August 17, 2009

Every Patient Tells a Story

You just don’t feel right. Maybe you’re a little more tired than usual. Your muscles themselves seem weak. That’s odd, since you lift weights nearly every day. Maybe you’re just pushing yourself too hard. Over a few months, you notice that your handwriting is hard to read, and it takes both hands to lift a cup of coffee. In the Emergency Room, they said that you weren’t having a heart attack and sent you home. Then, gradually, your fingers seem less sensitive….

In this remarkable book, Dr. Lisa Sanders opens a new and original window into the diagnostic process. As patients, we’ve all had a sore throat or sprained ankle, and the doctor’s work seemed obvious: do a test, get an x-ray, write a prescription. But sometimes we don’t have a straightforward collection of complaints that we could have figured out by ourselves. Is the headache I had a few days ago somehow connected to my cough today? How do doctors make sense of the information we give them?

She’s got great material. As the long-time author of the Diagnosis column in the New York Times Magazine, she has been collecting the stories of diagnostic hits and misses for years. She uses her network of medical contacts to find the valuable pearls of seeing patterns in what looks like chaos. Her column’s focus on diagnoses that aren’t obvious always makes for compelling reading that can’t be put down.

But there’s a lot more in this book than a compilation of some of her columns. In her Diagnosis writing, she seems like an invisible narrator, allowing us to observe a medical detective story unfold before our eyes.

Every Patient Tells a Story has plenty of those medical mysteries. But Dr. Sanders has shared not just the events, but her own insight into the process. She’s completely candid about missed diagnoses, tests that should have been done, questions that should have been asked—including instances when she was the physician who might have done better. She does not hesitate to point out the dangers of skimping on the physical examination of every patient, and has convincingly written about changes that need to be done to change medical education in a way that brings physicians back to basic exam skills and diagnostic thinking.

The book’s focus is not the detective stories, though they are fabulously written and fascinating to read. It is the process of discovery that clearly interests her. Why do some doctors miss something again and again, even though it’s right in front of them? Why do others see what’s hidden? How can we teach doctors to see the forest for the trees? Computer technology would seem to lend itself well to the understanding and improvement of this kind of analytical task, in which diverse bits of information are processed into a coherent result. She examines the development of artificial intelligence models for making a medical diagnosis, with data to illustrate their weaknesses and strengths. (They’re not quite here yet.)

Dr. Sanders makes her strongest arguments when pointing out a major weakness in physician behavior. The title, Every Patient Tells a Story, says exactly what she means. Doctors need to listen to what the patient has to say. Again and again, the trail of clues—even to the most obscure and unlikely diagnosis—starts there.

This is the most interesting book I have read in years. I couldn’t put it down. The narrative stories are fascinating, and her insight is right on target. Everyone who’s ever been a patient, and certainly every doctor, should read it.

The book moved me in many ways, so this won’t be the only blog post about it. If there’s a unifying theme to the book, it’s the importance of doctors listening to what patients say. Yes, she points out at length how many doctors don’t do or don’t respect the physical exam. She describes interesting cases in which basic observation would have provided a crucial diagnostic clue, yet the doctor didn’t observe—or maybe didn’t see—what was right in front of her. I don’t know if this was the work of her editor, but she does a very good job of staying ‘on topic.’ That’s a reasonable thing, and makes the book focused and coherent reading.

Dr. Sanders gives convincing proof that doctors are skimping on the physical exam of their patients, and doing a particularly poor job listening to patients. Many of the stories she recounts hinge on a key physical observation, or an event the patient described but didn’t seem important at first. She describes some new educational methods to improve these weaknesses. For example, doctors in training are now required to pass a practical exam on interacting with and examining a patient.

That’s a great idea, but I’m very pessimistic about its long-term impact. Here’s a statistic I’d love to see that she did not mention in the book: for a perfect score in this practical patient exam test, how much time would be necessary? Even if it wasn’t done by a medical student—I want to see the head of a patient-care department do it. Even if that department chairman had the notes in her hand (the teacher’s edition of what tasks had to be done in that exam to have a perfect score), how long would it take? I know nothing about this effort, and I applaud it. But when I read about it in the book, I started to think: introduce yourself, wash your hands thoroughly, find a seat and sit; describe what you’re going to do, ask some basic demographic questions. Most important in the interview: ask open-ended questions, listen to the patient’s complete answer. I figured that before even the most organized and experienced interviewer got to the physical exam, quite a while would have gone by. 15 minutes? 30? More?

Many medical practices schedule patient visits every 20 minutes. Some places I know are every 10 minutes.

I discussed this in my series of posts called Slow Medicine. I’ll add, after reading this book, that if the factory model of medical care is, as Dr. Sanders shows, likely to result in missed diagnoses and frustrated patients, it’s much, much more of a problem with children.

In pediatrics, the patients often don’t get to tell their story. I believe that every child does tell a story about themselves. The only way to hear it is to take the time to establish some level of rapport with the child. With many children, and with children the doctor is meeting for the first time, that’s just not possible in 5 or 10 minutes.

Until doctors stop getting paid per visit, the irresistible pressure to see more patients and spend less time with each one will force those laudable lessons of medical school into the dusty trash bin filled with good ideas.

More to come on this amazing book.

1 comment:

  1. Thanks, Dr. Wolffe. Not only in medicine, but in many other facets of life, listening is a dying art.

    Mr. Rogers


Please let me know what you think. Do you know a child or situation like this?