Stepping Out From Behind Our Reports

“I have reviewed your scrotal ultrasound and unfortunately I see some very suspicious findings which will need additional work up,” I said to the eager and nervous 32 year old man who I was speaking to on the telephone.

“What exactly does suspicious mean?” he replied.  “Please, doctor, tell me the truth, you are a guy, just tell it to me straight.”

“Robert, the findings on your scan most likely represent a tumor in your left testicle.”

There was silence, then Robert replied, “Is it curable?” 

Robert’s testicular ultrasound revealed diffuse microlithiasis and a circumscribed hypoechoic mass in the lest testicle, most suggestive of a seminoma or mixed germ cell tumor.  I proceeded to tell Robert everything I knew about testicular cancer in young men.  I tried to confine my conversation to the imaging work up he would undergo (my area of expertise) but also reviewed some basic epidemiology regarding testicular neoplasms.   I also spoke generally about treatment options including orchiectomy, radiation, and chemotherapy.  However, I stressed to Robert that the most important prognostic factor would be determining whether the cancer had spread, a determination that would be made by further imaging.

Unfortunately I had to speak to Robert over the telephone rather than in person.  His case came to my attention at 5:30 pm on a Friday afternoon, the typical time difficult cases seem to appear.  Robert was the last case of the day scanned by one our sonographers in an outpatient setting where the covering Radiologist had left for the day.  The sonographer phoned me immediately after the scan because of the concerning finding.  Being on call, I could not leave the inpatient tower and go to speak to Robert in person.   I regret having to convey such important news over the telephone, but I wanted Robert to know the results of his study rather than worry all weekend and not hear from anyone.  I also provided Robert with some reliable web resources he could review and my pager number if he had any questions over the weekend.

I had paged Robert’s primary care physician with the findings initially, but she was not available.  I was transferred to a covering physician who knew even less than I did about Robert.  She dutifully recorded my findings and recommendations and said she would tell Robert’s primary but did not offer to speak to Robert herself.  The sonographer had informed me when she called that Robert was anxious and wanted to speak to someone so I agreed, as a physician, to convey to him what I saw and its implications.

In November I wrote about a scenario regarding a patient I cared for where I knew the diagnosis was cancer but retreated from discussing this finding with the patient.  Multiple responses to that blog post debated whether Radiologists should or are equipped to discuss this type of diagnosis with a patient.  Since caring for that patient in November I had regretted not having a discussion with the patient.   I told myself that the next time the situation came up I would speak directly with the patient.  While I would have rather spoken to Robert in person, I am still glad I spoke to him about his diagnosis based on my imaging expertise. 

“Thank you, Doctor,” Robert said at the end of our conversation.  “I appreciate you discussing the findings with me honestly.”