A Tale of Two Doctors

Data is not always the path to identifying good medicine. Quality and cost measures should not be perceived as “scores,” because the health care process is neither simplistic nor deterministic; it involves as much art and perception as science—and never is this more the case than in the first step of that process, making a diagnosis.

I share the following story to illustrate this lesson: we should stop behaving as if good quality can be delineated by data alone. Instead, we should be using that data to ask questions. We need to know more about exactly what we are measuring, how we can capture both the physician and patient inputs to care decisions, and how and why there are variations among different physicians.

A Tale of Two Doctors

“As soon as I start swimming, my chest feels heavy and I have trouble breathing. It is a dull pain. It is scary. I swim about a lap of the pool, and, thankfully, the pain goes away. This is happening every time I go to work out in the pool”.

Her primary physician listened intently. With more than 40 years of experience, the physician, a stalwart in the medical community, loved by all, who scored high on the “physician compare” web site listing, stopped the interview after the description and announced, with concern, that she needed to have a cardiac stress test. The stress test would require walking on a “treadmill” to monitor her heart and would include, additionally, an echocardiogram test to see if her heart was being compromised from a lack of blood flow.

“But, I have had three echocardiogram tests in the last year as part of my treatment for breast cancer and each was normal. Why would I need another”?

“Well, I understand your concern about more tests, but the echocardiograms were done without having your heart stressed by exercise. The echo tests may be normal under those circumstances, but be abnormal when you are on the treadmill. You still need the test, unfortunately. I want to order the test today and you should get it done in the next week”.

The patient had other ideas. She refused the stress test and, instead, sought a second opinion. The second physician (another experienced, well respected, multiple-board-certified physician) asked more questions than the first. The complaint was queried for the context of the pain. When did it occur? Did it occur only with swimming? How long did it last? What made it better? What made it worse? Any associated symptoms? What was its course—gradually better, or suddenly better? Were there any other medical issues in her life?

The pain abated as she exercised; it did not worsen as she swam and was gone in less than a minute. The pain never occurred in any other circumstance. The patient offered that she worked out daily and never had the problem when she ran or exercised robustly. She worked out faithfully for one hour, seven days per week and in a strenuous fashion. Her symptoms only occured during swimming. She had tried nothing to improve it, but since it had been occurring regularly, she sought help.

The physician asked about how she started her swim; she anxiously jumped in the pool, and, since she hated the sudden blast of cold water, she tensed and then swam vigorously to warm up. After listening to her lungs and her heart as part of a brief physical exam, the physician asked her to try a common sense solution, while not offering a cause. The physician advised her to enter the water slowly, perhaps, even, walk in the pool for a bit until she warmed up before swimming.

Approaches to Diagnoses Fall Outside of Data Analysis With Huge Impact
​What is going on with this person? Is she having trouble with her heart? Could this be her lung? Could she have asthma? The differential diagnosis for the cause of her symptoms is filled with worrisome conditions—or not. This is a diagnostic dilemma. What would you do? Which approach seems most reasonable to you?
This anecdote, like a TV program, is based on a true story, and I will tell you the outcome.

But, first, think about how varied were the responses of the physicians. One directed the patient to testing; the other performed no tests other than the history of the complaint and a focused physical exam. One physician’s care will be expensive, but will the stress test ordered by the first ease the worry of both the patient and the physician? Why did the first physician focus on the most serious cause and the second on the most likely cause?

The differences in approaches to this same patient are huge. Many quality improvement efforts aim to assess variations in physicians’ practice patterns. But these efforts of comparison are hampered on many fronts; foremost, that different patients, cared for by different physicians, vary in clinical context and disease burden. This blog’s story differs, pointedly. The patient variation is gone; the patient is the same, the variation is in the physicians’ responses to the patient’s complaint.

There is little information about the variations in how physicians approach a patient’s diagnostic dilemma beyond aggregate costs of care. This is a deficiency since physicians’ variation may surpass patients’ variation, as in this situation.

Variations in Care Are Not Fully Explained by Utilization in Care
A search for a diagnosis requires appropriate context. The complaint of “chest pain” has myriad causes; the complaint of “chest pain when jumping into a cold pool that abates as exercise progresses” has a much smaller list of causes. Too often, medical care improvement, safety and science truncate the discovery process regarding important aspects of a patient’s condition when a concerned physician fails, for whatever reason, to capture the nuance that is essential to medical care for an individual.

The second physician teased out the nuances of the complaint via questions and a physical exam appropriate to the contextual clinical situation. While we know, for example, that the physical exam done routinely will likely yield nothing of significance, a physical exam that aims to test a hypothesis based on the full “picture” of the patient’s complaint will bear more fruit.

More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in these physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.

Performance Improvement Must Include Both Physician and Patient Communications
We keep insisting on bland, poorly conceptualized ideas about how to improve care. We keep insisting on non-contextualized “data,” as if, somehow, that data includes something of value about what is going on between patient and physician. Medical care is a cottage industry of two and can be nothing else. It should be measured as such.

And now, the outcome: The patient followed the advice of the second physician. She changed her routine and now warms up before swimming; her complaint is gone and has not returned.

​She also changed physicians.

10 replies »

  1. Thank you for wonderful, insightful comments. Some comments back at ya, but probably less insightful.

    First, the data used by the second physician was not capture by the first. The first jumped at the complaint without assessing the timing, the course, the aggravating and alleviating factors, what had been done to make better or worse, or the context that the complaint occured only in a specific situation. These questions are taught to be gathered by every physcian for every patient, but underrepresented in data sets that attempt to understand why people do what they do, and to what end.

    Second, to think that a cardiologist knows more about heart disease than any good trianed internist is nonsense because there is no good evidence of the sort.

    Third, if we think that knowing how the coronary arteries look is a good thing in every person that even hiccups, then we are lost at the get go. Low probability state testing is precarious as the false positive looms. And show me that doing anyting to the arteries of a human being with stable angina, even if they have it which this patient does not, helps them in the first place.

    Again, as I have argued before, population health is a misnomer. No one even knows what a population is, averaging out is unethical and the goal of medical care is to inform and maximize the care from a single patient’s perspective, not the insurer’s, the government’s, the administrative staff, the marketer’s, the conflicted, or the physician.

    Not sure what would have happened if the patient went to the first doc. But, I would guess the same outcome to the patient with only a single visit. The patient, like more people should be, was the driving force in this story.

  2. Yes, it does seem that the plan of Doctor 2 worked. However, this does not mean that this woman is healthy. First of all, it is known that angina can be present at the beginning of exercise, but may disappear as the exercise continues. Secondly, sudden exposure to cold water can cause coronary artery vasoconstriction, which will cause an angina like symptom if there is a partial blockage, or if there is coronary artery spasm. Coronary spasm may be more common in female patients.
    One has to remember that in the Triathlon competition, most of the deaths are in the swimming part of this endurance test. Most of these individuals have exercised vigorously on a regular basis prior to the start of the Triathlon, and these deaths are believed to be coronary in nature, and related to the cold water.
    Therefore, while the first physician did not take as complete history as the second physician, the second physician may have exhibited confirmation bias in his diagnosis, and the patient may indeed have coronary artery disease.
    Unfortunately, sometimes these patients have normal stress tests as well.
    The bottom line is that she needs a complete evaluation performed by a cardiologist who takes a full history, and completes an appropriate examination, and is not predisposed to confirmation bias. Her symptoms may be the first manifestation of an underlying coronary problem.

  3. Pick the doc who asks a LOT of questions.

    What set of data was doc1 using as compared to doc 2?

  4. I would argue that data is more valuable at the population level than at the individual patient level. Suppose, for example, that there are five primary care doctors in the same town. Each one is board certified and well regarded in the community. Each has a panel of 2,000 or so patients comparable in socio-economic status, age distribution, health status and complexity. Perhaps one or two of these five generates significantly more in medical claims than the others because they practice more defensive medicine. They order more tests and refer more patients to specialists maybe because they have a greater fear of potential lawsuits than their colleagues across town. That extra defensive medicine raises healthcare costs and health insurance premiums without adding any extra value in terms of patient health status and outcomes. Both insurers and individual patients might find this information useful.

    One problem is that the risk adjustment state of the art isn’t where it needs to be yet. We don’t want to penalize doctors unfairly for treating older and more complex patients because that would create an incentive to avoid them.

  5. Nice story, but I am not seeing what part data played here. I suspect that Doc #2 knows that the data suggests that a person who can exercise strenuously and not have CP (SOB, etc.) probably doesn’t have CAD and needs no further testing.

  6. Patients are not widgets. The variability in patient personalities and encounters is unlimited, and to think we can use data to judge doctor’s interactions with patients is absurd.
    Consider a different scenario: What if the patient saw the second physician first, and he told her she didn’t need further testing? But let’s say she was alarmed based on her history that she could possibly have a cardiac condition. In that case, she may have sought another opinion from the “first” doctor, and been happy to have a stress test done, just to “make sure”.