NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

A young doctor and his wife had just moved to the mountains of eastern Kentucky, near the border of West Virginia. The small town was nestled among the coal mines of the region. Nearly all of his patients would be coal miners or family members of a miner. Bill would practice family medicine. His wife, a veterinarian, hoped to build a small-animal practice.

Liz McWherther, the forty-seven-year-old wife of a miner, came to see the young doctor. Over several weeks, she had developed a curious set of complaints. Each morning she woke with a dry mouth and slurred speech. She also noted blurred vision and difficulty urinating. Within a couple of hours of waking, she was completely free of any symptoms. These symptoms had been occurring each morning and going away by afternoon.

Liz had had a series of tests done by the previous physician, but none of these tests were abnormal. The physical examination by Dr. Hueston was entirely normal. She denied drinking alcoholic beverages or using illicit drugs. Hueston had briefly considered some unusual response to marijuana or other drugs that were prevalent in the area. Liz had not been down in the mines, nor did her husband bring back anything unusual into the house.

The complex of symptoms suggested multiple sclerosis or some diffuse neurological disease. However, the rapid disappearance of the symptoms was puzzling. The most perplexing feature was the improvement as the day went on. Nearly all neurological diseases get worse as the day progresses. In most cases after a night’s rest, the neurological circuits are improved, and patients are at their best on arising. Not so with Liz. She was at her worst on arising and rapidly improved within a few hours.

Dr. Hueston went through a long list of possible neurological conditions. None seemed to fit the findings or course of the symptoms. Hueston came to the conclusion that he needed a neurological consultation. The nearest neurologist was over fifty miles away, so he began filling out the request for consultation and other forms required by the miners’ insurance.

Hueston was chatting as he wrote. “My wife and I are new to the area. You know she is a veterinarian. She’s having a hard time dealing with the amount of skin disease in her patients. All of the cats and dogs are loaded with ticks and fleas. She didn’t have that problem in her city practice.

Liz’s attention became alert. “Yeah, I had that with my cat. But I fixed it.”

“How’d you get it fixed?”

“I just dust her every week.”

Hueston stopped writing and paused. “You dust her. What do you mean ‘dust her’?”

“I just take my rose dust I use in my garden. Dust it on my cat. Then just rub it in.”

Hueston asked, “Rose dust? What’s that?”

“I don’t know what all’s in it. It kills the insects on the roses and it sure kills ticks and fleas on my cat. My cat is free of ’em.”

Hueston, now in full alert, asked, “Where does the cat sleep?”

Liz smiled and answered, “Why, she sleeps right on my pillow with me.”

Hueston said, “I want you to go home and wash your cat. Don’t use the rose dust anymore, and don’t let the cat in your room at night. Let’s see what happens and maybe you won’t have to go all the way to Lexington.”

Liz came back a week later. Smiling widely, she told Dr. Hueston she had not had any more dry mouth, blurred vision, or slurred speech. Her urination was completely normal. The “disease” had gone away. She even brought a bag of the rose dust with her.

Dr. Hueston smiled back. He read the chemical contents on the rose dust bag and found what he suspected in the contents—organophosphates.

He went on to explain to Liz McWherther how organophosphates are nerve poisons. They cause some segments of the nervous system to fire continuously. The pupils constrict to pinpoint size. Salivation is inhibited. The urinary bladder does not function normally. If the exposure to organophosphates continues or the dose is large, death can occur.

Everyone wondered why the cat did not get sick. We will never know. Liz’s problems were symptoms that she noted and described.

Cats don’t talk.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

A note on the Author: Clifton Meador has been practicing and teaching medicine for more than 50 years and some of the patients he describes in these stories are his own.

Not only is Meador an engaging story-teller (he has been called the “Will Rogers of medicine”) he  has had a lasting impact both as a doctor, and as someone who has thought deeply about how medicine is practiced in the U.S. His well-known satirical writings on the excesses in our the medical system include “The Art and Science of Nondisease, (the New England Journal of Medicine, 1965) andThe Last Well Person,” an essay he published as an “Occasional Note” in NEJM Journal in 1994.

“The Last Well Person” begins with this anecdote: “A supervising doctor asks a medical resident “What is a well person?” The resident  replies with some confidence: “A well person is a patient who has not been completely worked up.”

Meador then proceeds to tell a tale takes place in the not-too-distant future. The story’s only character is a 53-year-old professor of freshman algebra at a small college in the Midwest. Despite extensive medical evaluation, no doctor had been able to find anything wrong with the teacher. But he is the only remaining person for whom this is true. Doctors from all over the country flock to the Midwest to check him out.

At the time, Meador warned: “if the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick.” (Dr. Norton Hadler would later adopt the title for his book The Last Well Person: How to Stay Well Despite the Health-Care System, 2004)

Readers who have seen the film version of Money-Driven Medicine http://moneydrivenmedicine.org/ (produced by Alex Gibney, directed by Andy Fredericks) may remember Meador as the Nashville doctor who takes them on a tour of his town. Nashville is best known as the nation’s Country Music Capital, and Meador takes readers past “Music Row,” but as he reveals, Nashville also is the headquarters for a “massive complex of healthcare corporations.”

Their pristine headquarters are set high on a hill. In most cases, there are no corporate logos, no signs to identify who the companies are. (Perhaps they are trying to avoid surprise visits by Michael Moore.) But as he drives past, Meador identifies them:

“We have three mother corporations here:  HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, and Health Trust, which is a spin-off of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that’s headquartered here in Nashville.” In the background, we hear the song that Alex Gibney, the film’s producer, chose for this scene: “If you’ve got the money, honey, I’ve got the time.”

Over the years, Meador has watched Nashville’s medical industrial complex develop into one of the country’s biggest money-spinners, while, at the same time, health statistics in Tennessee have slid to the bottom of the national rankings

The Pressure to Diagnose: Meador and Balint on The Physician’s Creed

The doctor who treated the Coal Miner’s Wife in the story above solved the mystery both because he listened to his patient–and because he didn’t rush to diagnose.

As Dr. Jerome Groopman, author of How Doctors Think, has told us:  “Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what’s wrong.   And too often, we make what’s called an anchoring mistake — we fix on that snap judgment.”

Meador has taken that insight a step further: Sometimes doctors diagnose a “non-existent disease.”

Not long ago, Meador posted a comment on Health Affairs that sums up his doubts diagnosis: “The fact a patient is experiencing ‘symptoms’ does not necessarily mean that he are suffering from a disease. After 50 years in teaching and practice, I have come to see that not every symptom or set of symptoms has a medical diagnosis to fit. What I am sure about is that every symptom has a cause.”

The symptoms are real. Meador does not assume that because he can’t crack the case, the patient must be a hypochondriac. Something is triggering the pain. It’s just not something that a doctor will find on a list of known maladies. For example, the coal-miner’s wife wasn’t suffering from a rare disease; she was “dusting” her cat.

“Most patients in primary care have stressors causing their symptoms either from home or work,” Meador adds. “I agree with the old dictum that says ‘what the mind cannot absorb goes to the body.’’

Ultimately, he believes, “the insistence on a diagnosis” –i.e. the pressure to find a disease –“is at the heart of medical excesses and false diagnoses.”

Doctors Must Remain Open, Doubting Their Own Diagnoses

Groopman agrees that false assumptions lead to misdiagnosis: “Usually doctors are right,” he says, “but conservatively about 15 percent of all people are misdiagnosed. Some experts think it’s as high as 20 to 25 percent . . .

“The reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab,” he adds. “Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.”

The initial “snap judgment “could be based on the first thing the patient says,” he points out. “It could be based on something on their chart or in their file that somebody else has concluded in the past. It could be anything.” At that point, a doctor is likely to order tests that he believes will confirm his diagnosis. Often those tests do just that–or at least they seem to, in part because the physician expects that they will.

But Groopman warns, “each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.”

How can a doctor avoid misdiagnosis?

Not All Patients Fit On a “Decision Tree”

Groopman believes that when trying to assess complex cases, today’s physicians are too quick to trust “the preset algorithms and practice guidelines” that form so-called “decision trees.”

“The trunk of the clinical decision tree is a patient’s major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes,” he explains. “For example, a common symptom like ‘sore throat would begin the algorithm, followed by a series of branches with ‘yes’ or ‘no’ questions about associated symptoms. Is there a fever or not? Are swollen lymph nodes associated with the sore throat? Have other family members suffered from this symptom?

“Similarly, a laboratory test like a throat culture for bacteria would appear farther down the trunk of the tree, with branches based on ‘yes’ or ‘no answers to the results of the culture. Ultimately, following the branches to the end should lead to the correct diagnosis and therapy.”

He is quick to acknowledge that “clinical algorithms can be useful for run-of-the-mill diagnosis, distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases — the kinds of cases where we most need a discerning doctor — algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.”

If the doctor attends to the patient in front of him, not just by listening to him, but by observing him–perhaps even laying hands on him– he may realize that the patient just doesn’t fit on the tree.

In the course of his clinical practice, this is just what Clifton Meador discovered.

Symptoms of Unknown Origin

Before writing True Medical Detective Stories, Meador published Symptoms of Unknown Origin: a Medical Odyssey (2005).

The book describes Meador’s own Odyssey. “For years after graduating from medical school, Dr. Clifton K. Meador assumed that symptoms of the body, when obviously not imaginary, indicate a disease of the body–something to be treated with drugs, surgery, or other traditional means,” his publisher explains.

Experience would teach Meador that he was wrong. “Over several decades, as he saw patients with clear symptoms but no discernible disease, he concluded that his own assumptions about diagnosis were too narrow. In time he came to reject a strict adherence to the prevailing bio-molecular models of disease and its separation of mind and body.”

He studied other theories and approaches–for instance “George Engel’s biopsychosocial model of disease.” (Engel recognized the effect that our social environment has on our body/minds; he believed that physicians treating the body must also take notice of “psycho-social issues.)

“Meador also came to recognize Michael Balint’s studies of physicians,” his publisher reports. (Balint coined the term “patient-centered medicine” and stresses the importance of the doctor-patient relationship. In “The Doctor, His Patient and the Illness.” Balint concludes that once a doctor and a patient agreed on a diagnosis, the “non-disease” becomes incurable.)

As a result, his publisher notes Meador came to recognize “the defense mechanisms that physicians use to cope when encountering their  patients’  distress” –and adjusted his practice accordingly to treat what he called ‘nondisease’.”  He had to “retool” his publisher reports, “learn new and more in-depth interviewing and listening techniques, and undergo what Balint termed a ‘slight but significant change in personality.’”

Defense Mechanisms: the “Physicians’ Creed”

When a patient visits a doctor complaining of symptoms, he expects the doctor to diagnose what ails him. If he doesn’t, the patient is likely to view the visit a failure.

For his part, the physician presented with a patient in pain quite naturally wants to solve the problem. His medical training has taught him that the resident who names the disease wins the gold star. Thus, both patient and doctor conspire to “insist” on a diagnosis.

If the doctor cannot find a satisfactory answer, or the patient does not respond to treatment for the diagnosed disease, the physician may become testy–and ultimately blame the patient. In Symptoms of Unknown Origin, Meador quotes Michael Balint:

“every doctor has a set of fairly firm beliefs as to which illnesses are acceptable and which are not; how much pain, suffering, fears and deprivations a patient should tolerate, and when he has a right to ask for help and relief: how much nuisance the patient is allowed to make of himself and to whom, etc., etc.

“These beliefs are hardly ever stated explicitly but are nevertheless very strong. They compel the doctor to do his best to convert all of his patients to accept his own standards and to be well or to get well according to them.”

This, of course, is the opposite of what Dr. Donald Berwick has famously described as “patient-centered” medicine.

Balint then goes on to describe a hypothetical “physician’s creed” based on a conventionally narrow biomolecular model of illness.  The creed reads: “I believe my job as a physician is to find and classify each disease of my patient, prescribe the proper medicine, or recommend the appropriate surgical procedure. The patient’s responsibility is to take the medicine I prescribe and follow my recommendations. I believe that man’s body and mind are separate and that disease occurs either in the mind or in the body. I see no relationship of the mind to the disease of the body.

“Medical disease (‘real,’or  ‘organic’ disease) is caused by a single physicochemical defect such as by invasion of the body by a foreign agent (virus, bacterium or toxin) or from some metabolic derangement  arising within the body. I see no patient who fails to have a medical disease.” (Hat Tip to “The Renaissance Allergist” for posting Balint’s comments on his blog

One wonders how many students graduate from medical school today believing some rough version of this doctrine. At least one reader commenting on Meador’s book suggests that the “Creed” remains part of our medical culture:

“Although the biomolecular model of Dr. Meador’s day has since been supplanted by the biopsychosocial model in academic circles, in actual clinical practice this transition has yet to occur. Instead of searching for root causes, we learn to blame our patients for their refractory illnesses by characterizing them as “problem patients”, “difficult”, or “noncompliant”. Those labels are often true, but they don’t encourage or help us to address the underlying problems. Dr. Meador’s book does.”

Or, as another reader puts it, “Meador not only pulls the rabbit out of the hat, he shows us where the rabbit was hiding.”

As we struggle to reduce that amount of overtreatment in our medical system, I hope that medical educators will begin to warn young doctors against the “insistence” on finding a single organic “defect.” Very often, behind human suffering, a wise physician and compassionate physician will find  multiple causes–biological, psychological and sociological–that cannot be easily separated.

I recall a post I published on HealthBeat in May of 2011 quoting a doctor who mistook poverty for disease: “I diagnosed ‘abdominal pain’ when the real problem was hunger. . . .  My medical training had not prepared me for this ambush of social circumstance. Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.”  She was able to help her young patient only when she realized that he was going to bed with an empty stomach.

Maggie Mahar is an author and financial journalist who has written extensively about the American health care system. Her book, Money-Driven Medicine: The Real Reason Health Care Costs So Much, was the inspiration for the documentary, Money Driven Medicine. She is a prolific blogger, writing most recently for TIME’s Moneyland. Previously she wrote and edited the Health Beat blog for the progressive think tank, The Century Foundation. Previous work for the Health Insurance Resource Center includes Will the Supreme Court strike down health reform? She also recently provided background on Congressional health care legislation for HealthReformVotes.org, a special project of the Health Insurance Resource Center. This post first appeared at Health Beat Blog.

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4 Responses for “The Art of Diagnosis”

  1. coriolanus says:

    But she’d have saved such much money if she’d gone to a nurse practictioner.

  2. SJ Motew, MD says:

    The post could have easily been titled “The Lost Art of Diagnosis”. I recall (not that long ago) my more senior surgical mentors demanding I develop my diagnosis in a step-wise manner, based on long-standing investigative techniques of questioning, observation, examination and then testing as needed usually only to confirm what you had already figured out.

    The improvement in diagnostic methods (imaging, testing) have allowed the entry of phenomenal technology, but at times perhaps we now rely too heavily on these expensive and at times risky method and thus diminish the necessity perhaps of the ‘old methods’ or worse act as a replacement.

    Surely factors such as time (it takes a longer visit to be comprehensive), defensive medicine (good luck if…forbid…. you are wrong) and patient preference drive the minimization of the Art of Diagnosis.

    Dr. Olga Jonasson, a pioneer in transplant and woman leaders in surgery, mandated the diagnostic, hands-on personalized approach to a fault. Even after retirement, her weekend rounds were painfully arduous, but her point that ’90% of the diagnosis is complete before you even lay hands on the patient’ holds true today. In the day of comprehensive care, wellness, disease management and need for cost containment maybe we would do better to remember these words of wisdom.

  3. Tom says:

    You seem to be missing one of the most common underlying causes for excessive Healthcare cost. Most would agree prevention is the lowest approach to lowering cost. The next in line would be early diagnosis and correct treatment. The current medical model of the 10 minute GP visit and the GP’s best guess referral to a specialist is a bad model. The GP has little time to hear and analyze the patients whole picture so typically refers based on the symptoms with the most obvious match to a specialty and maybe a few tests. The GP often gets it wrong and the specialist is too specialized to find the problem. This leads to ER visits followed by more 10 minute attempts to diagnose, more simple tests followed by another specialist. This goes on and on, sometimes for years. The failure to correctly diagnose early often leads to chronic diseases that cause more visits, tests, expensive ER visits and on and on. With GP visits getting shorter and shorter especially at HMO like Kaiser, this is driving a costly cycle of diagnosis failure. There are many strategies to correct this problem. The simplest for an integrated system like Kaiser would be to offer members access to online software that provides the most obvious differentials for the GP and a summary. Patients have lots of time to interact with software providing far more details and history than a 10 minute rush to diagnose. If the GP had the diagnosis software output available at the 10 minute meeting, its suggestions could quickly choose the most sensible tests and referral suggestions. This would dramatically help the GP and cause a 10 minute visit to be as effective as an hour with a team of experts. This sort of software is already available. An integrated data organization like Kaiser could provide access to the software whenever a GP felt it made sense. That in turn would aid the doctors in getting the right tests and referrals and diagnosis much more quickly than the existing model. This could be combined with a diagnosis experts group for complex cases where the software and GP felt it made sense. Why don’t simple ideas like this just happen? Doctors and Healthcare seem to be attached to their dogmas. Its time to break it.

  4. This is a great website you have and I believe my site can be a great benfit to yours. As its related to the same industry sector, your viewers might appreciate our link to your page. a calculator

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