Monday, October 5, 2009

The Dog That Didn’t Bark

It is often pointed out that Arthur Conan Doyle’s model for the great detective Sherlock Holmes was based on the methods used by physicians to determine diagnoses.  While patients are invariably most concerned with the treatments, as the treatments will make them better, most physicians, especially family practice physicians, internists, pediatricians and ER doctors, all of whom are on the front line of medical treatment, are usually much more concerned with making a proper diagnosis as the treatment often follows the diagnosis in a very straightforward way.  Missed and incorrect diagnoses can lead to disaster and it can be a true mystery to determine the cause of an ailment or a symptom. I think about this while reading a wonderful book Every Patient Tells a Story by Lisa Sanders.  Dr. Lisa Sanders describes the challenges of making diagnoses through stories of real situations between doctors and patients.

Finding what Doesn’t Fit

I admit that I enjoy watching formulaic detective shows on television.  Give me a good episode of NCIS or Monk (prior to this season in which the writing has gone downhill) and I am happy.  As you watch these shows, you often see that the trick in finding the killer and solving the mystery, is finding the fact that does not fit with the others and persisting until a different answer can be found that does explain all the findings.  In many ways, a good diagnosis follows this approach.  You tend to start with a number of possibilities in your mind and you then test these possibilities with the patient’s history, physical exam and lab tests.  You have to know quite a bit from just the history and physical to select the right lab tests.  This is the most important part of the science and art of making a diagnosis.  One patient story comes to mind.  A young physician with severe abdominal pain comes into the Emergency Room saying that he has right sided abdominal pain that is excruciating and also has a low grade fever.  He tells the ER doctor that he thinks he has appendicitis and a surgeon comes and starts to take him straight to the Operating Room.  No one notices that he is squirming on the gurney and cannot get comfortable.  That doesn’t fit.  People with appendicitis have to hold very still to minimize their pain.  The appendicitis turns out to be a kidney stone, luckily discovered before the incision is made to operate. (I was the patient in that story some thirty years ago when I was an intern)

Solving the Mystery

It turns out that, for a physician, making a diagnosis often requires thinking about each patient in a new way and not allowing yourself to become complacent about every person having the typical illness.  Dr. Jerry Groopman has written about this in articles in the New Yorker and in a book How Doctors Think.  Dr. Groopman talks about doctor’s use of heuristics, or rules of thumb, and how it makes the physician more efficient but also may make a physician less thoughtful and therefore less accurate in making difficult diagnoses.  It takes time to carefully take a history and perform a physical examination in such a way to get to a potential list of diagnoses.  It also takes some strong presence of mind not to see twenty cases of constipation  due to poor diet and perform just as careful a history and physical on the twenty-first to discover that colon cancer while it is still treatable.  Good medicine takes time.  Yet our payment systems do not reward for this time.  Rather the payments encourage large numbers of patients seen briefly with little true “thinking” about each person seen.

The Best Diagnostician

The most impressive diagnostician that I know is my wife who sees newborns who may have rare genetic diseases.  The history that she takes can go back for generations in a family.  Her physical examination will often cause her to precisely measure the distance between the eyes and carefully describe the ear folds.  She will routinely take two hours or more to see and evaluate a new patient.  That may be why, despite her many years of training, first as a pediatrician, then as a Clinical Geneticist, and her many years of experience including running statewide programs in genetic diseases, her income is below that of a general pediatrician. 

Paying for the Best

I think about all this as we continue the health reform debate in this country.  While we debate the public option and the mandated coverage while also talking about cutting Medicare payments and eliminating a popular Medicare program (Medicare Advantage), we avoid talking about the payment reform that will actually encourage physicians to perform careful, thoughtful histories and physical exams and likely save money on procedures, tests and surgeries.  Right now, Medicare and Medicaid have the market power to initiate payment reform and encourage the type of payment system that would improve quality of care by improving the solving of medical mysteries that is the heart of diagnostics.  I only hope that someone in government wakes up to this basic need in reform.