Medicine is a life of learning. Take My Advice is a Medscape series where physicians share their best lessons, the wins and losses, and how to use everything you know to become a better caregiver every day. 

“Agress, why are you making trouble?” I used to hear this from other doctors. Providing the best patient care won’t always make you the most popular. But even if you irritate someone, you should make the effort. I learned this firsthand 30 years ago.

A woman diagnosed with cancer in her right lung came to me for a PET scan. Studying the images, I saw an unexpected, small, abnormal focus of activity in her left breast. I suggested she get a specialized focused mammogram and, because the case left me with questions, jotted down a note to myself to follow up.

Normally, that would have been the end of my involvement. But I felt compelled to know more because this was an unusual finding in a patient with lung cancer.

When I didn’t see the patient’s imaging results in the hospital electronic record a couple of weeks later, I called her referring doctor. He told me she had had the mammogram, and it was read as negative. The patient was referred to a breast surgeon who didn’t feel anything abnormal in her breast and advised her to “forget about it and get another mammogram in a year.”

I wasn’t satisfied. I asked the doctor to send me the imaging report and immediately realized the patient had gone to an outside facility and had a standard screening mammogram with no specific focused views around the PET abnormality. I called her physician back, explained the problem, and offered to have the patient come to our hospital for a focused mammogram and breast ultrasound at no charge.

There was resistance. But after some gentle persuasion, the patient agreed to return. Our breast imagers performed a focused (spot compression) mammogram, which showed a nodule in the same location as the PET abnormality. The nodule was confirmed and biopsied under ultrasound guidance, which showed it to be breast cancer. Fortunately, it was at a very early stage, and the patient was able to have it resected.

She was very appreciative.

Persisting when you feel uncomfortable with a diagnosis isn’t easy. Trainees or younger doctors might hesitate to tell more senior physicians about unexpected findings that indicate a need for additional testing. Doctors might be resistant to your follow-ups and not want to worry their patients. But it’s worth it.

A patient with a facial squamous cell carcinoma was once referred to me for staging with PET imaging. When I looked at her imaging, I saw something suspicious in a very distant part of her body, her rectum. I suggested the patient get a colonoscopy. When I later searched for those results, they were negative. I was surprised.

A few months later, the patient returned for another PET related to her treatment. When I looked at her new imaging, I noticed the suspicious rectal focus was still present. I told the referring doctor I was concerned the original procedure had missed this area and suggested the patient get a second colonoscopy.

The response was less than enthusiastic. “Agress causing more problems!” And I don’t think the patient was all that excited about doing another prep. 

I also asked to speak with the GI physician scheduled to perform the second colonoscopy so I could warn them about the suspicious area. The colonoscopy revealed a mass, which turned out to be a primary rectal cancer.

These cases and others like them taught me the incredible value of persistence and following up, even if it risked irritating or inconveniencing the referring doctors and their patients. If I’d pursued the expected course of action, I would have reported my findings and then been done with each case. But going the extra step was critical.

Unless I followed up, I realized, I wouldn’t know a patient’s full pathway. I couldn’t assume they would get the procedures I’d recommended or that those procedures would be performed correctly. I could check hospital medical records or ask referring doctors to send me new results. But there was no guarantee I would receive them, especially if patients went to different medical systems.

So, I started tracking cases that concerned or interested me. In an Excel spreadsheet, I recorded the patient and doctor names, primary diagnosis, unexpected finding, and a blank column for follow-up biopsy reports. I would review it every few weeks and, if I didn’t see new test results, I would get in touch with the referring doctors.

Sometimes my colleagues appreciated my check-ins. Other times, they were resistant because I was bringing up issues unrelated to the reasons for the initial scans. “Agress, what are you talking about?”

I was making things more complicated for them since they had to order more examinations and talk with their patients about getting further testing. To a patient who’d come in to be evaluated for lung cancer, their physician might have to recommend a colonoscopy. “It’s just going to make the patient more anxious,” they argued. Why was I making trouble? 

Pressuring doctors wasn’t easy or comfortable. But the extra follow-up had huge benefits: Patients got better care, and I could apply what I’d learned to future cases. Ultimately, it became the single best learning tool in my decades-long clinical practice. In the long run, it even enhanced my relationships with my fellow physicians.

Eventually, I authored a study on the importance of unexpected findings on PET scanning as proven by follow-up and presented lectures to associations in my specialty.

In my retirement, I had more time to consider ways to move the concept forward. While volunteer teaching at the Weill Cornell Department of Radiology, I suggested launching a follow-up program for the radiology residents. Though they were receptive to my idea, I still had to be persistent to get it done.

The program started 3 years ago. Each resident follows up on three cases to the point of biopsy/surgery and then presents them in conference to their peers. It has been popular, as all the residents get to see the most interesting or unusual cases.

They are learning, as I did, that following a patient’s entire journey, rather than just one part of it, is more satisfying, educational, and impactful. To say this has made me happy and fulfilled is an understatement. So don’t be afraid to inconvenience someone. Make that phone call. It might save a life.

Harry Agress Jr, MD, retired from clinical practice in 2015 after a 36-year career in diagnostic radiology and nuclear medicine. He is the author of “Next Years Best Years: Taking Your Retirement to the Next Level” and volunteer teacher at Weill Cornell, Memorial Sloan Kettering Cancer Center, and New York-Presbyterian Hospital/Columbia Irving Medical Center, New York City, where he is a clinical professor. 

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The experts cited in this article had no relevant disclosures.