Welcome back to The DO Book Club! Starting last month, two literary DOs are alternating writing this column each month. December’s author, Joan Naidorf, DO, read Every Patient Tells a Story by Lisa Sanders, MD. If you have suggestions for books to review, please submit them to firstname.lastname@example.org.
Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis by Lisa Sanders, MD (Harmony, 2009, 304 pages)
Lisa Sanders, MD, reminds us that Every Patient Tells a Story in her book by the same name but wonders if the physicians treating each patient are listening. 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.
More recently, the pandemic pushed the ancient practice of the physical exam, which was surviving on life support, to total flat-line status in many of our emergency departments and medical office settings.
Dr. Sanders’ work will be familiar to many through the “Diagnosis” column in The New York Times and as featured case studies on Netflix. She also contributed as an advisor to the medical TV show House MD. In addition to exploring medical mysteries and the art of diagnosis in her book, 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 workup. While for the majority of conditions this works, when anything out of the ordinary presents itself, the weaknesses of our health care education and treatment model are revealed.
Dr. Sanders explains how we got to this place but emphasizes the benefits, in case-study style, of thorough and intelligent investigations. As a former journalist, Dr. Sanders suspensefully lays out several 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 to communicate medicine’s limitations to the public.
It asks patients to trust physicians in their abilities and also to have patience as the medical profession continues to evolve. 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. For the trusting public, the lengthy discussion highlights the uncertain nature of a 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-diagnosed rheumatologic condition, not chronic Lyme disease. The author attributes the misdiagnosis to 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.” (Page 182)
The book is not just a collection of fascinating medical “mysteries,” but the author uses these difficult-to-diagnose cases to illustrate what is needed in medical training to equip doctors with the necessary skills and open-mindedness not to fall into the trap of over-relying on lab tests and technology.
The death of the hands-on exam
She eulogizes the death of the hands-on physical exam and 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 in this case, it most certainly has not.
Dr. Sanders relays the story of a crusader in teaching the physical exam, Eric Holmboe, MD. 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 actually performing his exams.
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. The author emphasizes that a careful physical examination combined with truly listening (with curiosity) to what the patient says are the bedrocks of making accurate diagnoses.
Dr. Sanders addresses 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 when biases and heuristic shortcuts may still fail us.
The author also explores the digital and artificial intelligence systems that might aid the diagnostic dilemmas that befall our beleaguered physicians. What seems to be an advanced answer for complex problems, is still mitigated by humans with their own strong biases and judgements. If a physician is sure of her provisional diagnosis, she will not consult a database 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.
Humans vs. computers
On replacing the fallible humans with computers, Dr. 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.” (Page 238)
Osteopathic physicians will enjoy this well-written book. Which of us have not cut a patient off less than thirty seconds after 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 the patient interview and examination that Dr. Sanders described.
Some of the problems lie within the systems, the time pressures, and EHRs. Dr. 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.
Anyone who might be a patient or a medical professional one day—that is, everyone—should read this book. 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 work, curiosity and commitment.
The author leaves us with this thought. “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.” (Page 238)
For January, Daniel J. Waters, DO, MA, will review Lightning Flowers: My Journey to Uncover the Cost of Saving a Life by Katherine E. Standefer; Frankenstein, or the Modern Prometheus by Mary Shelley (1818 edition); and The C-L Psychiatrist by Omar Mirza, DO. We encourage all who are interested to read along (this book club can be followed at any pace)! If you are unable to get out to a local library or bookstore, we recommend checking out eBook options.
If you read Every Patient Tells a Story or any previous Book Club selection and want to share your reflections, please leave a comment below or email email@example.com.