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When the Experts Are Wrong

A Blue Christmas in London

Frivolous Use of Antibiotics Can Be Dangerous

Putting Up a Good Fight


January 29, 2001
When the Experts Are Wrong

liff was a curmudgeonly 60-year-old ex-Marine who hated everything. In Vietnam, he had been a prisoner of war and was awarded the Silver Star. After the war, he worked as a tow-truck driver and started drinking heavily. His wife left him, and he was not on speaking terms with his son and two daughters. Cliff had lived his life as a tough guy and now, faced with the diagnosis of terminal cancer, he had few words.

Cliff didn't have a primary care physician, so I inherited him when he was admitted to the hospital where I worked. He had come to the emergency room with difficulty breathing. When I first tried to examine him, he told me to wait because he had to go out and have a cigarette. His chart said, "60 y.o. Heavy smoker with likely lung CA (cancer)." I showed him the chest X ray, which revealed a "white-out" pattern in the entire left lung and a partial white-out pattern in the right. A white-out pattern is an abnormality that indicates an inflammatory process. "It looks like cancer," I said seriously, "but we won't know for sure until we do some more tests." Cliff just sat on the gurney looking at the floor, his chest heaving with each breath.

I got the usual consultants involved. The pulmonologist performed a biopsy that came back showing primary lung cancer, and the oncologist said there was no hope. At that period in my career, I also worked part-time on a palliative care unit at a different hospital, so I admitted Cliff there. Because he had such a grim prognosis -- less than six months to live -- he would receive only comfort care. Initially, Cliff was an extremely difficult patient: He complained all the time, made sexist remarks to the nurses, called the AIDS patients "homos," refused to take his medication, and even smoked when his oxygen tank was nearby (a real fire hazard). The nurses didn't like him, and they complained regularly to me. I didn't enjoy Cliff's gruff ways either, so it was easy to commiserate.


I moved Cliff's car when the hospital administrator complained, saying it looked strange for one of the patients to be working under the hood of a car dressed in a hospital "johnny" with a cigarette hanging out of his mouth.


One day during my rounds, three months after his admission to the unit, Cliff insisted on having a chest X ray. "I'm supposed to be dead, for Christ's sake," he responded when I asked why he wanted it. And he had a point. Instead of getting worse, Cliff was getting better. We attributed his improvement to better nutrition and to the fact that Cliff was making peace with his estranged family. He had met his infant grandchild for the first time. His ex-wife was genuinely concerned and called every few weeks for progress reports. I even gave Cliff permission to have his 1963 Buick Tempest brought to the hospital parking lot, where he worked on it for hours at a time. I moved the car to the employee lot out back when the hospital administrator complained, saying it looked strange for one of the patients to be working under the hood of a car dressed in a hospital "johnny" with a cigarette hanging out of his mouth.

Cliff had his family bring in big bags of M&Ms, and he passed them out to all the nurses in little paper pill cups. He sorted them by color. To his favorites, he gave cups filled with red M&Ms, because he said they represented truth. To those he didn't like, he gave cups of blue ones, which he called "fake" M&Ms. The nurses who got the blue ones just laughed and called Cliff crazy.

The new chest X ray showed significant improvement, so I called the oncologist and asked for his opinion. "Kevin, all I can say is that sometimes we see this," he said. "Temporary improvement before the inevitable demise." Another month passed, and Cliff asked for a weekend pass to spend some time at his lady friend's house. "Of course, I don't really give a hoot what you say cause I'm goin' anyway," Cliff informed me. "And, hey, I need a 'script for some Vitamin V." "You mean Viagra?" I asked in disbelief. "Listen, Sherlock, just leave it at the nurses' station," retorted Cliff. And I did.

When Cliff returned early Monday morning, he was his usual cantankerous self. "I didn't know you pretty boys got up before nine," he shot at me. I took Cliff into his room and shut the door. I told him that after he had asked for the Viagra I suspected there was something wrong. I mean, four months ago he had been at death's door. Now, although still debilitated, he was obviously stronger.

Over the weekend, I had gone through his four-volume chart, searching for an explanation. Why was he still alive? I reread the pulmonologist's report, the pathology report confirming the cancer, and the oncologist's opinion that the cancer was too advanced for meaningful therapy.

The last section of the chart contained lab results. When I discovered Cliff's PSA level -- a measure of prostate cancer progression -- was the highest level I had seen in my career, I stood up abruptly. I couldn't believe it. This meant Cliff had prostate cancer that had spread to his lungs, not primary lung cancer. The difference was huge, because we had treatment for prostate cancer.

After my conversation with Cliff, I hastily called all the consultants. Nobody knew what to say. We were all at fault for missing the PSA count. The doctors all asked if I thought Cliff would sue.

Cliff was readmitted to the oncology unit, where he underwent surgery, radiation therapy, and chemotherapy. His chest X ray normalized, and he breathed without supplemental oxygen. Both the prostate and lung cancer appeared to be in remission, so he was discharged from the hospital. He moved into a new apartment and went back to his old job driving the tow truck.

Cliff never sued. He just went on with his life. He said he was a better man because of cancer. After the correct diagnosis was made, the same consultants treated him. We all had a team meeting with Cliff, and we discussed the "mistake." Cliff just said, "God knows we all screw up sometimes, but you jerks really screwed up royally here." When the pathologist started speaking uneasily about a possible lawsuit, Cliff cut him off and said, "Try thinking less about your own butt and more about your patients" -- and with that comment he ended the meeting.

Several months later, I was at K-Mart buying a mop when I ran into Cliff and his lady friend at the checkout. Cliff was buying a case of motor oil, two cartons of cigarettes, and several large bags of M&Ms. As we chatted in the parking lot, Cliff reached into his shopping cart and pulled out a bag of M&Ms. He grabbed my hand, put the bag into my palm, and held on for a few seconds.

"The bastards are still making assorted colors, so you'll have to handpick the red ones," he said with a wink.

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 J. Kevin Shushtari, M.D., is's Chief Medical Officer and a co-founder of the company. He is also a board-certified internist with a medical degree from Dartmouth College. In Dr. Kevin's Column he will share his own experiences as a physician, a family member, and a patient.