DEAR THYROID^TM

I just finished another book detailing some of the difficulties between doctors and patients and, in this case, making proper diagnoses.   Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis by Lisa Sanders, M.D. is a collection of interesting and uncommon medical cases, dissected down to reveal where the mistakes and successes arrived at the result.   Most of the patients survive in these stories, although all of them suffer some duress before the final accurate diagnosis is discovered.

Dr. Lisa Sanders also writes for New York Times Magazine, and has penned a similar ongoing column entitled “Diagnosis“ for years.   This column served as the inspiration for the television series House, M.D. and she serves as their technical advisor.   In her book, along with the collection of presented cases, Dr. Sanders flashes back to her own medical training, and provides some insight on weaknesses of medical training and continuing education, as well as new or different current strategies that are trying to correct this.   There is no doubt upon reading this book that she feels the majority of errors of diagnosis originate with the doctor (in other words, not due to lab errors, etc.) and are preventable, even in complicated cases.

The book itself is a good read–I particularly recommend it for anyone who has, or knows someone who has, a chronic health issue.   Why?,   It goes to overall awareness of how doctor’s “work” and being our own best advocate.   The more we know the inherent weaknesses of the system, the better able we are to protect ourselves from those weaknesses.   To be fair, some of the errors are almost built-in by the very nature that we are human.   Not surprisingly, however, the majority of errors could be reduced with better training of doctors during their school and residency programs.

To try to get around “human” errors, technologies have been developed to allow more and more detailed testing for various conditions.   While this sounds fantastic at the outset, unfortunately it has come at considerable expense–doctors are increasingly relying more and more on these advanced technologies and less on the physical exam.   Says Sanders of her own training (she graduated medical school from Yale in 1997, and finished her Internal Medicine residency in 2001, so not long ago):

“I graduated from medical school with a set of physical exam skills that was spotty and idiosyncratic, and may have been considered unacceptable–had the doctors I then worked with ever observed me.   I wasn’t worried, though.   I figured I’d learn the proper way to examine a patient when I was a resident.   I was wrong.   Studies show that by the end of a residency training a physician’s skills may not be better than the skills he had as a medical student…

The story is similar regarding procedures, by the way.   Sanders notes that a British study of residents in England revealed that nearly one third received no training prior to performing common simple procedures such as giving injections or taking an ECG.   Nearly half did not feel qualified the first time these procedures were attempted, and nearly half also described being unsupervised the first time the procedure was performed!

As an aside, as I was reading this book, I harkened back to my own training frequently, and was feeling a bit, uh, superior, until I read this last bit.   Because veterinary medicine mostly relies on client payment (rather than insurance), we are less likely to jump immediately to the ultra-specialized (and therefore, expensive) testing, and more apt to rely on history and physical exam (along with more routine testing like blood work and cytology) to guide our diagnosis, and are trained accordingly.   That said, this last paragraph really struck a cord.   Imagine a young Dr. Hahn, newly graduated and practicing medicine on horses, when a pony with a ruptured eye crossed my path.   The owners were reluctant to spend much more money than it would cost to euthanize this old guy, so I struck a deal:,   with full disclosure, I had never performed an enucleation before, but would charge only the equivalent of the euthanasia (about 25% the regular cost).   Confidently, (arrogantly?), I felt that because I had adeptly performed other surgeries, how difficult could removing an eye be?,   (There are a couple “small” hitches to field surgery in equine practice–you don’t have anything close to a sterile operating area, and since there is no inhalant anesthesia, surgery is done with injectable anesthetics only, providing a maximum of 20 minutes of sleep.   This is not a lot of time!),   Honestly, I had not even READ about the details of the procedure before that day.   I distinctly remember my heart pounding in my ears, and I’m sure my adrenals were squeezed to capacity.   The surgery went perfectly, and the pony recovered beautifully (although my assistant remarked when we had finished and were driving away that I conjured up an image in her mind of Edward Scissorhands).   One could make the argument, of course, that it was luck that spared my hubris.   Or maybe my training adeptly prepared me to apply my knowledge and skill to an unfamiliar setting with a high probability of success.   Reality is rarely black or white, so it’s probably both.

Boiled down, Sanders’ book highlights the three main elements required for a correct diagnosis, at least one of which are most often bungled when it is not found: time, tools, and thinking.   We’ve talked over and over here at Dear Thyroid about doctors’ lack of time with patients–hurried exam visits, over packed schedules, etc.   Dr. Sanders cites a study revealing that doctors interrupt patients giving their history within 8 seconds, and often several times after that, while other studies glean a 70% diagnosis rate can often be achieved on a good history alone.   While tools can mean any number of sophisticated testing modalities, most diagnoses could be made with a GOOD physical exam, a BP cuff, thermometer, and “ -scopes- (ophthalmoscope, otoscope, stethoscope, etc.), but these skills are often overlooked and poorly learned or maintained (refer back to “time”).   Poignantly, and depressingly, medical training has traditionally focused more on memorization and pattern recognition than engaging the brains, and encouraging real thinking, of these clearly intelligent and motivated individuals.   It’s not that they aren’t capable, but it is not how they have been trained.   Luckily, Sanders does point out some new standards for testing physical exam and history taking competency skills implemented in 2004 as a requirement for all medical students to graduate, and the improved training approaches that have been implemented at many schools as a result.   My hope is that the next generation of doctors will at least have better tools and improved thinking, so they can make the best use of our time.

Robyn

If you missed the first installation of this column, “Art Imitates Life“, click on over and give it a read.

Tags: Art Imitates Life, chronic health issues, correct diagnosis: time tools and thinking, Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis by Lisa Sanders M.D., House Television Show, how doctor's work, Lisa Sanders columnist Diagnosis, patient advocacy

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