I am a mid-40s female rheumatologist. Fortunately, I consider myself to be fairly healthy; my diet and weight are OK, I run 30 to 35 miles per week, and my only medication is a low-estrogen oral contraceptive that I have been self-prescribing for years. Work and life are busy, and my health maintenance could be better. I have been getting regular mammograms since age 40 (some self-prescribed), maybe I see my gynecologist every two or three years, and I can’t remember the last time I went for a routine physical exam. When I do annual corporate insurance screens to lower my health care premium, my heart rate and blood pressure are fine, and all of my labs are normal. I never smoked. I feel fine, so why do I need a primary care doctor, or an annual physical exam? I am board-certified in internal medicine as well as rheumatology. I am my own primary care doctor!
Recently, one of my psoriatic arthritis patients who is my age came in for follow up after undergoing a wide local excision for melanoma. Come to think of it, many of my patients in their 40s have had skin cancers. Gee, I don’t think I ever went for a full skin check, and I am certainly guilty of more sun exposure than I should admit. At that point, I decided to use some paid time off (PTO) for health maintenance, because when else would I have time? I diligently scheduled a dermatology appointment, dentist appointment (my dentist’s office has been texting me for six months), gynecology appointment, and asked one of my colleagues to be my new primary care doctor.
Last week on a PTO day, I went for my routine physical exam. We went through the appropriate motions — review of systems negative, I feel pretty good, work and family life are stressful for us all, and so on. My colleague then proceeded with a careful and thorough physical exam. As she palpated my abdomen, she told me to relax, as my abdominal muscles seemed tight. “I’m not that muscular,” I laughed. Nonetheless, my colleague palpated a painless upper abdominal mass, which she pointed out to me. Maybe it was the protein bar that I just ate, languishing in my stomach. I had no unusual gastrointestinal symptoms. Just to be safe, since we both felt something, she ordered a complete abdominal ultrasound.
My father died of pancreatic cancer. That evening, I nervously palpated my upper abdomen, definitely appreciating a smooth mass, despite long digesting that morning protein bar. I looked at my eyes and under my tongue — no jaundice. No back pain. No weight loss. I feel fine, except for an uneasy feeling that this incidental finding on physical exam was the beginning of the end. Since I don’t usually palpate my abdomen for painless masses, this is something I would have never noticed.
I skipped my standard early morning run (which I never do) because I needed to be fasting for the abdominal ultrasound. Besides, how could I focus on running when I was about to be diagnosed with a terminal cancer? As the technician was scanning my abdomen, it was obvious that she found “the mass.” With a quizzical grimace, she took numerous measurements, and then told me that she would discuss with the radiologist and bring him in. In a few minutes, I would learn of that cancerous mass in the head of my pancreas obstructing my gallbladder. What else could this be? But I have no other symptoms. Brace yourself.
The radiologist, also my colleague, came in. “It seems that you have a hepatic adenoma arising from the left lobe of your liver. I see you take oral contraceptives, which is probably contributing.” Adenoma? That’s not adenocarcinoma? My pancreas is OK? Yes, I have been taking oral contraceptives for a million years! OK, maybe more like over 20 years, except, of course, when pregnant. “The doctor who is prescribing your oral contraceptives needs to know, and you should stop taking them.”
I am the doctor who has been prescribing them.
Hepatic adenomas are uncommon benign liver tumors that are strongly associated with the prolonged use of oral contraceptives. The mass on ultrasound was well-circumscribed and slightly over 5 cm in its largest diameter, which is on the cusp of what may need to be resected due to risk of spontaneous rupture. However, with stopping oral contraceptives and close follow up, we hope this will shrink and can be managed with close surveillance alone. At my upcoming scheduled gynecology appointment, I will discuss non-hormonal contraception.
I consider myself to be extremely fortunate. Had it not been for the astute physical exam performed by my primary care doctor, this abdominal mass would have remained unnoticed. I would have continued my self-prescribed oral contraceptives, and perhaps in a year or so, I would have developed compressive symptoms from this enlarging adenoma, or worse yet, a spontaneous rupture with bleeding into my abdomen. This routine physical exam may have saved my life! In this overwhelming era of reliance on documentation, metrics, and advanced imaging in medicine, I am indebted to my colleague, who used her clinical intuition following a thorough physical exam. This is something that Dr. Google can never replace.
So I urge my physician colleagues, despite your busy schedules, please be diligent about your own health maintenance, just as we advise for our patients. And regardless of your specialty, please make sure you have a primary care doctor who is not yourself, and schedule your annual physical exam.
Deborah R. Alpert is a rheumatologist.
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