy. When I told her I was concerned that it might be something more serious, she said, “Sugar, I know I was out in the yard pulling some vines. If this isn’t poison ivy, I don’t know what is.”
I had to tell her that many things look like poison ivy, but if this were poison ivy, it should be better already. She held out her arms, “It is getting better,” she said. In fact, it was unchanged from when I saw her 10 days ago.
“We just need to do more two more little biopsies,” I said, “so I can be sure what’s going on here. I can’t make it better until I know what you’ve got.”
“But it isn’t skin cancer?” she asked.
I said, “It’s a kind of skin cancer, not the one I thought it was. It’s not the kind you just cut out and stitch up.”
In truth, if she does have this form of lymphoma, it’s likely to smolder on for decades. She’s in her 70s and will probably die from something else, but I need to do a thorough evaluation to make sure it’s still in the early stages. If it’s more advanced, she’ll need chemotherapy or radiation.
“Well, am I going to die?” she asked me.
“If this is cancer, it’s not an aggressive form.” She looked at me blankly.
“People who have this cancer in the early stages have the same expected lifespan as people who don’t have the cancer.”
Blank.
Finally, I said, “If it is this cancer, it probably won’t give you a problem for another 20 years, so if you make it to your 90s, I think we’ll both be happy.”
“Well, I don’t want any more biopsies,” she said.
I told her they wouldn’t hurt. Biopsies of the skin really are less painful than having blood drawn. “Ooooh-eee,” she sighed. She smoothed her hands over her pants and shrugged. “I just don’t see what all this fuss is about when it’s clear I have poison ivy.”
I shook my head, “Mrs. Bryan, you do not have poison ivy.”
“Sure looks like it,” she said.
She finally agreed to the biopsies, and she did concede that it was not painful. My nurse explained to her how to care for the biopsy sites, and I told her I’d see her 10 days to get the stitches out and discuss the results. She stared down at her arms where there were two tiny stitches. “I still don’t understand. Do I have cancer or not?”
I said, “I’ll know better when I get the results. But as I said, this is probably not a bad kind of cancer.”
“I didn’t know there were any good kinds,” she said.
She had a point, of course. I clarified. “Some are worse than others. This is one that’s not so bad.”
She looked at the skin samples swimming in formalin in the specimen jars. “I’ll bet they call you up and tell you it’s poison ivy.” She smiled. “Then you’re going to have to give me my money back.”
One of the biggest challenges that doctors face is bridging the gap between science and the human beings we care for. There’s no reason Mrs. Bryan should know anything about lymphoma. For that matter, she may not even know what a white blood cell is. She knows that cancer is bad, and everything beyond that is just dressing. There is no course in medical school on how to talk to your patients, and different doctors do it with varying degrees of skill, but if I can’t explain to Mrs. Bryan what is happening to her own body, then I can’t get her to help me make it better.
