Do You Think I’m Out of My Mind?
1982, A pathology laboratory, Dallas
Sitting at the big table where we examined new biopsy specimens, I fished the little piece of tissue from its container. It was another small biopsy, firm and gray from an overnight soaking in formaldehyde. On the accompanying paperwork I could see that the patient was a 69 year-old man. In the “Specimen” box the surgeon had written “Thigh mass.” I dictated a short description and sliced a thin sample from the middle. Giving it no more thought, I passed the sliver of tissue across to a technician who would shepherd it through the overnight ritual that would turn it into multicolored transparent slide for microscopic study.
The next day I plowed through the trays of slides, each of which offered the usual array of common diagnoses: skin warts and other innocuous lumps and bumps that are the daily diet of pathologists examining outpatient biopsies. More or less on autopilot, I slid the next slide under the scope. What I saw was a sea of bizarre cells with microscopic features so wild that there could be no doubt that it was a vicious malignancy. The only thing remaining was to decide exactly what kind.
I walked the slide around to other pathologists. All agreed with my provisional diagnosis: malignant fibrous histiocytoma (MFH), a well known but rare tumor that usually occurs in bones or the soft tissues of the body.
I called the surgeon with the grim news. He told me the tumor was deep in the thigh amid the big nerve and blood vessels that supply the lower limb. I promised to send the microscopic slide to a consultant pathologist for a second opinion because the implications were so dire. There was no way to remove the tumor and spare the limb. Amputation was the only choice. The standard therapy was radical: disarticulation through the hip joint with removal of the buttock and entire leg.
Weeks passed without further thought of the matter until I got a message from an internist asking me to look again at the case and give him a call. It seemed odd. Internists usually don’t insert themselves into cases like this. Surgeons and cancer specialists: yes; but internists, no.
The internist in question was one I knew because he marched to the tune of a different drummer. Famously iconoclastic, he was forever questioning the received wisdom of the general medical community, even about firmly established notions. He practiced in a small office with only one employee, and he often answered his own office phone.
When I called he answered the phone. He asked a few questions about the case and then invited me to his office to discuss it with him, explaining that he was the patient’s primary physician and had originally discovered the lump. We arranged a time to visit, and I hung up more puzzled than before. What further could he have to do with this case other than offering general care after the surgeons finished their grim chore?
A few days later I met him in his office. As we talked, I found he’d done his homework. He was surprisingly knowledgeable about the cancer. We talked about the patient and the tumor at length. After a while he paused, deep in thought. Then he said something like this, “What would you say if I told you I was thinking about recommending to him that we leave this thing alone, that we not cut off his leg, and that he not have chemotherapy?”
I asked him to explain. “Well,” he said, “you know what they’re going to do. They’re going to take his leg off at the hip. This guy will be 70 next year, he still has sex with his wife, he plays a little golf, he goes to the market. In short, he has a life, all of which will come to a miserable end if we go forward with what the experts say. He’ll be in a wheel chair. Sex, golf and travel will come to an end. “So,” he continued, “I’m serious when I ask: ‘Do you think I’m out of my mind?’”
Now I could see where he was going. He really did want to know if I thought his idea was so far off base that I might, for example, testify against him if it came to a malpractice trial or a disciplinary hearing.
As we continued to talk the wisdom of his idea became more evident. “No,” I finally said, “I don’t think you’re nutty. In fact, the more I think about this case the more sense you seem to make.”
That is what he recommended, and the patient took his advice. Years later I asked the internist about the patient. The tumor, which was fist-size when diagnosed, had grown slowly. It did not spread to other parts of the body, nor had it much interfered with the patient’s life until he was several years older, at which time it had grown to football size and interfered with the motion of his leg to such a degree that he had to give up golf and was confined to a wheel chair. Eventually the tumor became massive and proved fatal.
Looking back, the patient’s doctor was unusually wise … and brave. It was a good decision, made by the type of physician everyone should wish to have as his or her doctor.
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