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BLOG: Doc, you need a doctor
Preparing to do a thyroid biopsy, I was reviewing the prior biopsy the patient had few years ago, when I noticed something.
“The biopsy in 2014 was done by my colleague,” I said to the patient. “Was I on vacation or something?”
“Doctor, you may have forgotten that you had hurt your back at the time, and you could not do biopsies that day,” the patient said. “You asked your colleague to do your patients’ biopsies that day.”
“Oh, yes, now I remember,” I said.
That was the summer when we were vacationing in Mackinac Island. As I was biking with the kids, doing the 8-mile island’s perimeter, I felt the most excruciating back pain of my life. The biking perhaps instigated a compression fracture in my back, so-called Schmorl’s phenomenon (the disc of thoracic 11th vertebra into the body of the 12th vertebra). The cause, in retrospect, turned out to be a severe case of osteoporosis, worse than the most severe osteoporosis of my own patient. My T-score was -3.9 at the spine.
At the time, I was in terrible pain; I could not do thyroid biopsies that day. That back pain prompted me to go for urgent care, the first and last time I went to one. I received a tramadol injection. It did not touch the pain. Physical therapy — no use! Luckily, the pain resolved after 6 weeks, and I began intensive treatment of my own osteoporosis.
“Yes, I now remember,” I said to my patient who was lying on the biopsy table. Then we proceeded with fine needle aspiration, because his thyroid nodule had increased in size in the interim.
“Doc, you needed a doctor, then,” my patient said.
A biopsy is the term we use to describe these minor diagnostic procedures in medicine, like liver biopsy, kidney biopsy, breast biopsy and thyroid biopsy. We refer to the thyroid biopsy as FNA, though I am not sure why the “fine” description was emphasized here. I would guess that perhaps this is more friendly to patients.
In the old days, thyroid biopsies were done with the so-called core needle biopsy: large needles that have cutting stylets. While core biopsies are still used in kidney and liver biopsies, they are no longer used for thyroid biopsy. Bleeding and infection were not infrequent complications with thyroid cord biopsies. So, now the standard procedure for thyroid biopsy is FNA.
We do thyroid biopsies when we diagnose thyroid nodules. At least half the population have thyroid nodules, diagnosed by ultrasound; however, palpable thyroid nodules are much less common, about 5% to 10% depending on which study you read. Of all these nodules, about 5% to 10% could be cancerous, so the vast majority are benign. We do thyroid biopsies to try to send fewer patients for thyroid surgery. In the world of thyroid cancer, the slogan is “less is more.” That is, given the slow progress and favorable course of the most thyroid cancers, it is best to follow a careful diagnostic work up to confirm benignity of thyroid nodules, to avoid surgery.
Additionally, complications of thyroid surgery are quite concerning; damage to the innervation of the vocal cords (threatening voice) and resection of parathyroid glands (with resultant hypocalcemia).
Unlike biopsy of all other organs, thyroid biopsy is quite an ordeal for patients. For the last 23 years, since I began doing thyroid biopsies, each patient coming in for thyroid biopsy comes in with a very high level of anxiety. Imagine someone inserting long needles deep in your neck, and you are awake.
I speak from a personal perspective. I was diagnosed with a thyroid nodule myself in 2007, and I underwent four biopsies. My nodule is quite vascular, so the first three attempts were non-diagnostic (inadequate thyroid cells to make a diagnosis, so called Bethesda-I category).
How was my thyroid nodule detected?
In short, I went for a workshop to learn ultrasound-guided FNA in Scottsdale, Arizona. These workshops are held by the American Association of Clinical Endocrinologists, and my friend, Dan Duick, MD, is one of the co-founders of these workshops. When you attend these workshops, you are paired with a colleague, and you perform ultrasound on each other. I was paired with an endocrine fellow.
His thyroid was clean and nice; mine had a nodule!
So, before I start FNA, and as I explain the procedure to every patient, I mention that I understand the anxiety, because I had FNA done on myself. I know the pain. I speak from personal experience.
No doubt that when doctors experience being a patient, that will be educational to doctors. These health experiences are powerful tools to teach empathy to doctors, because they experience what it is like to be a patient. To read more about empathy and the doctor-patient status, you can refer to prior posts referenced below.
The patient who was lying on the table waiting for me to insert needles in his neck showed a great deal of empathy toward me when I recalled my injury. He was meaning to say that at the time he felt like saying to me: “Doc, you need a doctor.”
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