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Going For The Throat: Paging Doctor House Part II

Post Published: 04 March 2010
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Category: Going for the Throat, Health Care Column Thyroid Diseases and Thyroid Cancers
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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.

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3 Responses to “Going For The Throat: Paging Doctor House Part II

  1. Lori says:

    Great,Great article Robyn. I could go on all night with this one but I’ve been so distracted by the posts today when I should have been working, I have to make it short and get back to work.

    I have witnessed doctors teaching students and fellows how to do a physical exam in both a small community hosptital in the office setting and hospital setting, and large boston hospital orthopedic department during residencies and fellowships. In a nutshell their history taking skills are as good as their teacher and their own initiative, IMO. The stories, like you mention as far as first time procedures, OMG! People would be shocked and horrified at what happens. One example I witnessed was in the ICU on the night shift when the house officer had to intubate and he had never intubated a patient before, what a sight that was. It is really unbelievable to me how someone can get through medical school and not know how to take a good history and do a thorough physical exam (the most important skills), never mind not know how to intubate a patient. It’s wrong on so many levels. If they could learn how to ask the right questions, can you imagine how much that alone would help?

    This sounds like a good book. Have you ever seen the show “Mystery Diagnosis” on Discovery Health channel. I love that show!

  2. Robyn says:

    Thanks for the comment Lori, and YES I love that show!

    Part of the problem is that there is just SO FREAKIN’ MUCH TO LEARN. My veterinary program has changed for current students, but when I was in school it was 2 years of straight course work (ie, could practically never touch an animal), except for a “teaching animal unit” lab 1 hour/week that was all farm animals and horses, and cadavers for anatomy. My third year we began to have “hands on” stuff with cadavers and “research” animals(procedures like physical exams, TPR, drawing blood, etc. on the live animals, nothing invasive) a FEW hours/week, and TWO surgeries the second semester (one spay, one neuter). Your 4th, or clinical year, you are working up all the patients, helping get samples, but mostly interpreting the exam and lab/diagnostic tests. In surgery you are usually watching, or at best, a human retractor. When I was a student I did get to do more stuff out in the barn, because I was “eager”–rectals on colics, long term foal catheters, etc. with supervision that students can’t do today because of LAWSUITS! Really? So you bring your animal to a TEACHING hospital, but then if something goes wrong you’re gonna sue? So then if the vet is not trained when they graduate because they aren’t allowed to actually do anything, but if something goes wrong you are going to sue? It’s a catch 22, and I’m sure it’s similar in human medicine.

    So I graduated having done 1 spay, 1 nueter. Nothing else. I had done many physical exams, and I do feel I am quite proficient at that for the reasons I stated in the article.

    And then I have “winged it” many times. I helped with 1 bladder stone removal once out, and then did a bunch by myself. First eye and toe amputation were “by the book”, and the same goes for other “advanced” procedures. You just are not there (in school) long enough to learn all the stuff and practice all the stuff, even if you would be allowed to!

    I’m not sure what the answer is to that–when I take my horse to the vet school I have always insisted on the surgeon, not the resident, being primary on the surgery so I have been part of the problem myself!

  3. Lolly says:

    Another Great Article Robyn. I worked in a teaching hopsitla nothing better than hadns on experience you can;t learn the things that you can stuck behing=d a desk.

    Lolly

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