Letter From a Cleveland Jail to the ABIM: Patient Practicum

Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio, and editor-in-chief of ASH Clinical News

Dear American Board of Internal Medicine (ABIM):

Writing to you, as usual, from behind the bars of emotional turmoil, political dissonance, and unresolved neuroses regarding K-type questions, hematology reprobate that I am. Like Henry David Thoreau and Martin Luther King Jr., both of whom penned meaningful essays while held captive, I beseech you with my keyboard to hear my tales of woe.

First, my kudos for offering internal medicine doctors more choice in how to recertify. Your regular emails have given me hope, particularly in how you write that you are “working on” implementing open-book assessments. I noticed, though, that you haven’t mentioned much about specialty exams. I had the most curious day at work recently, and I wonder if this story might prompt you to reveal more specifics about your plans as you “explore” (your word) other changes.

I walked into my clinic room in our cancer center and was greeted by a woman sitting on the examination table.

“Good afternoon, Ms. Pearson,” I said, flashing her a winning smile.

“Hi,” she answered back, flatly.

“How are you today?” I asked, taking a seat.

“Are you ready to begin?” she responded.

Wow, no beating around the bush for her, I thought.

“Sure,” I answered. “I was just hoping to get to know you as a person a bit before we discussed your medical history. I’ll be a better doctor for you if I understand your background, what kind of support structure you have at home, and how you like to make decisions.”

She looked at me as if I had three heads and then started speaking. “A 22-year-old woman presents with lymphadenopathy of her axilla and groin bilaterally. She has been having night sweats for the past month and has lost 10 percent of her body weight. Recent laboratory tests show the following: a white blood cell count of 13,000/μL with 80 percent lymphocytes – 20 percent of which are atypical. Which diagnostic procedure is best to perform?”

I was a bit taken aback. She hadn’t brought along any medical reports and her electronic medical record was bare, except for her name: Pearson, V. So I appreciated the information she provided, despite the odd delivery. But, more importantly, as a hematologist/oncologist at a referral center, I see patients who have a diagnosis already established. And, even more importantly than that, in my practice I see exclusively patients with myeloid malignancies; Ms. Pearson had what sounded like lymphoma, or a bad infection!

“Um, a core needle biopsy?” I answered, hesitantly. She looked at me with disgust. “I mean, I would excise a lymph node! No, wait – I’d send your blood for flow cytometry! That’s it! Uh … on second thought, maybe a bone marrow biopsy?” I was starting to sweat. “What’s the right answer?” I almost shouted.

She stared at me, her lips pursed tightly. I would never find out.

I pulled out my phone to check the time. What kind of reality was this? Was the world standing still? But the seconds kept ticking away, almost too fast.

“WHAT ARE YOU DOING?” a voice shouted at me, almost making me drop my phone.

“Checking the time!” I answered. “Just checking the time!”

“YOU CAN’T HAVE THAT IN HERE! GIVE IT TO ME!”

I quickly handed it over to her … no, him. My patient was now an old man. He confiscated my phone and started speaking.

“A 75-year-old man presents with fatigue, recent weight loss, and epistaxis,” he said. “He has pancytopenia with a hemoglobin of 8.2 g/dL, a white blood cell count of 2,100/μL, and a platelet count of 8,000/μL. A bone marrow biopsy is performed, which shows acute myeloid leukemia (AML) with 29 percent myeloblasts in his bone marrow. Cytogenetics reveal a complex karyotype, including a deletion in chromosome 7. What treatment do you recommend?”

Well, at least this was more up my alley. But this decision of how to treat an older adult with AML is far from straightforward and largely dependent on individual goals.
“Well, can we talk first about your aspirations and what you want to do with the rest of your life?” I asked.

He looked at me, incredulous. “I mean, if you want to be really aggressive about treating your leukemia, we could talk about the risks and benefits of 7+3.” His eyes widened. I hesitated. “There’s a population study from Sweden that shows a survival advantage in older adults with this type of induction therapy. Here, let me show you the results.” I swiveled my chair toward the computer on the desk in the clinic room and started accessing PubMed.

“STOP!” he shouted. “YOU’RE NOT ALLOWED ON THE INTERNET!”

I quickly pulled my hands off the keyboard. “Why not? I access it all the time with my patients so we can review laboratory results together. I also use it to check publications to see how their eligibility requirements and results can be applied to my own patients.”

“BECAUSE IT’S NOT ALLOWED!” he said, indignant. “JUST TELL ME WHAT TREATMENT YOU RECOMMEND!”

“It’s not an easy answer.” I said. “The studies aren’t conclusive. Do you want me to tell you what the National Comprehensive Cancer Network recommends or go into more depth about the level of evidence? It’s nuanced.”

He gave me a withering look, clearly not open to the subject of nuance. I continued, now withered. “Well, I guess with your presentation, I’m supposed to answer that you should be treated with a hypomethylating agent. Is that right?”

“For my lung cancer?” he asked, surprised. He seemed younger all of a sudden.

“No …” I hesitated again. “Don’t you have leukemia?”

He sighed, exasperated. “I am a 63-year-old man and have a 4 cm mass in the right lower lobe of my lung and ipsilateral hilar lymph nodes. I also have a pleural effusion. What stage am I?”

“I have no idea – I’m a leukemia doctor!” I said, equally exasperated. “I haven’t treated someone with lung cancer in 15 years!”

He shook his head slowly. “Sad. Don’t you consider yourself a hematologist/oncologist?”

“Well, yes,” I answered.

“Then what test would you order to determine my stage?”

I tried to stall. “I guess I would order a lot of tests all at the same time: computed tomography, positron emission tomography, mediastinoscopy …”

“But which would you order first?” he repeated. I didn’t answer as we stared at each other for a solid minute.

“Time’s up,” he said. He handed my phone back and I looked at the time. Eight hours had passed.

“That’s it?” I asked, as he stood up to leave. “But, when should I schedule a follow-up appointment?”

“Oh, I’ll let you know in about 10 to 12 weeks,” he said. “If all goes well, I’ll explore whether to see you back every couple of years or every 10 years. If not …” he shrugged his shoulders and walked out the door.

How absurd, I thought to myself. Seeing one patient after another with disorders unlike any I regularly see, each requiring answers to questions a patient wouldn’t ordinarily ask, and all in the absence of information about their medical histories or goals of care and without the usual computer access I have come to depend on to provide adequate care.

Wouldn’t you agree?

Sincerely,
Mikkael A. Sekeres, MD, MS
Board certified through 2022


The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

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