Important things to ask your doctor

It's not the treatment, it was the radiologist who administered it--and he was definitely not a “people person." I had my biopsy guided by ultrasound, and I took a Valium before leaving the house (I had a ride). The hospital's legal dep't wasn't going to let me go through with it because they were afraid I wasn't competent to give informed consent--I mentioned I too am a lawyer (mostly retired) & a cardiologist's wife and was acutely aware of their concerns, so they had me sign an oath in blood that I was not stoned and was informed of a laundry list of possible complications. The radiologist was affable and sweet as well as funny. She used lidocaine, but it took effect even before I could feel her remove the needle. The core biopsy was sort of disconcertingly noisy (the clicks sounded like empty chambers in a game of Russian roulette). It was over fairly quickly and I was able to drive to dinner that night.

The radioactive seed placement was done by the same radiologist, guided by ultrasound, with lidocaine (no Valium, as I was NPO). When it was in, a resident from Nuclear Med Geiger-countered me and declared “She's hot." I replied “Thank you;" shoulda replied “that's what HE said." Some still do wire localization, but seed placement is getting more & more common.

Why not under anesthesia? First, a general is always risky (and requires the services--and fees--of an anesthesiologist). Even twilight sleep or Propofol can be risky. Why no Valium? If you take one orally, you run the risk of inflaming the nerds & bean counters in Legal. If administered by IV drip, that requires starting an IV, finding a vein--and for the actual surgery, you want as many good veins available as possible.

Wanna go back to the good ol' days? In 1975, my m-i-l found her nipple suddenly inverted and went to her gynecologist. Back then, all biopsies were surgical (incisional or excisional), done under general (halothane gas) anesthesia, followed by a frozen section being sent immediately to the path lab. If benign, the patient was sutured and sent to recovery to waken, then sent home with a giant bandage. If malignant a radical (breast, chest muscles, all neighboring lymph nodes and sometimes some arm muscles) mastectomy was performed, with no skin or nipple spared, no thought of reconstruction. The patient found out her tumor was malignant only by waking up without a breast, which was what happened to my m-i-l who had a “modified" radical--breast, some arm muscle and axillary nodes removed. That was it as far as pathology was concerned: no grading; staging was purely determined by lymph node status--which if positive was followed by chemo as brutal as that given today...but fewer chemo drugs were available and there were no drugs to deal with nausea nor biologics to help prop up the immune system. Women often didn't survive the full course of chemo, Nobody knew about hormone-receptor status or HER2--there were neither targeted nor endocrine therapies. Radiation treatments lasted longer and were more debilitating. My m-i-l was lucky: she didn't get chemo, but did have radiation. She survived another 32 years, but with permanently impaired mobility; she wore a prosthesis but eventually tired of it and never wore a swimsuit again.

In my state, radiologists can't prescribe. My biopsies hurt like hell and I'm still disgusted by how this possibility was dismissed when I raised it. It would have been easy enough to say, "Talk with your PCP or BS now to get a couple of Tramadols."

No, it's state law. I've had several radiologists explicitly state it.

I bet these radiologists don’t have DEA prescribing numbers, which are necessary for MDs to prescribe controlled substances. And I would also be willing to wager that as a condition of employment at the imaging clinics the radiologists must agree either to not apply for DEA numbers or not prescribe any controlled substances or psychoactive drugs. Dollars to donuts this is to protect the facility from prosecution. Why do I say this? First, if OR statutes prohibit radiologist MDs (as opposed to techs) from prescribing controlled substances, why are there several websites for musculoskeletal radiologists in OR who also specialize in pain management? A pain specialist can’t effectively practice with an arsenal limited to OTC meds and non-pharma techniques.

Second, I speak from my experience as a former IL Special Asst. Atty. Gen. in the Welfare Litigation Div., which handled not just public assistance but Medicaid cases--specifically, physicians getting Medicaid reimbursement. We worked closely with the Cook County State’s Atty’s and U.S. Atty’s offices because we found that doctors operating “pill mills” targeted by criminal law enforcement agencies also tended to fudge on Medicaid recordkeeping, filing fraudulent claims and therefore liable for recoupment of funds by the state. (With the help of the Pulitzer-prize-winning reporter who broke the Mirage tavern bribery case, we actually found physicians billing for pregnancy tests performed on men and nursing homes billing for slippers for double amputees without prostheses). Freestanding imaging clinics were major culprits--they were often unable to produce original x-ray films or reports to back up their claims for reimbursement--and the baby often got thrown out with the bathwater in that facilities attracting unwelcome gov’t attention for civil offenses not uncommonly got swept up in drug abuse enforcement stings as well. I don’t think IL (or even the Chicago area) was unique, and I’d bet these OR imaging facilities were feeling the heat and were therefore administrative-litigation-averse, as well as feared being enmeshed in drug enforcement sting operations. “CYA" is timeless and universal.

ChiSandy, it certainly could be something like that. Oregon has a big push to decrease controlled substances (even at the benzo level). I looked at a pain clinic associated with one of the medical groups--it only has opioid decrease programs, no opioid prescription. I got an unpleasant letter from the state when I got a refill on lorazepam last winter--essentially "The State Is Watching You, Potential Drug Abuser."

Praline, the really painful one was stereotactic. The other was punch, I think?, also not a pleasure. People who have told me their biopsies weren't bad have tended to have palpable or more easily reachable sample areas. Mine were behind my nipples and deep down on both sides. The lidocaine was painful, and I had pain at the biopsy sites (multiple on the right) for weeks afterward. It only stopped when I had surgery and no longer had nerves. The stereotactic left a scar that I still have higher up on my chest.

I had a surgical biopsy with wire in 1992. It was a horrible experience. A roomful of men doctors, used numbing agent on my skin but nothing else, then, when I said it hurt, told me they'd never had any other patient say that. I had to go to the waiting room, wait for my files, then go down to the parking lot, get my car and drive to the hospital (with wire in breast) and wait in another waiting room. Then, when they were taking me into surgery, a woman came at me and demanded I give the hospital another $500.00 (my co-pay, I guess). I mean, I was going into surgery right then. Terrible experience all around, except it was benign.

Fast forward to last November. Same hospital, biopsy in the same location, different doc, this time, a woman. She numbed my breast entirely and was actually nice to me. I still had to drive to the other hospital (who designed this process????) with a wire in my breast, but the rest was done with kindness and efficiency; no one hammering me about $ as I was going into surgery. Much better experience all around, except this time it was cancer. (Bummer. Major bummer. :-) )

There is no reason for this process to be so barbaric. None. I just fired a whole group of docs for treating me like a cancer instead of a person. I am sooooo glad I did.