(Estimated Read time: 11 minutes)

I recently shared a story with you about the first time I experienced something totally unexpected clinically, and was shaken out of “Dr. Bernard” mode. You can find that story here. Even though I was rattled at the time, it was a light, and fun story. Everything worked out in the end.

This story is very different.

I moved to Florida in the fall of 2009, right after finishing chiropractic school. It was for an internship to work in a chiropractic clinic that had a treatment and practice philosophy that wasn’t really common in the profession. The clinic director had been practicing for over 40 years at that point, his parents and grandparents were chiropractors, and his son worked at the clinic as well.

Chiropractic was clearly, in their blood.

The internship however, was unpaid. So I had to find an ‘evenings and weekends’ kind of job that wouldn’t interfere with my internship.

At this point, you might be thinking to yourself:

Come on Moses, just work in a restaurant, get a bartending job, work retail. There’s plenty of evening and weekend jobs..

And there are plenty of evening and weekend jobs. But at the time, it wasn’t that simple. See, as a Canadian living in the US, I had just come off of a student visa that rolled into a different category called “Optional Practical Training” (or “OPT”). The requirements for the OPT were that I would only be legally eligible to work in my related field or industry. So now the question is, how many chiropractic jobs out there are willing to take on new graduates, ONLY in an evening and weekend setting?

The answer? Not many.

I shared my dilemma with my immigration lawyer, and she mentioned that the Department of Homeland Security wasn't that strict when it came to the OPT being my exact field. She mentioned that anything even remotely related to health and fitness would work.

Armed with this new knowledge, I went to the mall, and applied at one of those specialty running stores. You know, the ones where they look at your feet when you run on a treadmill. Enter the manager.

Remind me again why you want this job? You’re a doctor. Most of the employees here are high school and college students. You’re WAY overqualified.

And I was overqualified. Overqualified, yet unemployed.

I told him about my internship, and the OPT requirements. And while this job was loosely in the “health and fitness” category, my lawyer mentioned that having a job description that seemed a little more professional would help.

“Sales associate” was out. “Biomechanics analysis specialist” was in.

So this is what I did throughout my internship. Clinic all day Monday, Wednesday and Friday. Half days Tuesday, Thursday and Saturday Mornings. So I worked at the shoe store any afternoon and evening that I wasn’t at the clinic, and as much as possible on the weekends.

At this point I’m working 70+ hours a week, with only around 30 of them being paid. Then in the evenings five days a week I went to the gym. Saturday in the early morning, I rode the bike.

Unfortunately, the clinic where I was working didn’t have a position for me when I finished my internship. And my backup plan at the time was to move back to Texas and work with a doctor I had been shadowing with throughout chiropractic school. So I took those 40+ hours of unpaid time and rolled them into a different paid position. I found a job as a trainer at a gym. OPT rules, still in effect.

“Personal Trainer was out. Rehabilitation” & “Rehabilitation and Corrective Exercise Clinician” was in.

A nice little bonus about this gym, is that the owner’s husband was also a chiropractor. And he ran a satellite clinic out of one of the rooms in the gym for a few hours a week. So even though I wasn’t in a chiropractic office, I still was able to learn some things from a much more experienced clinician.

At this point, it’s early 2010. I’m working two fairly entry level jobs, and I’m still trying to figure out exactly what I want to do with my professional life. Well due to some unforeseen events over the next few months (that I’ll definitely share with you some other time), I ended up staying in Florida and working those two jobs a lot longer than originally planned.

Which brings us to spring 2011. Now this entire time, I had been working with a Texas-based immigration lawyer, to help transition me from a work visa into permanent residency. And she was dropping the ball. I found one locally in Florida to see if they could figure out exactly what was going on, and much to my surprise the new lawyer tells me:

Your old lawyer dropped the ball BIG TIME. You’ve been out of status for several months now. You need to leave the country NOW.

Awesome.

Apparently lawyer #1 misinterpreted the laws as written.

Whoops.

(In her defense, US immigration law is confusing AF – but it was still my ass on the line.)

The only way back in, was with a new type of work visa, and it had to be much more specific to being a chiropractor. Which brings us back to my original internship.

Fortunately for me, now they DID have room for me to come on as an employee. So I got my paperwork and affairs in order, left the country for the required amount of time, and was able to get back in without too many hiccups.

So now the stage is set. It’s been a little under two years since I graduated, and I finally have my FIRST grown up chiropractic job. And even though I was able to intermittently talk about chiropractic things with the Dr. at the gym, I wasn’t really seeing patients. So I was a little rusty.

The patient flow of this clinic was set up so that I did the initial new patient exams, and I’d shoot and analyze their X-rays if indicated. I was also responsible for doing what’s called a “Report of findings” in chiropractic circles. The “Report of Findings” (or ROF), usually happened on their second visit, right before they received their first treatment. It would be the place where we went over their exam findings, their X-ray findings, talked about the treatment plan, and any questions they might have. My job was to do all of the above, and then hand the patient off to the treating doctors.

It had been less than a month at the new clinic, and a patient that I’ll never forget came in. He had the swagger and demeanor you’d expect from someone who’d lived through a major war.

Because he did.

This was NOT the kind of guy who would go to a chiropractor (or any medical professional for that matter) unless he absolutely had to. Take your typical marine, and let marinate for over 50 years. He was THAT guy.

And let’s talk about the elephant in the room – Florida IS still the deep south. I’d encountered levels of racism that as a Canadian, I didn’t know still existed when I moved to the US. And more than once in that very clinic. And I knew this could be one of those situations.

Fortunately, I didn’t have to keep my guard up. The patient (let’s call him Jim) was extremely nice, extremely polite and had some other veteran friends who had come to the clinic and got great results. He mentioned that there was a pinpoint location in his neck that had been pretty painful over the last few years. There wasn’t any specific event that kicked things off, it had just been gradually worsening and he wanted to know if anything could be done about it.

Nothing seemed too out of the ordinary in Jim’s history, so we went to the exam. The exam seemed pretty typical aside from the painful spot in his neck being a little shifted from where most people feel things. In retrospect, I’d realize that there were a few clues in both the history and the exam that would have left me less shocked with what was to come.

Protocol at that clinic was to x-ray any patient we were considering adjusting. So in shooting the images, I wasn’t thinking about what I saw on the images themselves, just that the positioning was acceptable.

I remember something felt a little off, but I couldn’t put my finger on it. I didn’t put it all together until I sat down to do my analysis a few hours later.

You know those “spot the difference” games where there are two similar pictures and you need to figure out what’s missing in one and not in the other? You used to see digital versions of them at bars or restaurants.

Alright, so the non-medical people are about to get a basic lesson in x-ray analysis. Don’t worry, it’s not much more complicated than the lobster example above.

To start, here’s a fairly typical neck x-ray:

In this example, the person’s face is looking to the right of the page. Medically, the neck is called the “cervical” spine, and there are 7 bones in the cervical spine. Medical people aren’t creative, so they’re called C1 to C7. Original right?

You may notice that C3-C7 are all fairly similar in their shape. This will become important.

The example I’m going to give you is my best photoshop representation of what Jim’s real x-ray looked like.

Ready?

Notice how C3 and C4 are smooth squares on the left picture, yet don’t exist on the right picture? Well as a general rule, bones are supposed to exist. Also, neck pain is more common in the C5-C7 areas. So imaging findings in C3 and C4 are a lot less typical.

Class one: “x-ray analysis for dummies”.

Class two: “Well fuck, that’s cancer”.

Let’s recall. I mentioned earlier there were some clues in the history that should have tipped me off. Well, Jim mentioned that he had a history of prostate cancer around 20 years earlier. You know how when you roll an ankle, you’re more likely to roll it again in the future? Well without trying to be insensitive, cancer is like that too. Getting cancer once is among the biggest risk factors to getting it again.

History of cancer. ❌

When it comes to types of cancer, some symptoms are easier to ignore than others. And in some cases, the symptoms where the cancer has spread are more severe than where the cancer originated. Sometimes - especially in people who don’t do regular bloodwork or screenings, the first thing that causes a patient to seek treatment is when the cancer has progressed to causing pain in their bones and joints.

Localized, unrelenting pain in the bones and joints. ❌

Statistically speaking, neck pain is something that’s way more likely to be a biomechanical issue than a cancerous one. So in most cases “neck hurts -> see chiropractor” makes sense.

Not a lot of people know this, but because of this “neck hurts -> see chiropractor” reality, chiropractors are the first line of ‘defense’ in a lot more cancer cases than you’d expect. EVERY chiropractor I’ve met with at least 10 years of experience has told me that they’ve had at least one patient with an advanced cancer. An advanced cancer that the patient didn’t know about until the chiropractor found something off in the exam.

So let’s recap. The patient had a history of cancer in his pelvic area (prostate), localized pain in his neck, and atypical x-ray findings.

Oh, and the patient was over 80. Advancing age is another major cancer risk factor.

Advancing age. ❌

Let me share some stats with you from a 2010 study out of Denmark, with over 23,000 participants:

Advanced prostate cancer survival incidence

Without bone metastasis

One-year survival: 87%

Five-year survival: 56%

With bone metastasis

One-year survival: 47%

Five-year survival: 3%

With bone metastasis and skeletal-related events

One-year survival: 40%

Five-year survival: less than 1%

A “skeletal-related event” would mean there’s pain or symptoms in the bones. And this particular war veteran DEFINITELY had that.

So here I am, less than a month into my first chiropractic job. I’m looking at an x-ray that CLEARLY isn’t normal. A lot of thoughts were rushing into my head.

How do I tell a patient he has cancer, and may only have a few months to live?

The clinic director was at a computer next to me, so I showed him my screen.

Is this what I THINK it is?

My boss, channeling his 40 years of clinical experience as if this wasn’t a big deal:

…Yep…

Me on the inside, screaming.

“This patient has cancer! I have to show him these x-rays in 20 minutes. All I get from you is an indifferent “yep”?!?!?”

Remember, I’m in Florida. This clinic had a HUGE geriatric population. And the southern US has this unique “rub some dirt on it and walk it off” approach to healthcare. Waiting until it’s too late probably happens more than necessary here.

Clinic director:

We see cases like this every 6-8 weeks. 40 years in, it stops being surprising. Always devastating, but never surprising.

Me, now out loud:

Alright, so….how exactly do I tell him what this is?

Clinic Director:

Here’s the good news: you don’t. You’re not an oncologist. Even though this looks a LOT like cancer, and is very likely cancer, it’s not your job to say whether it is or isn’t. That’s the oncologist’s job. YOUR job is to make sure the patient knows this isn’t normal, and make sure he follows up with his GP or oncologist ASAP.

What he said made me feel better, but I still knew this wasn’t going to be an easy conversation.

It was a surreal experience. Describing that area on the x-ray as “kinda blurry”, knowing what that blur really meant. Telling Jim I wanted to make sure he saw his GP before we did any chiropractic treatment, knowing that chiropractic treatment was never going to happen.

You sure you can’t just adjust me today doc?

Jim, I REALLY insist you follow up with your MD, just to be make sure this looks normal.

He eventually realized I wasn’t going to treat him that day, and booked a follow up for a few days later.

Well, I guess this has been bugging me for years, a few more days won’t make that much of a difference.

That follow up appointment never happened.

A few days later, the office received flowers from Jim’s wife. In the card, she mentioned that she was so happy - they had a trip around the world they were planning next year, and they decided instead to leave next week.

See, Jim ended up listening to me, and saw his oncologist. Their tests showed that the cancer had metastasized all over his body, and at best, treatments would make the end of his life a little more comfortable. He took a pass on treatment, and decided the trip around the world seemed like a better way to ride things out.

About six months later, we received flowers from her again. Jim had passed away. Guess what though? He died AFTER finishing his trip.

Jim, thank you. Thank you for reminding me that everything can change in an instant. Thank you for reminding me that sometimes the stakes are a lot higher than what you’re expecting. Thank you for reminding me that this healthcare thing can blindside you. Thank you for making me a better doctor, and a better person.

-Moses