Every Patient Tells a Story

by Lisa Sanders

  Chapter 2: The Stories They Tell

  28 Current thinking focuses on stories as the key: Lucey CR. From problem lists to illness scripts: a new strategy to learn and teach professional thinking in small groups, a lecture given 1/14/03. Hunter KM. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991, p. 17. Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine. New York: Oxford University Press 2006;45–53. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355:2217–25.

  28 These stories, what researchers now call illness scripts: Schmidt HG, Rikers RMJP. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Ed. 2007;41:1133–39, Charlin B, et al. Scripts and clinical reasoning. Med Ed. 2007;41:1178–84.

  29 One of the ways doctors are taught to think about disease: Mangruikar RS, et al. What is the role of the clinical “pearl.” Am J Med. 2002; 113(7):617–24. Ioannidis JPA, Lau J. Uncontrolled pearls, controlled evidence, meta-analysis and the individual patient. J Clin Epidemiolo. 1998;51(8):709–11.

  31 Dr. André Lemierre, a physician in Paris, first described this disease in 1936: Lemierre A. On certain septicemias due to anaerobic organisms. Lancet. 1936;1:701–3. Centor RM. Should Lemierre’s syndrome reemergence change pharyngitis guidelines? Manuscript from author. Singhal A, Kerstein MD. Lemierre’s syndrome. Medscape. 2001;94(9):886–87. http://www.medscape.com/viewarticle/410830.

  32 Like those presented to Fitzgerald: Hunter KM. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991.

  34 Anderson spent a year interviewing patients about their experiences in the health care setting: Anderson A. On the Other Side: African Americans Tell of Healing. Louisville, KY: Westminster John Knox Press, 2001.

  Chapter 3: A Vanishing Art

  39 A man in his fifties comes to an emergency room: Jauhar S. The demise of the physical exam. N Engl J Med. 2006;354:548–551. 42 most of the doctors holding a post-residency fellowship: Mangione M, Nieman LZ, Kaye D, Gracely E. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: a nationwide survey. Annal Int Med. 1993;119(1):46–54.

  42 If letter grades were being handed out: Mangione S, Nieman LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Resp & Crit Care Med. 1999;159(4 pt 1):1119–1124.

  43 Residents, their teacher-physicians: Vukanovic-Criley JM, Criley S, et al. Competency in cardiac examination skills in medical students, trainees, physicians and faculty. Arch Int Med. 2006;166:610–616.

  43 Perhaps, Mangione suggests: Mangione S. Teaching and practice of cardiac auscultation during internal medicine and cardiology training. Ann Int Med. 1993;119(1):47–54. Mangione S, Nieman L. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Resp Crit Care. 1999;159:1119–1124. Mangione S, Duffy FD. The teaching of chest auscultation in primary care training: has anything changed in the 1990’s. Chest. 2003;124(4):1430–1436.

  44 In 1980 the average length of stay: Chassin MR. Variations in length of stay: their relationship to health outcomes. Report for the Office of Technical Assessment, U.S. Congress, Washington, D.C., 1983.

  44 In a recent study done at Yale: Private communication, John Moriarty, Associate Program Director, Yale Tradition, Internal Medicine Residency Program.

  45 In 1950 approximately 15,000 people died of rheumatic heart disease: http://www.americanheart.org/presenter.jhtml?identifier=4712.

  52 In a study published in 2002: McGreevy KM, et al. Clinical breast examination—practices among women undergoing screening mammography. Radiology. 2002;24:555–559.

  Chapter 4: What Only the Exam Can Show

  56 The patient’s story contained the diagnostic tip-off: Hampton JR, et al. Contribution of history-taking, physical examination and laboratory evaluation to diagnosis and management of medical outpatients. BMJ. 1975;2(5969):486–489. Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J. 1980;100(pt 1):928–931.

  56 When he couldn’t find a good answer: Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–1105.

  Chapter 5: Seeing Is Believing

  84 “If the patient’s normal appearance is preserved”: From “Prognosis” in Hippocratic Writings. NY: Penguin Books, 1983, p. 171.

  84 “By realizing and announcing beforehand”: Ibid., p. 170.

  88 The decision to either admit the patient: Mellors JW, Horwitz RI, et al. A simple index to identify occult bacterial infection in adults with acute unexplained fever. Arch Int Med. 1987;147(4):666–671.

  90 “I have trained myself”: Doyle AC. “The Adventure of the Blanched Soldier,” Sherlock Holmes: The Complete Novels and Stories, vol. 1. NY: Bantam, 1986.

  91 But the most important trait they shared: Several sources were used in researching this: Klauder JV. Sherlock Holmes as a dermatologist. Arch Derm Syphilology. 1953;68(4):363–377. Reed J. A medical perspective on the adventures of Sherlock Holmes. Med Humanit. 2001;27:76–81. Massey EW. Joseph Bell MD—Mr. Sherlock Holmes? South Med J. 1980;73(12):1635–1636. Scarlett E P. The old original: notes on Dr. Joseph Bell whose personality and peculiar abilities suggested the creation of Sherlock Holmes. Arch Int Med. 1964;114:696–701. Conan Doyle dead from heart attack. New York Times, July 8, 1930. Wisser KM. The creation, reception and perpetuation of the Sherlock Holmes phenomenon 1887–1930. Master’s thesis, University of North Carolina, Chapel Hill, 2000. Leibow E. Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, OH: Bowling Green University Popular Press, 1982.

  92 “From close observation and deduction”: Leibow E. Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, Ohio: Bowling Green University Popular Press, 1982.

  94 These students also improved: Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA. 2001;286 (9):1020–1021.

  95 On a monitor I see six adults: This video was conceived and produced by Daniel J. Simons, Associate Professor, University of Illinois, Visual Cognition Lab. Screen it for your friends by going to http://viscog.beckman.uivc.edu/djs_lab/index.html.

  96 So did more than half: Simons DJ, Chabris CF. Gorillas in our midst: sustained inattention blindness for dynamic events. Perception. 1999;28:1059–1074.

  97 Researchers call this phenomenon: Chun MM, Marois R. The dark side of visual attention. Curr Op Neurobio. 2002;12:184–189. Most SB, Scholl BJ, Clifford ER, Simons DJ. What you see is what you set: sustained inattentional blindness and the capture of awareness. Psych Rev. 2005;112(1):217–242.

  106 Participants in the study were shown two pictures: Kelley TA, et al. Effect of scene inversion on change detection of targets matched for visual salience. Journal of Vision. 2003;2:1–5.

  Chapter 6: The Healing Touch

  109 “It is the business of the physician”: Adams CD, ed. The Genuine Works of Hippocrates. NY: Dover, 1868, from The Digital Hippocrates, http://www.chlt.org/sandbox/dh/Adams/page.160.a.php.

  112 The third that didn’t have the CT scan: Musunuru S, Chen H, et al. Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental. J Gastrointest Surg. 2007;11:1417–1422.

  125 Mammographers agreed with one another: Elmore JG, Wells CK, et al. Variations in radiologists’ interpretation of mammograms. N Engl J Med. 1994;331:1493–1499.

  Chapter 7: The Heart of the Matter

  133 “tip of the iceberg”: Salvatore Mangione, personal communication.

  136 “on account of the great degree of fatness”: Nuland SB. Doctors: The Biography of Medicine. NY: Vintage Books, 1995, p. 220.

  136 “I recalled a well known acoustic phenomenon”: Duffin J. To See with a Better Eye: The Life of RTH Laennec. Princeton, NJ: Princeton University Press, 1998, p. 122.
r />   137 They argued that diseases could be classified: Ibid., p. 26.

  139 It was usually attributed to heart failure: I usually explain heart failure to my patients using a scene from I Love Lucy. In this episode, Lucy and her friend Ethel take jobs in a candy factory, wrapping candies as they move by on a conveyer belt. Initially they are able to keep up and all the candies end up neatly wrapped. As the conveyer belt picks up speed, more candies are delivered, and it becomes harder and harder to keep up. Before long the two are overwhelmed and candies end up everywhere—in their pockets, in their blouses, on the floor. What happens to Ethel and Lucy is analogous to what happens to the heart—with even the slightest physical stress, the weakened organ is overwhelmed by the amount of blood being brought in and, like the overflowing candies, the extra fluid backs up, ending up just about everywhere.

  139 the now classic finding of emphysema: Duffin J. To See with a Better Eye: The Life of RTH Laennec. Princeton, NJ: Princeton University Press, 1998, pp. 157–58.

  139 “oppression and palpitations”: Major RH. Classic Descriptions of Disease. Springfield, IL: Charles C Thomas Publisher, 1932, pp. 371–372.

  145 In one large multispecialty group in Boston: Blanchard G P. Is listening through a stethoscope a dying art? Boston Globe, May 25, 2004.

  146 five cardiologists were pitted against echocardiography: Jaffe WM, et al. Clinical evaluation versus Doppler echocardiogram in the quantitative assessment of valvular heart disease. Circulation. 1988;78:267–275. 146 In a study done by Christine Attenhofer: Attenhofer Jost CH, Turina J, Mayer K, Seifert B, Amann FW, Buechi M, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med. 2000;108:614–620.

  146 One study done of emergency room physicians: Reichlin S, et al. Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologist. Am J Emerg Med. 2004;22:71–75.

  147 Several studies have been done evaluating programs: Smith CA, et al. Teaching cardiac examination skills: a controlled trial of two methods. J Gen Int Med. 2006;21(1):1–6. Barrett MJ. Mastering cardiac murmurs: the power of repetition. Chest. 2004;126:470–475. Favrat B, et al. Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work? BMC Med Ed. 2004;4:5. http://www.biomedcentral.com/1472-6920/4/5.

  161 “Direct observation of trainees”: Holmboe ES, Hawkins RE. Evaluating the clinical competence of residents in internal medicine: a review. Ann Int Med. 1998;129:42–48.

  162 A study published recently shows how inadequate: Hicks CM, et al. Procedural experience and comfort level in internal medicine trainees. J Gen Intern Med. 2000;15:716–722.

  Chapter 8: Testing Troubles

  171 Furthermore, there is plenty of solid evidence: Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. 2001;345:85–92.

  172 Finally, in October 1975: Clark E. Lyme disease: one woman’s journey into tick country. http://www.yankeemagazine.com/issues/2007-07/features/lymecountry.

  173 Comparing the location of Steere’s mystery cases: Steere AC. David France, scientist at work. New York Times, May 4, 1999.

  173 In order to transmit the infection: Steere AC, et al. The emergence of Lyme disease. J Clin Invest. 2004;113(8):1093–1101.

  173 some studies suggest that the most common presentation: Tibbles CD, et al. Does this patient have erythema migrans. JAMA. 2007;297:2617–2627.

  178 Post–Lyme Disease syndrome: Steere AC, et al. Association of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles. N Engl J Med. 1990;323:219–223.

  178 They recruited one hundred residents: Shadick NA, Phillips CB, Logigian EL, Steere AC, Kaplan RF, Berardi VP, et al. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Int Med. 1994;121:560–567.

  178 Other studies too have found: Cairn V, Godwin J. Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms. Int J Epi. 2005;34:1340–1345.

  179 Researchers at Tufts Medical Center: Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. 2001;345:85–92.

  179 Two other rigorous trials: Krupps LB, et al. Study and treatment of post Lyme disease. Neurology. 2003;60:1923–1930. Fallon BA. A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. Neurology. 2008;70:992–1003.

  181 They don’t trust either physical exams: The International Lyme and Associated Diseases Society Evidence-based guidelines for the management of Lyme disease, published November 2006, p. 7, http://www.ilads.org/guidelines.html, accessed December 31, 2007.

  181 In fact, when used as recommended: Tugwell P, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Int Med. 1997;127(12):1109–1123.

  181 These are some of the most common symptoms: Fletcher K. Ten most common health complaints. Forbes, July 15, 2003. http://www.forbes.com/2003/07/15/cx_kf_0715health.html.

  Chapter 9: Sick Thinking

  197 Diagnostic errors are the second leading cause: Bartlett EE. Physicians’ cognitive errors and their liability consequences. J Healthcare Risk Manage. 1998(fall):62–69.

  197 And a recent study of autopsy findings: Tai DYH, El-Bilbeisi H, Tewari S, Mascha EJ, Wiedermann HP, Arroliga AC. A study of consecutive autopsies in a medical ICU: a comparison of clinical cause of death and autopsy diagnosis. Chest. 2001;119:530–536.

  198 One survey showed that over one third of patients: Berner ES, et al. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5A):S2–S23.

  200 Faulty synthesis … by comparison, played a role: Errors of inadequate data collection are probably underrepresented in this sample because it was based on chart review. If something was missed, it won’t be in the chart. To pick up this kind of error requires access to the patient at the time of the diagnosis.

  201 “Thinking stops when a diagnosis is made”: Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):1–6.

  201 “process of matching”: Croskerry P. Overconfidence in clinical decision making. Am J Med. 2008;121(5A):S24–S29.

  201 “the power of thin slicing”: Gladwell M. Blink. NY: Little, Brown, 2005. http://www.gladwell.com/blink/.

  203 “The trick lies in matching”: Croskerry P. The theory and practice of clinical decision-making. Can J Anesth. 2005;52(6):R1–R8.

  206 black men are significantly more likely: http://www.cdc.gov/cancer/prostate/statistics/race.htm, accessed May 1, 2008.

  207 “despite their ‘objective’ medical training”: McKinlay JB, Potter DA, Feldman HA. Nonmedical influences on medical decision-making. Soc Sci Med. 1996;42(5):769–776.

  207 And even those factors: Ibid.

  207 One of the many careful experiments: Arber S, McKinlay J, Adams A, Marceau L, Link C, O’Donnell A. Patient characteristics and inequalities in doctors’ diagnostic and management strategies relating to CHD: a video-simulation experiment. Soc Sci Med. 2006;62(1):103–115. 214 In the 1930s: Gawande A. “The Checklist.” The New Yorker, 12/10/07, http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande.

  214 These basic steps: Wachter RE. Understanding Patient Safety. New York: McGraw-Hill Medical, 2008, p. 23.

  215 surgical safety checklist: Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360, pp. 491–499.

  215 checklist before certain procedures in the ICU: Pronovost Petal. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355, pp. 2725–2732.

  Chapter 10: Digital Diagnosis

  216 In a 1976 article, a group of doctors: Pauker SG, Gorry GA, Kassirer J P, Schwartz WB. Towards the simulation of clinical cognition taking a present illness by computer. Am J Med. 1976;60:981–996.

  221 I
n 1994 she and a group of thirteen other physicians: Berner ES, Webster GD, Shugerman AA, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994;330:1792–1796.

  229 In order to measure how well the program can perform: Leonhardt D. Why doctors so often get it wrong. New York Times, February 22, 2006.

  229 Mark Graber and a colleague: Graber MI, Matthew A. Performance of a web-based clinical diagnosis support system for internists. J Gen Int Med. 2008;23(supp 1):37–40.

  231 According to a 2005 survey done by the Pew Center: Boone S. Computer users can catch the health bug on line. McClatchy-Tribune Regional News–The Walton Sun, November 17, 2007.

  234 Finally, the visiting professor asked the fellow: Greenwald R…. And a diagnostic test was performed. N Engl J Med (letter). 2005;353:2089–2090.

  235 This story and their own experiences with patients: Tang H, Hwee Kwoon Ng J. Googling for a diagnosis—use of Google as a diagnostic aid: Internet based study. BMJ. 2006;333;1143–1145.

  236 Even the august New England Journal of Medicine: Fan E et al. A gut feeling. N Eng J Med. 2008;359:75–80.

  Afterword: The Final Diagnosis

  241 Medicine’s first toehold: Much of this comes from Roy Porter’s wonderful history of medicine, The Greatest Benefit to Mankind. NY: Norton, 1999; as well as from Jacalyn Duffin’s biography of René Laennee, To See with a Better Eye. Princeton, NJ: Princeton University Press, 1998.

  232 These days, patients who die in a hospital: David Dobb wrote a terrific piece about autopsy, “Buried Answers,” for the New York Times Magazine, April 24, 2005.

  243 Small residency programs objected to the ever growing cost: From Accreditation Council for Graduate Medical Education, a private nonprofit council that evaluates and accredits medical residency programs in the United States, personal communication.