DAVE DAVIES, host:
Dr. Lisa Sanders is fascinated with medical mysteries. A practicing internist on the faculty of the Yale Medical School, she writes the "Diagnosis" column for The New York Times Magazine, in which she describes and analyzes unusual cases. And she's a technical adviser for the Fox TV series "House," in which a condescending, pill-popping doctor solves a tough medical puzzle every week.
But Sanders' new book is more than just a collection of fascinating yarns from the examining room. She argues that despite remarkable advances in medical technology, doctors are misdiagnosing their patients' ailments at a surprising rate - between 10 and 15 percent of the time, according to studies.
She offers some interesting reasons for why physicians sometimes miss the boat and some ideas for sharpening their skills. Her book is called "Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis."
Well Lisa Sanders, welcome to FRESH AIR.
You make the point in the book that it's really important to take a thorough history from the patient. Find out, you know, why they're there and what their medical and history has been - what they've experienced. Do doctors listen as well as they should?
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Dr. LISA SANDERS (Internist, Yale Medical School; Consultant, Author): I think we all know the answer to that.
Dr. SANDERS: No. We don't. And shame on us. Because it's been known for a really long time that the patient is the source of the information that most of the time, sometimes up to 90 percent of the time, will give us the answer to the question: What's going on? What does this patient have? But we don't listen to patients, and it's hard to listen to patients.
As a news interviewer, or as an interviewer, you know that when you talk to somebody, you have two conversations that are going on. You have the conversation that you're having with the person you're talking to, and you have the other conversation: Am I getting what I need?
A doctor, what a doctor does is very similar. They're having a conversation, just a regular conversation. Tell me what's going on. When did you start feeling bad? But they're also having this other conversation inside their heads of, am I getting what I need? Is this enough information? What does this all mean?
And so, I think that we're not trained to do that. You just have to pick it up. You have to learn it on the fly. And some doctors are better at it than others. But it hasn't really been valued in the way we train doctors. And so if we don't listen, maybe it's because we didn't really teach doctors how to listen.
DAVIES: Wasn't there a study which actually recorded interviews by physicians and gave us a sense of what the interaction was like?
Dr. SANDERS: Absolutely. There's actually been two that were a few years apart, and they showed the same thing, which is basically, doctors let patients talk for an average of 20 seconds before they interrupt - sometimes even less. In the most recent study, some doctors let a patient talk for only three seconds before they interrupted. And they interrupted with a very specific question, usually. But the chance that the patient would go back and finish that story is almost zero. I mean, it almost never happens.
They get distracted. New information prompts new questions, and people go on to, you know, describe other symptoms. But having the patient tell the story is thought to be the most efficient way of getting all this data out, and yet we don't do it.
DAVIES: And do the studies also indicate that when doctors do interrupt, that they get an inaccurate picture of what's going on with the patient?
Dr. SANDERS: They can. Sometimes you can be right, and you take it in the direction where it absolutely needs to go. But that's not always the case. And up to 50 percent of the time, when a patient leaves the doctor's office and they've been asked about it, they have symptoms that they didn't get to talk about. Half the time, a doctor and a patient will not agree on what the purpose of the visit was about.
DAVIES: That's after the visit?
Dr. SANDERS: After the visit. If they're questioned separately, what the doctor thinks that the appointment was about, and what the patient thought that the appointment was about, are going to be two different things half the time. So that's crazy, and that's a bad way of collecting the most important data that we have.
I mean, I think that there was a sense that we all know how to ask questions. We all know how to hear the answers, that this was not something that needed to be taught. But I think that studies like these suggest that we're wrong on that. And actually, one of the other difficult things about it is there's a certain anxiety when you're confronted with something that somebody who's sick or facts that you haven't - you're not able to add up. And that uncertainty, that provokes a certain anxiety that makes you want to find an answer. And so…
DAVIES: You mean that the doctor - the physician may be uncomfortable with sort of the emotional atmosphere of the encounter?
Dr. SANDERS: I think the doctor himself will have emotions about seeing a patient where you don't know what's going on. And those feelings - I mean, we're - none of us are wildly comfortable with uncertainty, I think. You have to be a very special kind of person to be comfortable in the face of real uncertainty. So when a doctor is faced with this kind of uncertainty, the first thought that passes his mind is often grabbed on with both hands.
The right thing to do, of course, and what I teach my residents and medical students, is to make note of what you're thinking but listen, listen and wait because you - because the average patient's story last less than two minutes. So you only have to wait two minutes before you ask your question. And yet sometimes, it can be very hard.
DAVIES: You write in the book that the physical exam, once our most reliable tool in understanding and diagnosing a sick patient, is dead. What do you mean?
Dr. SANDERS: I think it's gone. We're all taught the physical exam in medical school, but it doesn't take long for you to realize as a student, as a resident, as a young doctor, that no one cares what you find on physical exam, that it's really what the tests show. It's what the, you know, it's what the tests show. And yet it's clear that the physical exam has important things to tell us. It can direct where we look. It can tell us - show us in a very real way what's going on.
DAVIES: Can you think of an example of a case where reliance upon tests and technology and neglect of a physical exam led to a misdiagnosis?
Dr. SANDERS: Oh, many. There was one case - a young woman, she was a resident, a doctor in training. She came - she was brought to the emergency room by her fiance. Her heart was beating quickly, too fast to be normal. Her eyes were incredibly insens - sensitive to the light. And she was speaking incoherently. She was delirious. When she opened her mouth, a flood of words came out but they didn't make any sense. She was taken to the emergency room, put in a nice, quiet room. When the doctor came in and turned on the light, she called out because the light hurt her eyes. And so he shut down the lights so that it was very low and she was comfortable. You know, he was her friend, he didn't want her to be uncomfortable. He was worried about her.
And so because of that, he didn't notice a couple of really important things. He didn't notice that her skin, which was normally fair, light colored, was bright red. He didn't notice that her mouth was very dry. He didn't notice that her eyes were incredibly dilated. All these things would have been important clues to what was wrong with her. She had been poisoned by a plant in her yard that she had thought was lettuce and so had eaten. This set of symptoms is so common, we have a mnemonic for it, you know, when somebody is mad as a hatter, red as a beet, hot as a hare, blind as a bat. So these are all clues that we're all taught about this kind of poisoning.
But because he didn't want to make her uncomfortable and didn't really value what he could see by doing this exam, he didn't turn on the lights. And yet if she had said, I'd really rather not have a CAT scan - oh, that would never stand. Everybody would be in there, trying to talk her into it. But without a peep, he lowered the lights, cutting himself off from the data that could have led him to a diagnosis.
DAVIES: Our guest is Dr. Lisa Sanders. Her new book is "Every Patient Tells a Story." We'll hear more after a break. This is FRESH AIR.
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DAVIES: If you're just joining us, our guest is Dr. Lisa Sanders. She has a new book about errors in diagnosis, called "Every Patient Tells a Story." I was interested in a case that you describe in the book, a woman you called Carlotta(ph), your own patient, I believe, as a first-year resident, who had a lot of difficulty and a lot of pain. And you were struggling, despite tests, to figure out what was going on. And a third-year resident listened to them and noted that she seemed to be having pain out of proportion to the physical exam. And she said, now that, when I put it together with the other things, are the classic symptoms of ischemic colitis - which is an infection of the colon, caused by a shortage of blood supply.
The point you made was that, that wasn't a collection of symptoms and diagnosis that you would have found in any book. She just knew that that excessive pain, combined with the other things, tended to be classic symptoms of ischemic colitis. Do you find that there is this oral tradition in which doctors shared things with one another that may be aren't there in books.
Dr. SANDERS: This is one of the ancient parts of medicine, that it really does have to be learned at the bedside, from the patient with the guidance of somebody older, more experienced, wiser. We all hope to get to be that older, more experienced and wiser doctor. But, this is the route to getting there - is to being at the bedside with the patient and somebody smarter than you. It's how medicine is learned, and has been always, even when there was not that much to know.
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Dr. SANDERS: It was - it's always been the way medicine is done. There's all these aphorisms that, one of the teaching tools in medicine, ways to remember all the millions of pieces of data. My favorite aphorism, when I was taking care of a guy who was found down in the snow on the side of the road. So, he had hypothermia, very, very low body temperature. The emergency room doctor - I mean, he had no pulse, nobody could hear a heartbeat, EKG couldn't pick up anything. But the ER doctor said, you're never dead until you're warm and dead. And so, they slowly warmed him up.
And as his body warmed up, we started to feel a quiet pulse. And then his respiration became obvious. And then we could pick up his heartbeat. And he was fine. He walked out of the hospital. But I'll never forget that - you're never dead until you're warm and dead. This is the way medicine is passed on. It's part of this old tradition that we've - that has been part of medicine from the beginning. Hippocrates, the father of medicine, wrote three volumes that he called aphorisms. And they're just these one-liners about - with an associated story about things to observe and things to know in medicine.
DAVIES: For years, you've written this column for the New York Times Magazine about diagnosis in which fascinating medical mysteries are explored. And you're a technical adviser for "House," the very successful, FOX-TV series about the acerbic, pill-popping doctor who is so brilliant at cracking a medical mystery every week. So what's your role? Do you provide, you know, obscure illnesses and mysterious diagnosis to the show and then they build a series - an episode around them?
Dr. SANDERS: Yeah, I mean, usually the writers have an idea of what kinds of things they want to have happen. And they'll call me up and say, so do you know of any diseases that can do this, that and the other thing? Okay. And what aresome of the complications of that disease? And what are some of the complications of treating what we thought it might have been but isn't? And what are some of the complications, what are some of the problems you can run into if you're doing this strange test for this other disease?
So, they call me up and I'm a resource, and it's great. I love coming up with weird diseases. When I read the literature, the medical literature, I'm always on the outlook for some odd thing to pass on to "House." And then in the hospitals that I work in, people come to me with odd things. And I pass them on. Last season - or the season before last, House was doing surgery on a patient and cut him open, and his bowel gas caught on fire. There was a huge fire in the operating room…
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Dr. SANDERS: …it was fantastic. But, that was based on something that happened in the hospital where I'm an attending physician. So, I passed - as soon as I heard it, I knew it was "House" material. In fact, I heard it because the resident it happened to ran to tell me as soon as she - as soon as her hand healed.
DAVIES: You're telling me that in your hospital, someone's bowel gas caught on fire?
Dr. SANDERS: Uh-huh. It happens, you know. I'm sure - there are only two cases written of this in the medical literature. I'm sure it happens a lot more frequently than that. But it's - I guess people don't really want to talk about it that much, but it's fantastic. And it totally makes sense once you understand the physics of it.
DAVIES: Well, at the risk of being crude, how does it get ignited?
Dr. SANDERS: When you make a cut, you sew up large vessels that bleed. But little, tiny vessels that bleed are usually cauterized. And to do that, we use -basically an arc welder on a very tiny scale. So it puts out a little spark, and that cauterizes the little vessel. So, you take methane and a little spark and a tiny hole, and you have high-pressured gas going by a flame. And you have an explosion. So, you know, the resident who was operating said that the flame shot up 10 or 12 feet, and said that the lights at the top of the ceiling were, you know, covered in smoke and melted. The covers were melted. So, it was - let me just say, the patient did fine.
The attending physician - the attending surgeon took the scalpel out of the surgeon's hand and opened the incision wider so that the gas just diffused out quietly. And that put out the fire. And the patient - they went ahead and did what they needed to do for the patient and sewed him up, told him about it, and he was completely fine.
DAVIES: You know, as you've looked at the art of diagnosis - I mean, you've made the point that some studies suggest as many as - as much as 15 percent of diagnoses are inaccurate, and that there are a number of ways in which, kind of the training and structure of medicine don't give physicians the kind of habits that they really should have to, you know, to do careful physical exams and listen to patient histories and think, you know, in an open-minded way about problems. And the nation's now beginning to think about how it's going to restructure - at least, how it pays for medical care and to some extent, how medical care may be structured. Do you have an opinion about how health- care reform should proceed?
Dr. SANDERS: Absolutely. And I think that it would be hard to find doctors, especially internists, who don't have very strong opinions on this. We don't have the time that we need. We don't have the tools that we need because what we do is not valued. Thinking, which is really what a doctor does - thinking, examining, questioning, is not valued by the system. It wasn't designed that way. It was just an accident but doing is what really counts, thinking not so much. For example, not long ago I had - I guess nine or 10 patients in a half day. My first nine patients were the usual diabetes, high blood pressure, hyperlipidemia, cold, cough, bronchitis.
The last patient I'd scheduled at the end of the day needed his ingrown toenail removed. So, I see everybody, every patient gets 20 minutes ,for the most part. This last patient also gets 20 minutes. I cut out his toenail and gave him a Band-Aid, and sent him on his way. But for that procedure, I got paid more than I did for all the patients I had seen prior to him because we value doing rather than thinking. So I would certainly encourage reform, to allow for people to think. Because it's thinking, fundamentally, that's going to save us money.
DAVIES: Well, Lisa Sanders, it's been really interesting. Thank so much for speaking with us.
Dr. SANDERS: Thank you so much, Dave.
DAVIES: Dr. Lisa Sanders' new book is called, "Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis."
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