Add ovarian cancer Pain no physician to the differential can take away “Postmenopausal bleeding: After her second day in the 8th First steps in the workup” grade, my 13-year-old daugh- (J Fam Pract. 2012;61:597- ter, Gracie—a smart, outgo- 604) brought to mind a pa- ing, and nonconfrontational tient whose condition was not girl—came home in a terrible included in the differential for mood. She’d gone to the wrong postmenopausal bleeding, restroom, been chastised for but should have been. her attire, and threatened A year ago, a 79-year- with detention, all in one day. old woman came to see me When I complained about the because of vaginal bleeding. way she was addressing me, Her Pap test was normal, she said I would just have to and lab tests and a transvaginal ultrasound cut her some slack because she was having were negative. I referred the patient to a gy- “a really bad day.” necologist, who did an endometrial biopsy. My response, I’m certain, was not what That, too, was negative, but the spotting did she expected to hear. Starting not stop. “Let me tell you about a patient of mine, medications, The gynecologist told the patient not to and what it means to have a really bad day.” they say, is worry and to check back in 6 to 9 months. That morning, I had received a call from like the bliss But a week after seeing the specialist, the pa- Sheila, who told me, through her tears, that of marriage; tient—still worried—came back to see me. I her son, Jonathan, had been killed in a mo- stopping them did a CT scan of the pelvis and found ovarian torcycle accident the night before—just 2 days is like the cancer. before he was to be married. agony of Needless to say, ovarian cancer is not Ten years earlier, Sheila’s daughter died of divorce. very common in women of her age. Yet it cancer. Now she had lost 2 children. And, in is part of the differential (and another test) the last year alone, Sheila had a heart attack that the authors did not include, but that and a fractured hip and knee, spent several physicians evaluating women with post- months in a nursing home, and had been left menopausal bleeding should consider. with physical pain that wouldn’t go away. “Gracie,” I asked, “how could you possi- Randy M. Bork, DO Lapeer, Mich. bly compare your bad day with Sheila’s?” She stared at me, eyes wet with tears, and I knew I Getting patients off meds had gotten her attention. is hard to do Doctors are healers, trained to identify and Dr. Hickner’s editorial, “Let’s put a stop cure disease and to comfort those with incur- to the prescribing cascade” (J Fam Pract. able illness. Yet some patients face devastating 2012;61:645), reminded me of the clinicians loss that we’re often unprepared to handle. I at the Therapeutics Education Collabora- am not a minister or a rabbi. I had no medica- tion—a Canadian physician and pharmacist tion that could take away Sheila’s emotional who produce podcasts on evidence-based pain. The only thing I could offer was comfort. medicine. Starting medications, they often I phoned Sheila that night and told her say, is like the bliss of marriage; stopping that her call to me had taught an impression- them is like the agony of divorce, and is some- able teenager an invaluable lesson. She re- times very hard to do. plied that while she will never get over the loss Personally, I love stopping medications. of her son, her faith in God and determination I like to say I’m reducing patients’ medica- to live on are strengthened by the loving kind- tion burden. ness of her family doctor. Jeff Unger, MD Michael F. Mirochna, MD Chino, Calif Valparaiso, Ind Editorial board, The Journal of Family Practice

718 The Journal of Family Practice | december 2012 | Vol 61, No 12