Sunday, May 22, 2005

SPN's, malpractice and Stephen Gould's essay " the Median is not the message"

Stephen Jay Gould's family is suing the Dana-Farber Cancer Insititute and Brighams and Womens Hospital for allegedly missing a solitary pulmonary nodule on a CXR which was apparently an ultimately fatal cancer.
Missing a SNP haunts radiologists and pulmonary docs.I have been abnormally sensitive to that issue ever since my oral exam in pulmonary disease (yes, at one time the pulmonary exam was oral and the internal medicine exam had both an oral and written component) The examiner had a stack of cxrs which he put on the view box one at a time and asked what I saw. The first 15 or so films or so were normal and the 16 th had a faint, poorly outlined SPN behind a rib on a underpenetrated film,which I missed.
Apparently, because my performance otherwise was so incredible, I passed anyway but I was scarred for life. Years later, ,a seasoned chest doc told me the best way to not miss the SNP was after you viewed the film in the usual way,to view it upsidedown.(This is easier if you invert the film, as opposed to standing on your head, although that might work as well).When you view a film this way small shadows that don't belong really do seem to jump out of the film to your visual consciousness. Anyway, it works for me.
Gould died in 2002 ,20 years after the diagnosis of an abdominal mesothelioma and according to news articles not from mesothelioma.When he learned of the diagnosis, he researched the prognosis, learned the median survival was said to be 8 months and wrote the well known essay "The Median Isn't the Message".It is worth reading. He talks about means and medians etc being the abstractions and that variation is the hard reality. He relates that his oncologist hesitated to give him a time frame from survival. I remember my very avuncular chief of pathology in medical school telling the class to be careful about telling someone how long they have to live , they may end up pissing on your grave. A recent article from the NCI gives imformation on current treatment and outcome of abdominal mesothelioma.

1 comment:

james gaulte said...

Good grief,Altho I spelled SPN correctly in the heading,I managed to type SNP in the body of the blog.