August 19, 2009

Every Patient Tells a Story, Part 2

In this brilliant new book by Dr. Lisa Sanders, Every Patient Tells a Story, the key success factors that make diagnoses appear for some and stay hidden from others are pointed out in compelling clarity.

She's just the right person to do this, too. Writing her column in the New York Times Magazine, Diagnosis, she must see hundreds more cases that she can possibly write about. Each of the cases are intricate, and even for relatively common conditions the diagnosis often hinges on one key piece of information—sometimes a few pieces. And very often, the clues are there in the patient's own words. Sure, a specific test might confirm it, or rule out some alternatives, but in many of these mystery cases, the patient's story is indeed the single most important factor.

This has led her to important insights into the method of diagnosis, and the impediments to teaching it. She cites evidence that key physical exam skills continue to weaken among recent trainees. I recall hearing that when I was in medical school 15 years ago, and an older colleague confided that he had heard it 35 years ago also. (I speculate that the optimal exam skills are probably found in places where there is not enough technology to do the work for the physician, but there is just enough to validate the doctors findings. Maybe this should be called the second world, somewhere between First and Third.)

And most importantly, she documents the failures of listening skills among doctors. Frequent interruptions, closed-ended questions, and premature closure of the differential diagnosis are cited by example and in research studies. Her thorough approach assesses the impact of artificial intelligence decision models and innovations in hands-on medical education. As I pointed out in my previous essay[link to epts1] on this great book, however, the current economic model of physician-patient interaction is likely to put irresistible pressure on the examining physician to keep visits short, questions closed, and interruptions as frequent as ever.

Every Patient Tells a Story is about doctors. How they think, how they approach patients, problems, and data. It's particularly brave of her not to sugar-coat the stories of several doctors missing an important diagnosis because they didn't do the full job of examination and history-taking. She never says, but it's clear by example, that some doctors are just more motivated and tenacious than others about getting to the bottom of a patient's problem. Dr. Sanders does a superb job of pointing out what some did right.

But there's another book here, too. It's the unwritten shadow book, this same book, these same stories, through the looking glass. Sanders gives the reader insight into what is usually invisible to them—the intensely caring physician who's calling all her colleagues and spending time in the library for the benefit of a patient. The mirror book would give the physicians insight into what Sanders shows to be completely invisible to them: what the impact of a rushed or absent physical exam means to the patient, how the frequent interruptions feel, the frustration of not being able to tell the story that every patient tells.

Illness often affects us in unanticipated ways. For a child, the new feeling of feeling bad is usually unfamiliar and frightening. Fortunately, the relationship I have with most of my patients is helpful under these circumstances. Kids are usually not afraid of me. Many awaken and tell their parents that they need to see Dr. Wolffe, just because they think I'll make them feel better. I'm not interjecting this to brag—I think it gets to an important part of the patient-side of Every Patient Tells a Story. Usually, when I see a sick child, I don't start even by talking to the parent in the exam room. I am totally focused on the child. I always start by asking them if anything hurts. They generally will tell me, often to the surprise of the parent. I ask them to tell me how it happened, what it feels like, and when it started (this last is often the least dependable of the questions, and sometimes results in a 3-year-old telling me that her ear has been hurting for 5 years, while holding up 2 fingers). Only rarely does a parent not interrupt. This is done, I know, with the best of intentions, to help give me the most accurate information on which to base my professional assessment. They stop when I hold up my hand and indicate that I want to listen to the child, but they will get their turn soon.

Here's why I do it. It makes the child feel better. To them, their symptoms are not just uncomfortable. The symptoms are out of their control, and appear to trigger actions by their parents that are obviously concerning and also out of their control. This all can be very anxiety-provoking. I purposefully give them this opportunity to voice these anxieties in a safe place, where they can say it their way and I will listen to them and respect them.

One of my patients just started preschool for the first time. Every morning before he was to leave, he complained of a stomach ache.

Just like adults and headaches, there are stomach aches of all different kinds and intensities. It didn't take a particularly intense interrogation to figure out that the child wasn't having any other gastrointestinal symptoms. The pain started on the first day of preschool, when mommy was leaving for work. A couple of times she called in sick to stay with him. On those days, his abdominal pain vanished as soon as she said she'd stay. I gave the mother some ideas of behavioral things to try to make the transition easier, and told her to call and let me know how it was going. Realistically, no exam was going to help me make a diagnosis in this happy active boy who was running and jumping around in my office. But I knew that the exam could have a powerful effect on the patient. I had listened to him tell his story. But he had to know that I would understand his pain when I examined him. Carefully, without joking, I listened to his chest and stomach. I looked in his ears and mouth, felt his neck. And last, I slowly examined his abdomen. I had a serious expression on my face, as if searching for something. Finally, I spoke to his mother directly, with him in the room. She's a school principal—but I used mostly 1-syllable words in my most grown-up voice and cadence. 'I can see what the problem was,' I said thoughtfully. 'I'm sorry he was so sick and his tummy hurt so much. I think it's all better now and it won't hurt any more.'

OK, maybe the analogy to this use of the placebo effect isn't perfect. But I hear it from adults all the time. 'The doctor saw me but he didn't even examine me.' I hear it from my mother.

I believe there is something important in gentle physical touch. During a physical examination, the touch isn't as a friend, and sometimes elicits pain. But the touch of the doctor's hands is more than a one-way data cable from patient to doctor, providing resources to the diagnostic algorithm. The patient is getting information, too. The patient's information is not examined in Every Patient Tells a Story. I suspect some of the information is about the caring of the physician. But the deliberation of the touch, how unhurried it is, how focused it is on finding out just where it hurts are all things that I suspect every patient perceives. And patients value this as well.

This is more than a placebo effect. Obviously, when we don't feel well, it's good to have somebody available who's a sympathetic and patient listener, a good observer, with a gentle and caring touch. That would make anybody feel better. But I think there's an important feedback loop here that has a real impact on the Story that Every Patient Tells. It's the rapport, the unrushed atmosphere in the exam room, the openness of the examining physician that elicits that story. And hearing that story--listening to that story--can sometimes determine if the patient lives or dies.

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