Science in the Triangle

Lisa Sanders is a physician and a professor of medicine, but you probably heard of her in a different context: Lisa writes the Diagnosis column in The New York Times, has recently published a book Every Patient Tells a Story, and has inspired and acts as the medical adviser to the TV show House (of which I heard, not being a TV watcher, at the beginning of her talk).

Lisa Sanders came to the Triangle last month and gave talks at Duke and UNC. Bride of Coturnix and I went to the UNC talk which filled a large auditorium. Her book is being read by all the UNC medical and nursing students who will then discuss the book in smaller groups.

The process of diagnosis has three steps: interview, physical exam and laboratory tests.

Laboratory tests have become more and more dominant as the preferred part of the diagnosis process, for a number of (cultural) reasons:

First, they are the quickest, thus save the physician time (others do the work).

Second, unlike interviews that seem subjective, or physical exams that look medieval, lab tests look like ScienceTM! - there are numbers there. And you can’t argue against numbers, can you? This works great on the background of lack of statistical sophistication (or outright innumeracy) on the part of both physicians and patients. No arguing. No second opinions. The process moves on smoothly for everyone. Except, the numbers cannot be trusted as much they usually are.

Third, a number is not an opinion, thus it is a safeguard against lawsuits. It saves physician’s asses in such cases. Both the frenzy and the (perceived) lack of time and the fear of lawsuits would be diminished if we had a real healthcare reform (not the compromise of a compromise of a compromise bill that is brewing in the US Senate right now, but an actual reform) in which the physicians could get their authority and trust back and be able to practice their art and craft and science with some degree of freedom. In a system in which insurance companies determine how care is done, physicians are just technicians and cannot earn authority and trust.

So, with everyone jumping onto lab tests, the art of interview and the art of physical examination are slowly dying out. They are not even taught in some medical schools any more. Where they are taught, as soon as newly minted physicans are on their own they join the medical culture that frowns upon these two steps of the diagnostic process.

Yet, Dr.Sanders showed data from two studies (done in different countries by different people in different years), both providing almost exactly the same results. In about 75-80% of the cases (physician encountering a new patient for the first time), the physician comes up with a correct diagnosis after the interview. In about 10-12% of the cases, the doctor has to correct her/himself after the physical exam in order to arrive at the correct diagnosis. And in only the remaining 10-12% or so cases did the lab tests provide information that forced the physician to change one’s mind and come up with the correct diagnosis. In 8 out of 10 cases, the interview was sufficient!

When asked why they are shunning the interviews, physicians respond that they have no time - the system is forcing them to see too many patients per day. A study shows that physicians interrupt patients’ stories abruptly, very soon, sometimes as early as 3 seconds into the interview. Yet, in another study, when doctors were asked specifically not to interrupt, the interviews lasted only one minute longer. Just one minute! Thus interruption does not really save any time - it’s an illusion.

But what is more important is that the interruption itself means something. First, it means that the physician is not really listening. Second, it tells the patient that the doctor is not listening. By relaxing for that extra minute and actively listening to the patient, not just fishing for diagnostically important information in the account but also listening to hear how the patient perceives him/herself, and how that perception is altered by the illness, the physician gains a better understanding of the patient, can probably come up with a better diagnosis and, most importantly, gains trust with the patient. That trust is very important later, when the physician needs to rely on the patients to be disciplined about the treatment. The interruption loses that trust, something that smooth-talking medical quacks are quick to jump on, offering to listen even if their treatments are completely bogus.

What a patient does during the interview is story-telling. A physician needs to be trained to listen to and understand such stories - to glean how the change in health status affects the self-confidence, self-view and self-worth of the patient, how it changes one’s life-plans and ambitions, what fears it brings, what difficult adjustments in lifestyle it requires. To see the patient as a person, not just a disease.

And then, the story-telling does not end with the interview. The physicians and nurses need to communicate with each other about the patient and that also entails, when done right, story-telling (which need not be spoken, it can be in the chart). Finally, the healthcare providers need to know how to tell the story back to the patient, both to convey the diagnosis and to gain the trust needed for the patient to accept and follow through with the treatment. Quick recitatiton of code-numbers and Latin words just won’t do.

So Lisa Sanders, with her book, her column, her advising of House MD and her speaking tour, tries to teach the importance of the interview and the physical exam, the art of listening and storytelling. I am glad that UNC is taking her seriously.

The next day, a bunch of us met with Dr.Sanders at the West End Wine Bar in Durham. It was great fun to talk to her in an informal setting and to ask questions that I did not dare ask at the public talk in front of hundreds of med school professors and students and something like the entire nursing school of UNC. After all, my only perspective on medicine is from the position of a patient (and a reader of some med-blogs) so I learned a lot, yet was aware how little I actually know about medical training and practice. Anton organized that meet-up with the local science communicators and wrote his summary of the week’s events on his blog: