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I f*ckin’ hate #breast #cancer.

It feels so unfair. It attacks the better half of what makes goodness persist in the heart of humanity from generation to generation. It seems so unfair.

I also detest physicians who don’t do proper physical exams. Please know mammogram will miss roughly 1 in 6 cancers and ultrasound is a shitty substitute for MRI. There are things you can feel that I can’t see with the cheap imaging tools. And it’s your responsibility to diagnose those cancers…these can literally occupy half the breast or more and leave no trace on standard imaging. And this is not “rare.” It’s your f*ckin’ job…you should at least know what you’re getting paid for.

Marcos Wolf, MD 2y ago

Regarding imaging: yes and no.

And a minor addition:

Using the right tools is the challenge. ;-)

Physical examinations are key. While MDs can do a good job. Best is to educate patients. They can detect even very small changes. (e.g. regular checkups in the shower)

Imaging:

* Mammograms are old but good. technological updates worth it. However, mostly good for "old" breasts (less density)

* MRI is really helpful (esp. with a proper setup; e.g. I have seen images with new coil-designs - really great CNR improvement)

* Ultrasound can help too; esp. for young patients as mammae are too dense usually. Also for biopsy worth it!

The art is to merge the right tools.

I believe that the best is to make your patients the experts of their body and (upcomming) diseases.

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Discussion

Dr. Bitcoin, MD 2y ago

Patients frequently find their own cancers. It’s less common for patients to ignore their cancers for “too long,” but that’s not rare either.

I’ve spoken with many women whose physicians haven’t performed a breast exam in years. Some have been said that they’re too old for breast exam because they’re 50,60,70…ugh…

I love ultrasound. But it’s a shitty substitute for MRI in screening. Less sensitive and less specific, easily can miss cancers that can be palpated. In fact, I biopsied a palpable cancer on Thursday that appeared, if anything, as a 5 mm mass…which was a stretch as the sonographer could tell by feel there was a problem but couldn’t really see anything…so she used every technical parameter in the book to inject artifact to simulate an abnormality. Dense on mammo with no appreciable abnormality.

I biopsied her using “the force” and she’ll be getting an MRI to see how big her cancer actually is (if opting for breast conservation therapy).

If she had a different US tech, she would have almost certainly been returned to her PCP for management based on clinical findings…which in an ideal world would have been referral to a breast specialist or surgeon or diagnostic breast MRI.

You wouldn’t believe how small a fraction of ordering providers that feel a cancer bother to mention where it is or how large it is…about half don’t even bother to indicate left or right breast.

Dr. Bitcoin, MD 2y ago

A fee sats for your future.

Radiology is the best job in the hospital. You’ve chosen well. If you enter private practice, pick a group that allows you to interpret good images efficiently…

A lot of hospitals buy shitty machines that work fast. As I’m certain you know, fast MRI necessitates decreased image quality, all else being equal. Hospitals know this but don’t GAF. they buy cheap machines and run them fast; some radiologists don’t mind having no imaging evidence of the problem they didn’t dictate because they couldn’t see it. It’s bad incentive alignment.

Wherever you work, help your institution buy the right equipment. It’s tough and technical and salesman are scumbags.

Marcos Wolf, MD 2y ago

The problem is that doctors (in general) gave away their competence to the industry, Here in Europe, you are not allowed to adjust/change any machine; not even slight changes such as increasing the RAM. Even installing and using self made MR sequences is not allowed on clinical scanners.

And now, the companies let you pay.

This monopoly is even so bad that the companies write the laws nowadays. So that we can not even make new products by ourselves; without 100s of lawyers and product engineers. This reduces the competition and meaningful product upgrades become a rare event.

classical example of centralism and over regulation.

Dr. Bitcoin, MD 2y ago

I was a graduate student at a rather well known not for profit multi specialty private group medical practice located in southeast Minnesota during the time when modifying MR pulse sequences was minimal risk and part of routine clinical care. When I returned some years later as a radiology resident, even the world famous clinic had been hit with the ban on pulse sequences (which was obviated by having patients sign up as research participants in a non-existent study with no research aims).