Follow-up

Follow-Up I carry in my shirt pocket a bunch of 3 x 5 inch unlined index cards on which I write notes to myself. Sometimes I record things to be picked up at the grocery store on the w a y home, and sometimes I write down interesting or amusing things that people say (I recently wrote d o w n something that Richard Seizer said: "Suffering is just a bad habit."). But mostly I write on these cards the name, medical history number, and diagnosis or suspected diagnosis of some patient the residents and I have examined. Some of the recent cards say the following: "recurrent marginal ulcer"; "progressive avascular necrosis of the femoral head"; "good normal air-barium double-contrast esophogram and gastrointestinal (GI) series"; "cholangiocarcinoma and pulmonary hypertension in a middle-aged Vietnamese female (does Clonorchis sinensis get into the lungs?)." At the end of the day, these cards are placed on a spindle on my desk, there to gather dust for a couple of months. Every 3 or 4 months I gather them up (there are usually 3 0 4 0 of them by that time) and send for the films and the charts on these patients. My object is to follow up on the interesting or abnormal findings, to see h o w the diagnosis was verified or denied and, not incidentally, to see that what we found was acted on properly. Partly it is a way of continually acquiring materials for teaching (and, potentially, for publication), and partly it is a fail-safe mechanism keeping patients from getting lost in the complicated university hospital machinery. Most of the time I am gratified to discover that our diagnosis was correct and that it was verified by endoscopy and biopsy, by operation, by response to therapy, or by diagnostic laboratory studies. Some of the time I am disappointed to find that the patient has been lost to follow-up. We cannot do much about that, but it is distressing to discover a penetrating duodenal ulcer and arrange for the patient to be seen in the clinic that day or the next day (we consider that to be our responsibility), only to find on reviewing the chart a few months later that the patient did not keep the appointment and was never heard from again. I hope he or she sought medical attention elsewhere, but I bet the patient cut back on the booze and cigarettes for a few days until the symptoms abated a little bit and then went on with his or her life. Once in awhile I come across a situation that really irri-

tates me. Some months ago, for a patient with GI bleeding, we performed an u p p e r GI series that showed a large submucosal mass deforming the esophagus. It was the size of an apple and had a central calcification. We said it was probably a leiomyoma of the esophagus. A couple of months later, w h e n I retrieved the chart to see what the operation had disclosed, I was surprised to discover that a physician had written in the chart that the GI series was negative. Our report was also in the chart, indicating otherwise. I guess what happened is what frequently happens: one of the referring physicians checked out the films, looked at them himself or herself, perhaps even showed them to the senior resident or junior attending faculty (the who leading the whom?), and concluded that the study was normal because they did not see the lesion. I called the head of the GI medicine section and explained the situation, suggesting that the patient be recalled and therapy be considered. He said he would look into it, and he called me a few days later to say that it was a surgical house officer w h o had seen the patient and that I should probably contact the surgeons. I wrote a letter to the chief of surgery, and he passed it on to one of his faculty people, who contacted me directly. We looked at the films together, and the young thoracic surgeon said he would tactfully discuss the matter with the house officer in question and get the patient back. He called me from the operating room a few days ago to say that he had just removed an esophageal leiomyoma the size of an apple from this fellow's chest and asked whether I wanted to come and look at it. I was pleased for the patient, and I was especially pleased that the system worked. I am currently reviewing the chart of a 33-year-old man in w h o m w e found a cecal mass on barium enema. It could be a carcinoma, a lymphoma, or half a dozen other things, some of which we mentioned in our report. Anxious to k n o w what the endoscopy showed, I leafed through the chart. It turns out that the patient was a prisoner in the Texas Department of Criminal Justice Hospital on our campus. On the next to the last page of his chart is our report, and on the last page is a single word: "Paroled." I've got to call the warden. Melvyn H. Schreiber, MD University of Texas Medical Branch Galveston, TX 311