Editor’s Corner
D
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.
Letter From a Cleveland Jail to the ABIM:
Patient Practicum
EAR AMERICAN BOARD OF INTERNAL MEDICINE (ABIM):
Writing to you, as usual, from behind the bars of emotional turmoil, po-
litical 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 cap-
tive, 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 won-
der 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 per-
cent 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 pa-
tients who have a diagnosis already established. And, even more importantly
than that, in my practice I see exclusively patients with myeloid malignan-
cies; 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 re-
veal 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.
ASHClinicalNews.org
“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
Mikkael A. Sekeres, MD, MS,
this type of induction therapy. Here, let me
is director of the Leukemia
show you the results.” I swiveled my chair
Program at Cleveland Clinic in
toward the computer on the desk in the
Cleveland, OH.
clin ic 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 rec-
ommends 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 sup-
posed 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
ASH Clinical News
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