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.

Toddler Makes Friends with the Doctor

This was a great day and a great visit.

I had my first visit with a 16-month-old girl today. Her mother interviewed me a week or so ago. When her mother called today, I told her that I was surprised I passed the audition.

I didn't think she'd pick me as she looked for her new pediatrician. My practice is very grounded in practical science, and in general I am reluctant to intervene unless necessary. This is a luxury of good access to the physician and a willingness to see patients whenever they need it. It's a luxury of good follow-up. So I don't routinely give a prescription to every kid with a cold. This parent liked that, but I know she would have preferred a doctor who was ambivalent about vaccination but a cheerleader for something more alternative. It took a lot of humility for her to return to me with her child when it would have been easy to find a practitioner here in Berkeley who could meet every litmus test for alternative medicine. But her daughter had a cough for a few days. When she called, I suggested she bring her daughter in today.

During the interview last week, the girl was exploring the toys I have in the office. They are there for a reason, after all. She was reluctant at first, and didn't know what to make of the balding giant with the tie. It is an anxiety-provoking situation at her age. I saw she was not comfortable, so I took the basket of stuffed animals, turned it over, and let them all fall into a big pile on the floor. I laughed when this happened.

Today it was the first thing she did. She knew just where to go and didn't ask permission. She picked up the fabric basket and dumped out all the stuffed animals. She really laughed. Then she put the basket over her head. For the first 10 minutes or so, I sat on the floor and did silly things with her. When her mom and I were talking, she would sometimes seem bored, so I got up and fetched her a new toy from another room. Her mother looked a little concerned when the floor was covered with toys. I reassured her that this is exactly what will help the child be comfortable.

Eventually, of course, it was time for the exam. As I approached, the child backed away into mom's lap. I kept talking to her in a soft voice. I offered her my stethoscope to handle and check out, just to make sure it was OK and nonthreatening. I picked up a stuffed dinosaur. First I listened to the dinosaur, then her mother's leg, then the dinosaur. Back and forth right in front of her just to show that neither her mother nor the dinosaur minded even one bit. Back and forth she followed the movement as if she were watching a tennis match. Then I made a quick stop on her chest--just for a moment--and then back to the dinosaur. Then a longer pause on her right chest, dinosaur, left chest, dinosaur, right back, dinosaur, left back. I took off the stethoscope and handed it to her. She gave a big smile and put it on her ears. I took out my little otoscope and handed it to her. She knew right away! She put it in her own ears and I held on briefly to give myself a quick view. By this time she was laughing a lot and I as able to use one of those opportunities to get a good look at her throat. I felt her neck and we were done.

That was the first time in her life, her mother said, that she ever had a doctor visit in which she wasn't screaming throughout. Her mother said she'd start screaming when they approached the doctor's building.

I've seen doctors examine children who are screaming. Sometimes that's what has to be done and there's no way around it. But I've never met the 1 to 3-year-old who lets a non-parent adult get right into their space and poke around the way a doctor does. I have sometimes read exam notes that say that a kid's heart sounds were normal or their lungs were normal when the only exam was while the child was terrified and wailing. It takes practice and patience, and both only come when the doctor is willing to take the time to let the child come to him.

Medically, a child's uncooperative demeanor is a potentially serious confounder of physical exam findings. Crucial and subtle observations, such as sounds of the heart and lungs and abdomen, are easily eclipsed by the glare of screaming. Indeed, the gestalt of the child is an essential observation of the skilled examiner (ie does the child look sick?). Is the child in distress from the illness or from the situation? The good doctor needs to know these things and figures out how to get the information needed. It may look like play, but I take it very seriously and work very hard at it.

Just as with adults, some kids are a lot more anxious than others. But just as with adults, it's a lot less stressful to have a doctor you like. I believe that this results in better care. The exams are better, the communication is better. Even the communication between 16-month-old and pediatrician.

The kid had a cold, I thought. No need for medicine, I told the mother. Some home-made nose drops might help with the congestion. Nothing for the cough unless it gets to be a problem. And of course, call me anytime if you're worried or if she's not better in a few days. The only time the child was upset was when she was leaving. Her mom and I agreed to make another playdate soon.



The photograph: photographer Arnold Eagle is most famous for documenting the Lower East Side, a tenement area of New York City. In the 1930's he took a series of photographs he called One Third of a Nation, referring to children living in poverty. He made up a book from the prints of this series, and gave it to his wife as a gift. There are no other copies beyond the one that was in my collection.