Catching a Snowbird

He is a Snowbird and a 78-year-old cancer survivor.

He travels to New England as the weather gets warmer and heads back south as it gets colder. He visits me for his annual physical while he is home and we always catch up. We chat, and he tells me how he is enjoying retirement while I try to imagine his life, in between typing his notes. He eloquently describes how the sun warms him up for 4 months. His universe is in a stable routine; well compartmentalized into the two cities he lives in; home in the cold north but heart in the warm south.

Years ago, he had had localized prostate cancer and had chosen a curative radical prostatectomy. His oncologist felt after monitoring him for a decade that we should now switch to watchful waiting. My patient feels that he has paid his dues in health and now lives cancer free.

This year is no different. I see his name, Mr J., on my schedule as Daylight Savings Time starts; spring will soon be here. As a retired academician, he is a stickler for the rules. As his primary care physician, I too, follow current guidelines. Mr J listens carefully as I go over the recommended screening tests. I ask him, “Did you ever smoke?”

“Yes, many years ago. I have successfully quit that habit,” he proudly informs me.

“There is a relatively new screening recommendation—I would like to order a CT scan of your chest. It is now a routine screening test for patients who used to smoke.”

“Yes, you do whatever you need to, just be done before I head back, my partner and I love the sun.” He proceeds to describe his newest adventures in the sun and this warms me up.

I review his results at a follow-up visit. “The CT scan of your chest is clear. A few small nodules, nothing to worry about. We will monitor them annually for now. But there is a small shadow on your liver, most likely a cyst. A CT abdomen is recommended. I will have that scheduled.”

“You go ahead, do everything while I am here.” My patient worries about getting all his tests and checkups done while he is home. I am concerned about the timeline he is setting and how this will progress. The weather is changing and it is getting cooler.

“The CT abdomen was exactly what we thought: a 2 cm cyst on your liver, most likely a hemangioma, a collection of blood. But they see a small opacity in your pelvis. An MRI is recommended. I know you have no symptoms, but it is hard to even tell what it can be, and given your prostate cancer history, I want to be sure there is nothing to worry about.” I give him this information on the phone on a chilly evening. As always, he agrees to everything I recommend.

How often do we use screening tests with the patient’s perspective? I started with a screening test. I have now ordered whole body imaging. My patient trusts me and is confident that I will take care of him.

Myself, I am not sure; he had decided upon watchful waiting and here I am looking for more. Clinical acumen has no role here, just a gut instinct that will bother me if I do not see this through. “Do no harm” is what we have pledged, what physicians strive for, but there are so many intangibles, such as copays, quality of life, trust, and relationships. As physicians we are privileged sometimes in making decisions both with our patients and for our patients.

Daylight Savings Time is about to end. I schedule his test and wait anxiously for the results. He does not worry; I do that for him while the rest of my clinic continues.

Detection of disease is achieved; the MRI shows a 2 cm solid nodule in his pelvis. He visits his urologist, his prostate-specific antigen is elevated, and they palpate the nodule in the space where his prostate used to be. It is a recurrence of cancer. His options are reviewed by the oncology team, and the specialists take over.

From my perspective as his primary care physician, I appear to have done my part. But I ponder these events; I am not sure how helpful I have been.

My patient has cancer again. Life has changed.

Snow has arrived and he is not sure if he will travel this winter.