Saturday, May 5, 2007
Lymph nodes, personality and the practice of medicine
Well, the mono test came back showing that Arman has been exposed to the mononucleosis virus (which is officially called the Epstein-Barr virus - EBV) at some time in the past, but not recently. There are different antibodies in the blood that can be measured. They measure antibodies to a molecule (or "antigen") at the core of the virus. The viral molecule is called the "virus core antigen" or "VCA". We produce different types of antibodies in response to an infection. The first one our body produces is immunoglobulin G, or IgG for short. In the graph above (don't get thrown off by the labels -- apparently French people have the same stuff in their blood as everyone else) you can see that IgG to the viral core antigen (the red line) rises and stays elevated. The IgG stays high for years and years, so if you have a positive IgG, you've been exposed to the virus at some point. IgM, on the other hand, rises during the acute infection and then goes away after a few weeks (the purple line). Arman's IgG VCA is elevated indicating past exposure to EBV, but the IgM is not elevated, indicating that he does not now (or anytime recently) have an EBV infection. Conclusion: They enlarged lymph node is probably not from mono. I say "probably" because sometimes, the IgM may not rise even in an acute infection. Go figure.
Being on the receiving end of the practice of medicine, I'm learning quickly that so much of the care that you receive as a patient depends upon the personality of the doctor, not on their knowledge. After seeing these results, the pediatrician recommended biopsying the node and discussing things with the pediatric oncologist in San Diego. I said, "With the node getting smaller, why would we biopsy it? After all, any of the bad things would not get smaller." The main question in my mind is, will a biopsy change the course of action at all? We already know it's not cancer. It's getting smaller. What could a biopsy show that would affect what we do? Answer: nothing really, but we don't want to miss anything.
That approach is one made on the basis of personality -- the need to not miss anything no matter how remote the probability. The pediatrician recommended that I at least come in and let the ENT specialist see Arman and make his recommendation. "Sure, I'm happy to do that." "Why don't you talk to him, he's standing right here next to me." He gets on the phone and asks me, "Is the mass getting smaller?" "Yes, definitely." "Then we don't need to do anything," he says. "Do you want to check Arman?" "No, just let me know if it gets bigger." "No biopsy?" "No, why would we biopsy something that's getting smaller?" His response also is based upon his personality. He doesn't need to have it proven to him that it's benign. His approach is pragmatic, like mine.
In medicine, many times (maybe even most times) there isn't a clear answer on the approach to take. The approach is based upon personality. In my practice, I do my best to let the personality of the patient make the decisions regarding the approach. When to start glaucoma medications for someone who has certain risk factors for glaucoma, but who has not yet developed glaucoma is one of these common situations. I'll often say, "What we do at this point, really depends on the type of person you are. Do you want to start this medication and use it for your lifetime, knowing that you may not need it, but that it will reduce your chances of developing any visual damage? Or are you the sort of person who would rather monitor things closely and see if any damage occurs, and then start the medicine once we are sure you need it?" Some people would rather take medicine and not worry about developing damage. Other people would rather wait to see definite indication that they need treatment. In my opinion, what I as the doctor feel (because in such situations, it is about what one feels, not what one thinks), isn't very important. I'll share it if asked, but I'll say, "This is what I would do because of the type of person I am. It might not be the best approach for you if you're a different type of person."
Of course, in lots of situations, the answer is clear, and I'll lay down the law and say, "if you don't stop smoking, you will go blind. You must stop smoking." That's the science. That part is clear. Doctors sometimes get confused because they lose the science in the midst of their approach, which is personal. That's why it can be so confusing to patients. Every doctor seems to have a different opinion of the best course of action. The important thing in my mind is to discover the best approach for the patient, based upon their personality. I teach them the science, and help them find their path.
So anyway, Arman's enlarged lymph node and spleen probably were not due to mono. And also, probably not due to lymphoma or anything bad. The lymph node is getting smaller. I was going to take him in for an ultrasound of his spleen to make sure that's getting smaller too, but I had forgotten that it was an "austerity Friday." Our government is broke here, so every two weeks all government employees get an unpaid holiday as a cost cutting measure. The ultrasound tech was on "austerity leave", so we couldn't get the ultrasound. I'll take Arman in next week, just to double check the size of his spleen.