Communications to the Editor |


Dean Gianakos, MD, FCCP
Author and Funding Information

Lynchburg Family Practice Residency Lynchburg, VA

Correspondence to: Dean Gianakos, MD, FCCP, Associate Director, Lynchburg Family Practice Residency, 2097 Langhorne Road, Lynchburg, VA 24501; e-mail: deangianakos@yahoo.com

Chest. 2002;121(6):2085. doi:10.1378/chest.121.6.2085
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To the Editor:

The other day I asked Eileen when it was time to stop worrying about M. M is a pleasant, likeable guy in his forties, with a good sense of humor. He works construction for a local company. As far as I know, he works hard and pays his bills. In the office, we often joke around and swap stories. He tells me about his wild fishing trips on the Chesapeake. I tell him about the obnoxious parents I encounter at my son’s little league games.

When M comes in, it takes Eileen forever to get his BP. She enjoys his stories as much as I do.

We both like the one he told about spending 4 days on the bay with his fishing buddies. Didn’t catch a thing, he told us—not one tiny fish. He said one of the guys got so frustrated that he fished on a hand-held computer the last day of the trip.

“I learned a lot about myself on that trip, Doc. Blue skies, calm water, and good friends. Everything seemed perfect, and it really was, except for the fish. But hey, you can’t control everything.”

I’ve been M’s doctor for 5 years. On most visits I urge him to quit smoking. I don’t push hard, but I make sure he knows how I feel about it. He listens to me patiently. I see him maybe twice a year, which is a little more frequently than he sees his preacher, he tells me. Not that I preach, he quickly adds. He has been healthy, except for a period of depression 5 years ago during a messy divorce.

Last summer I discovered that M has a lung nodule. It showed up on a routine chest radiograph. It was his first chest radiograph ever. After a lot of back and forth, I had talked him into it (he smokes two packs a day).

“I don’t get it, Doc. I feel fine. There must be some mistake. Really, I’m okay.”

“I’m sure you feel fine, M. However, sometimes these things show up without symptoms. I think the next step is to do a CT scan to get a better look.”

“Doc, I’m fine. Don’t worry about me.”

“M, that’s hard for me to do, especially when you come to me for help. How about this—think it over, and call me tomorrow. This nodule could be many things, including cancer.”

“I’ve thought about it.”

“At least come back in 6 weeks for a repeat chest radiograph.”


M did not show up for his 6-week appointment. I thought to myself: many patients live in a state of denial after receiving bad news. Maybe M is one of them. He has a history of depression—could he be depressed? Sometimes patients forget appointments, maybe he simply forgot. M does not own a car—maybe he missed the bus. Being a single dad is tough. Maybe he could not get a sitter for his kids. He once told me that his boss was a bastard. Maybe he couldn’t break free from work. Maybe he can’t afford the scan. Maybe he is too embarrassed to tell me that he cannot afford the scan. Maybe he’s simply scared. Maybe there are other reasons. Maybe the reason is none of my business.

I called him the next day and left a message on his machine to reschedule the appointment. Several weeks went by. No word from M. I asked Eileen to call him. She got him at work, and he promised to come in. He didn’t. I sent him a certified letter explaining the importance of finding out what was in his chest. I never heard back. For the next 6 months, Eileen and I tried to reschedule him. No show. No show. No show.

I keep a list of patients like M—patients with abnormal tests whom I worry may get lost to follow-up. Patients who miss scheduled tests. M had been on my worry list for over a year.

I know that seems like a long time to worry about a patient. But how long is too long? What would a medical ethicist say? Several weeks ago, I decided to take M off the list. Don’t ask me why. Some combination of time, frustration, wisdom, prayer, other patients, and the final okay from Eileen. I don’t worry about him now. Really. Maybe he has cancer. Maybe he will die. Maybe he will sue me. No worry.

Your choices, M. Your life.

Months later, I saw M in the grocery store. He gave me a warm handshake that I gladly returned. We talked about fishing and baseball. We both had a good laugh. I did not ask him about his health. I think he appreciated that.

“You know, Doc, I’ve been thinking. Maybe I do need to come see you sometime.”

I smiled, shaking my head.

He smiled back.

“Maybe you do, M. Maybe you do.”




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