I spent thirty years in academic medicine as a dean for faculty affairs and development, training physicians to be not just clinically competent but genuinely patient-centered and thorough. I believed in the system I helped build. I still do, mostly. But I am also a patient. And as a patient, the system failed me for fifteen years, not through negligence, but through something quieter and harder to fix.

Fragmentation.

The history

In 2005 I was diagnosed with cervical cancer and treated with extended pelvic radiation and chemotherapy. Treatment was successful. About five years later I began developing progressive bowel and bladder problems which are known possible consequences of pelvic radiation. Over the next fifteen years I saw multiple gastroenterologists at academic medical centers. I disclosed my radiation history at every appointment.

The diagnosis, consistently, was irritable bowel syndrome. Not once did anyone suggest my symptoms might be related to my pancreas.

The four words

This past spring I came home from international travel with a bowel infection and went to the emergency room. They did a CT scan, found the infection, and sent me home. I read the scan report in my medical chart.

Listed as a passing, incidental note were four words that had apparently not warranted a follow-up conversation: Pancreas is severely atrophied.

I went home and searched the medical literature. Within an hour I had found what fifteen years of specialist appointments had not surfaced: Pancreatic enzyme insufficiency is a documented consequence of extended pelvic radiation. The digestive symptoms it causes are well established. And there is an effective treatment, pancreatic enzyme replacement therapy, specifically Creon.

I am now being treated. For the first time in fifteen years, I am hopeful.

The systemic problem

I am not saying my physicians were incompetent or uncaring. I am saying that the way we deliver specialty care creates conditions where critical connections across a patient’s full history are routinely missed.

A gastroenterologist treating bowel symptoms is not always thinking about what a radiation oncologist did to that patient’s pelvis fifteen years ago. An oncologist managing follow-up care is not always tracking what the gastroenterologist documented last year. And a primary care physician cannot reasonably be expected to hold all of it together in a fifteen-minute appointment.

Patients with complex histories, cancer survivors, people with multiple chronic conditions, older patients whose current symptoms are the downstream result of treatments from decades ago, fall through the gaps. Not because anyone failed individually, but because the system was not designed to see them whole.

I taught physicians for thirty years. I understand the pressures. I am not standing outside the system throwing stones. I am standing inside it, as both educator and patient, saying we can do better.

The specific clinical ask

Pancreatic enzyme insufficiency following pelvic radiation is not obscure. It is documented, if underrecognized, and affects a significant number of radiation survivors.

I would ask every physician reading this: When a patient with a history of extended pelvic radiation presents with unexplained digestive symptoms, please add pancreatic enzyme insufficiency to the list of possibilities. A simple blood test measuring pancreatic elastase is a straightforward starting point. And when a scan incidentally notes pancreatic atrophy, that finding deserves a follow-up conversation, not a notation that lives in a report the patient may never see.

This is not a call for additional testing across the board. It is a call for pattern recognition across a patient’s full history.

The broader ask

The patients most likely to fall through these gaps are older. They are often women. They are frequently patients who, like my mother’s generation, were taught to defer to medical authority and not to question or push back.

I am a different kind of patient. I have a PhD. I spent my career in academic medicine. I knew how to read a scan report and search the literature. I had the confidence to follow up on four words listed as incidental.

Most patients do not have those advantages. Which means the gap I fell through swallows far less resourced patients whole because they were taught that if something were important, someone would have called.

When you see a patient today, particularly an older patient, a cancer survivor, a woman who has been managing the same unresolved symptoms for years, ask the question nobody has asked yet: What in this patient’s history might explain what I am seeing right now?

Not just the history from the last visit, but the full history. The radiation from fifteen years ago. The treatment whose effects are only now becoming visible.

Connect the dots. Your patient has been carrying this history through every appointment, disclosing it faithfully, and waiting for someone to see what it means.

Sheila Crow is a professor of pediatrics and a medical educator.