‘Uncertainty Is the Sea We Swim In’
Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis. By Lisa Sanders, MD. 304 Pages.
Broadway Books 2009.
Making a diagnosis, writes Yale internist Lisa Sanders, MD, is often the “most difficult and most important part of what physicians do.” Yet the process is “mostly hidden, often misunderstood and sometimes mistrusted” by patients. To demonstrate her point, she puts readers “in the front line, in the shoes of the doctor at the bedside,” recreating both the thrill of solving a difficult problem and the anxiety of diagnostic error. A surprising number of her medical mysteries concern neurologic diseases or neurologic manifestations of systemic disease. In the process of matching wits with great medical minds, she touches on a wide array of contemporary issues in medicine.
Dr. Sanders was a television journalist before becoming a doctor, and she has a reporter's instinct for interesting stories. Her “Diagnosis” column appears monthly in the New York Times Magazine, and she is a technical advisor for Fox TV's “House, MD,” whose prickly protagonist is reminiscent of Sherlock Holmes.
Somewhat predictably she begins by detailing how complex it can be to obtain a good history and how the emotional impact of illness can lead patients to minimize symptoms or simply lie, particularly if rapport with the physician is poor.
Physicians will likely be more interested than the general public in her passionate dissertation on the “death of the physical exam.” Shorter hospital stays make it harder to learn clinical examination skills on ward rounds. The 80-hour workweek for residents often limits time spent with patients. Earlier detection of disease permits successful outpatient treatment. Despite training in physical diagnosis in medical school, she laments, house staff quickly learn that test results are valued more than physical findings on a hurried inpatient service.
As clinical skills have declined, so has physicians' faith in physical examination, which leads to reliance on and overuse of expensive tests. Although time consuming, attendings need to observe not only medical students but also residents and fellows actually examining patients, she contends.
Neurologists need no convincing about the value of careful examination, and most probably feel our colleagues in other specialties could refresh their skills. For example, neurologists may scratch their heads at the reasoning described during a “Stump the Professor” session. The discussant elects not to obtain a CT scan of the brain, opining that the patient, a 73-year-old woman with dementia progressing over three months, has “no neurological findings...except confusion.” Stylized case presentation might withhold information, but a retired high school Latin teacher who has difficulty finding words, gets lost while driving, and needs help with “basic daily activities” most certainly has neurological findings. Here, as in other case discussions, the problem of addressing both a general and a professional audience can be frustrating. Dr. Sanders is frequently vague on crucial details. Knowing the location and type of this patient's brain tumor would help reinforce the essential lesson of the case.
Neurologists, however, should take heed. In the early testing for the reinstituted United States Medical Licensing Examination of clinical skills, Dr. Sanders reports that 20 percent of fourth-year Yale medical students failed the test. She mentions one especially egregious example of a student who, when given feedback about his performance, replied that “he didn't need to know the heart exam — he was going into neurology.”
Refresher courses in clinical skills are now part of national meetings of the American College of Physicians and the AAN. In addition, learning detailed exam techniques from other specialties such as orthopedics proved extremely popular at a recent meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine. And, perhaps inevitably, an enterprising University of California-San Diego medical student has developed an iPhone application called iMurmur to help learn heart sounds.
Despite technical innovations and advances, Dr. Sanders observes that medicine is deeply conservative and traditional. There is, she concludes, an “almost pathological unwillingness to change the way doctors are trained.” And changing practice habits is worse. On average it takes 17 years for half of physicians to adopt research-proven changes in treatment, such as routinely administering aspirin during a heart attack.
Several overly long chapters seek to distinguish reliable from useless but traditional parts of the physical examination, focusing on situations where visual observation, touch and sound are crucial. Like many other authors, Dr. Sanders details how doctors learn patterns of symptoms and the many ways it is possible to get the diagnosis wrong: inadequate history and exam; misinterpreted tests; leaping to conclusions too early; ignoring pertinent findings that don't fit; subtle bias related to gender, race, age, or economic status; and finally inability to let go of a diagnosis previously made and perpetuated in the medical record. (As an aside, this last may be a special hazard of electronic medical records. Large chunks of previous notes are sometimes imported into new chart entries, apparently without reconfirming history or noting subsequent test results.)
While tests can make or confirm a diagnosis, Dr. Sanders emphasizes that “results are not nearly as crisp and clear as many patients (and doctors) assume them to be.” From there she launches into a long diatribe about the existence of “chronic Lyme disease” and the unshakable advocacy of chronic antibiotic treatment by true believers despite studies that show no proof of efficacy. Are ferocious attacks on skeptics by “Lyme literate” doctors and patients due only to “discomfort with ambiguity” and unwillingness to admit that no cause can be found for the patient's complaints?
Sources of diagnostic error are addressed but in less detail than in Jerome Groopman's How Doctors Think (Houghton Mifflin 2007). [For a review of this book in Neurology Today, search neurotodayonline.com for “An Insider's Look at the Uncertainties of Today's Medicine” (Bookshelf, Aug. 7, 2007.]
In searching for ways to improve care and knowing that checklists decrease surgical complications by a third and mortality by half, could computer programs and evidence-based decision trees improve diagnostic accuracy? After discussing several interesting attempts, it remains unlikely that trained humans can be supplanted by diagnostic computer programs any time soon. Finally, Dr. Sanders discusses the ultimate check on diagnostic accuracy, the autopsy, and her family's sad experience.
My one caveat is that Every Patient Tells a Story tries to cover too much ground and lacks a coherent theme. Although Dr. Sanders is a thorough researcher, a committed medical educator and an engaging storyteller, trying to address both a professional and a general audience at once is a tall order. Nevertheless, she touches the Sherlock Holmes in all of us. It is hard to resist putting on your deerstalker when the game is afoot.