#17 Have Doctors Stopped Listening? A Book Review
Dr. Lisa Sanders reminds us that Every Patient Tells a Story in her book by the same name but wonders if the physicians treating that person will even bother to listen. More importantly, she explores the general decline in the art and practice of the physical exam and its use in making an accurate diagnosis for the patient. All it took was one deadly pandemic to take the ancient practice of physical exam that was surviving on life-support to total flat-line status in our emergency departments and medical office settings.
Sanders’ work will be familiar to many through the “Diagnosis” column in the New York Times and her role as contributor and technical advisor to the medical TV show House MD. The subtitle of the book: Medical Mysteries and the Art of Diagnosis partly defines its contents. She also explores the effect of physician biases, the use of computers and artificial intelligence systems in making diagnoses and the use of Google searches.
The lay public might be genuinely surprised at how formulaic and thinking-free patient assessment has become. It seems like every patient gets the same generic algorithm driven work-up. While for the majority of conditions this works, when anything out of the ordinary presents itself, the weaknesses of our healthcare education and treatment model comes through. Sanders explains how we got to this place but emphasizes the benefits, in case-study style, of thorough and intelligent investigations on both the practitioners and the patients. As a former journalist, Sanders lays out the suspense of several more rare conditions and their successful investigation by physicians who took the time, listened to their patients and examined them thoroughly.
The value of this book lies in the questions it asks of both the medical profession and future patients. To the profession, it asks what might be done to not only improve diagnostic tests and techniques but also how to communicate medicine's limitations to the public. And to the patient, it asks for patience in a profession that is still evolving but to also trust physicians in their abilities. Even with the plethora of biochemical and imaging tests and studies, we simply do not know everything. While explaining the complex process of sifting through a differential diagnosis, the author writes in her introduction, “In medicine, uncertainty is the water we swim in.” (page xxiv)
Dr. Sanders explores the intricacies and uncertainties of the diagnosis of Lyme Disease and the label of “chronic Lyme disease” in the chapter “Testing Troubles” For the trusting public the lengthy discussion highlights the uncertain nature of medical diagnosis that appears ripe for charlatans to prey on unsuspecting patients. She questions the chronic Lyme disease diagnosis and believes most patients have some yet to be diagnoses rheumatologic condition. Sanders explains the overdiagnosis of chronic Lyme disease by the discomfort most physicians feel with ambiguity and uncertainty. “And the doctors most uncomfortable in this way are the ones most likely to seize upon a diagnosis or diagnostic label and distort their own thinking in an attempt to prove to themselves and their patients that they know what’s going on.” (p 182) I might add, those physicians who benefit monetarily from the return visits and the sham treatments, contribute to the problem.
The book is not just a collection of fascinating medical "mysteries' but the author uses these difficult to diagnose cases to illustrate important lessons about what is needed in medical training to equip doctors with the necessary skills and open-mindedness not to fall into the trap of relying too much on lab tests and technology. She eulogizes the death of the hands-on physical exam. In a section titled: The Old/New Chapter of the Physical Exam, she tells the story of a patient who had the cause of her med-resistant hypertension missed over several years. Of course, a relatively simple, but rarely done part of obtaining the vital signs, was never done. Every student, resident and attending assumes that a proper physical exam has been done and it most certainly has not.
Sanders relates the story of crusader in teaching the physical exam, Eric Holmboe. He realized that his own training in the techniques of physical exam were lacking and to make matters worse, he was almost never observed while performing it. He discovered that teachers were reluctant to observe their students because they felt inadequate at the intricacies of exams themselves. A training program was implemented with emphasis on continued observation and reinforcement of skills. This is the author's recurring theme that a careful physical examination combined with truly listening (with curiosity) to what the patient says are the bedrock of diagnoses.
Dr. Sanders is very honest about medical misdiagnoses, including her first “miss” when she was an inexperienced intern. She failed to recognize someone with impending respiratory failure. Her attendings came by shortly thereafter and no real harm was done to the patient. The patient was transferred to the intensive care unit. Learning what “sick” really looks like is what students and residents need to do. She discusses how “looking sick” may not tell physicians enough and those biases and heuristic shortcuts may still fail us.
I found myself at odds with Dr. Sanders over the “missed diagnosis” of a young man with chest pain. His first two times in the emergency department, he was ruled out for myocardial ischemia and discharged for outpatient work-up. Of course, the patient never followed up with a cardiologist or internist. By Sander’s telling, his revealing and atypical symptoms were either unheard or ignored by the emergency physicians. (full disclosure: I am an emergency physician) When the patient returns to the ED where the physicians only have a hammer and screw-driver, everything tends to look like a nail or a screw. The diagnostic study he required was only ordered when the patient was admitted after his third visit. Dr. Sanders calls this a missed diagnosis. It would be great if we could identify all of the Zebras during the four hours of the first visit, but of course, our system is not set up that way.
The author also explores the systems of digital and artificial intelligence that might aid the diagnostic dilemmas that befall our beleaguered physicians. What on the surface seems to be an advanced answer for diagnostic dilemmas, is still mitigated by humans with their won strong biases and judgements. If a physician is sure of her provisional diagnosis, she will not consult the computer data base to search for other possibilities. A nurse who does not question the dose of a medication prescribed, will not take the time to look it up to confirm. On replacing the fallible humans with computers, Sanders writes, “There will always be choices to make – between possible diagnoses, between tests to order, and between treatment options. Only a skilled and knowledgeable human can make those kind of decisions.” ( p.238)
Physicians will find much to like and ponder in this book. Which one of us has not cut a patient off less than thirty seconds before he starts telling us his problem. Who among us would not benefit from a refresher course on the intricacies of the physical exam. Many of us have observed the current deficiencies in patient interviewing and examining that Sanders described. Some of the problems lie within the systems, the time-pressures, and the electronic documentation systems. Sanders still believes that physicians can do better and rededicate themselves to the basics. I found myself shaking my head in agreement with the author’s idealistic point of view.
All physicians in practice should read this book. This book should also be read by anyone who might be a patient or medical professional one day--which would be everyone. Nobody is perfect, and Dr. Sanders points out that medicine is no different. However, the implication is that we all want to be--and can be--better. It just takes a work, curiosity and commitment.
Regarding the integration of computer databases and testing, Sanders leaves us with this thought. “And, of course, people need more that the right treatment for the right disorder. They need to be heard, they need reassurance, explanations, encouragement, sympathy- the full range of emotional support that is a critical part of what we doctors do: heal. (p.238)
This review first appeared in The DO Magazine
