Doctored (8 page)

On Sunday morning, after I had spent a long night helping Sonia with feeding and diaper changing, Rajiv phoned me in a panic. My father had been having episodes of numbness and tingling in his left arm (along with similar but milder symptoms on the right). Rajiv was worried they were transient ischemic attacks (TIAs), or ministrokes. He said he was taking my father to LIJ to be evaluated.

“Stroke?” I said dubiously. “With bilateral symptoms? Come on, what kind of nerve distribution causes bilateral—”

“Don't be academic about this!” Rajiv snapped, cutting me off. “Let's let the experts figure out what's going on.”

He called me a couple of hours later. Caroline Davenport, the neurologist on call, had seen my father in the emergency room. Suspecting a TIA, she'd sent him for a CT scan of the brain, which was normal. Since early strokes don't always manifest on a CT scan, she had ordered an MRI of the head and brain stem, which also revealed nothing unusual. Despite the normal studies, she had decided to admit my father for observation and started him on blood thinners.

I jumped into my car and sped to the hospital. It was a calm and clear day, a stark contrast with the maelstrom that had been unleashed in my chest. Though I doubted anything was seriously wrong with my father—I'd seen him only a couple of days earlier, and he hadn't mentioned any symptoms to me—I still felt afraid. Dad wasn't supposed to get sick. It was the one thing as children we were told to fear the most. I raced across the George Washington Bridge. The Hudson River was shimmering like a pool of mercury. Near La Guardia Airport, I got stuck in a traffic jam, honking my horn in desperation to get it moving while airplanes drifted precariously low overhead. By the time I reached the hospital it was already past noon, two and a half hours after I had departed.

I found my father in a semiprivate room on the seventh floor. His eyes were darting, and he had a strangely disconnected look, which I attributed to anxiety. Rajiv and my mother were there, too, sitting quietly, now looking bored. A medicated drip hanging on a pole was connected to my father's arm. Rajiv informed me that Dad's blood pressure was elevated, so doctors had given him lisinopril, the same drug that we had advised him to start several years earlier but that he had declined. We now took turns assailing him over how irresponsible he had been. He offered no defense.

The reason my father had refused to take lisinopril (or any other drug Rajiv and I had suggested) was that he no longer trusted medicines to keep him well. Six years earlier, when I was in my final year of medical school, he had started having headaches that were probably triggered by job stress but that over the course of several months became chronic. Initially he took over-the-counter medications like Tylenol and aspirin, but with little relief. Then, at the urging of doctors, he moved on to prescription drugs: Flexeril, Fiorinal, Imitrex, amitriptyline, Paxil, and finally, prednisone. During that period he was seen by an array of specialists: three internists, two neurologists, two rheumatologists, an anesthesiologist, and an ophthalmologist. No one could tell him what was wrong. Then one day, totally fed up, my father stopped all his medications. Two weeks later, his headaches were gone.

“It was the medicine that was causing the headaches,” he concluded incredulously (and probably correctly). And though he'd grown up in a culture in which doctors commanded tremendous respect, he'd been loath to listen to physicians ever since.

The following day in the hospital, my father got an echocardiogram to see if there was a blood clot in his heart that could have partially dislodged and landed up in his brain. There was not. He also got a transesophageal echo, in which an ultrasound camera was passed via a stiff tube into his mouth, down his throat (numbed with anesthetic), and into his esophagus to get close-up views of his heart. Apart from showing a mildly leaky aortic valve, probably a result of hypertension, it, too, was unremarkable. Again Rajiv and I got on his case about his blood pressure. “Do you want to end up with a stroke?” I blared. (Admittedly, I derived some pleasure from the scolding after a lifetime of his preaching.) “You won't be able to work.”

“I'd rather be dead,” my father replied quietly.

Over the next couple of days, my father underwent a battery of further tests: carotid ultrasound, transcranial Doppler, lower-extremity Doppler, and chest CT. It seemed a bit excessive to me, but I said nothing. The studies were normal. Since he was symptom-free with no speech or other neurological deficits, Dr. Davenport decided to observe him for one more day and then send him home. We hardly saw her during the hospital stay. Even when she did show up, she spent no more than a couple of minutes with my father and then rushed off. On the day of discharge, my father was given prescriptions for four medications—lisinopril, aspirin, Lipitor (a cholesterol-lowering drug), and Aggrenox (a blood thinner used to prevent strokes)—and was told to follow up with a neurologist once he got back home. Grateful for the reprieve, and appreciative of the efforts of his doctors, he said he had learned a lesson and pledged to take his medications regularly and his health more seriously.

Three days later, when I was back at work, my sister, Suneeta, called me from Rajiv's house, where she and my parents were still staying. Dad's symptoms had returned, worse than ever. He now had virtually no sensation remaining in his left arm.

“But he's had all the tests,” I said skeptically. “Let me talk to him.”

Suneeta was hysterical. “He says he's having a stroke!” she shrieked. “He says he can't feel his arm!” The strength she struggled to show as the baby girl in a traditional Indian family often devolved into anger or panic under pressure. In the background I could hear my mother yelling out in alarm, as though my father were falling down.

“It is happening,” my father announced when he finally got on the phone.

“What?” I demanded.

“I don't know, but I think I am dying.”

He had never sounded so frightened to me. I told him I would call an ambulance, but he insisted that Vandana, Rajiv's wife, drive him immediately to the hospital.

About an hour later I heard “LIJ, code stroke to the emergency room” over the intercom. Racing downstairs—even though I was running, I still didn't believe anything could be seriously wrong—I arrived to find Robert Holman, Dr. Davenport's portly associate, evaluating my father on a stretcher with a neurology resident and a rather severe-looking Filipino nurse. My father was whisked away for another head CT before I could even talk to him. When it revealed nothing new, preparations were made for a repeat MRI. As my father lay there among shouting drunks and screaming children, appearing about as miserable as I'd ever seen him, a nurse took me aside. “Don't know if I should mention this, Dr. Jauhar, but I've noticed your father's symptoms get worse when he tilts his head,” she said. She'd had him do certain maneuvers, like touching his chin to his sternum, that reproduced his symptoms exactly. I went over to his stretcher and had him repeat the motions. “That's it,” my father said, dipping his chin down unnaturally. “Now I cannot feel my arm.”

I found Dr. Holman in the radiology room, reviewing the head CT for any subtle abnormalities. When I informed him of the nurse's findings, he walked over to my father and, apparently examining him for the first time because the doctor looked so surprised, had him perform the exercises again. Sure enough, the numbness was reproducible, suggesting that my father only had a pinched cervical nerve, a relatively benign condition. Appearing chastened, Holman said the MRI was now probably unnecessary but advised my father to have it anyway (with the imaging extending into the neck) to eliminate any residual uncertainty. It confirmed what the nurse had suspected: a pinched nerve.

My father was given a prescription for a neck brace and sent home from the ER. I decided not to tell him too much about the final diagnosis. I didn't want to ratify his distrust of doctors, and I wanted to maintain a little fear in him so he'd take his blood pressure medication. The following day, he and my mother flew back home to Fargo, North Dakota, where he was then working as a plant geneticist.

A few weeks later I was having breakfast with Tom Antoni, a newly hired cardiac rhythm specialist, in the LIJ cafeteria. In the manner of most doctors in his specialty, Tom was calm, detached, and thoughtful, and we had become friendly. I was still fuming over Davenport's and Holman's incompetence. If only they had examined my father properly, a $20,000 diagnostic workup and a great deal of worry could have easily been avoided.

Of course, I should hardly have been surprised. At one time, keen observation and the judicious laying on of hands were virtually the only diagnostic tools a doctor had. Today they seem almost obsolete. Technology like MRI scans and nuclear imaging rules the day, permitting diagnosis at a distance. Many doctors don't even carry a stethoscope anymore.

Physicians' exam skills, as a result, have no doubt atrophied. In a study I'd read about at Duke University Medical Center, a leading teaching hospital, residents in internal medicine were asked to listen to three common heart murmurs programmed into a mannequin. Roughly half could not identify two of the murmurs despite testing in a quiet room with ample time—hardly normal conditions. About two-thirds missed the third murmur. (Retesting did not improve performance.) And in another study at thirty-one internal medicine and family practice residency programs on the East Coast, over five hundred residents and medical students were tested on twelve heart sounds taped from patients. On average, the residents got only 20 percent right, not much better than the students. Hard to imagine such abysmal performances when physicians had only a stethoscope and an electrocardiograph machine to examine the heart.

The impetus behind these lapses, I'd come to believe, is that doctors today are uncomfortable with uncertainty. Everyone wants a number, a lab test, a simple objective measurement to make a diagnosis. If a physical exam can diagnose a pinched spinal nerve with only 90 percent probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the stronger fear is that of subjective observation. Doctors are uneasy making educated guesses based on what they see and hear. If postmodernism teaches that there are many truths, or perhaps no truth, postmodern medicine teaches the opposite: that an objective truth is sure to explain a patient's symptoms if only we look for it with the right tools.

Under a flashing art deco coffee cup, I told Tom a story that an old-timer cardiologist at NYU had once told me. A group of residents had presented to him a case of atrial fibrillation, an abnormal heart rhythm, replete with results of echocardiograms, angiograms, and stress tests. He went to see the patient and immediately noticed that the whites of her eyes had black discoloration, a sign of a potentially serious metabolic derangement. No doctor had commented on it during the presentation. “I did a … hello!” the cardiologist recalled. “How could they have missed it? All through the chart was written ‘pupils equally round and reactive to light.' It was obvious no one had examined her. I subscribe to the Yogi Berra School of physical diagnosis. You can learn a lot by looking.”

Tom smiled, slowly chewing his scrambled eggs. “I majored in music in college,” he said. “Knowing how to separate sounds and time them correctly has helped me immensely in listening to the heart. It'd be a shame if we lost those diagnostic skills. When you think of all the useless things we learn in medical school, physical diagnosis probably isn't one of them.”

Then he added: “By the time patients get to me, they have already seen their internist and cardiologist. They have had their echos and caths. Still, I feel an obligation to examine them. When I listen to their hearts, I make sure to put my hand on their shoulder to convey a sense of warmth. I think it is enormously important to touch patients before I cut into them.”

*   *   *

I made my own mistakes that first year as an attending physician. There was so much to keep track of, it was hard to know where to start—or stop. I had to master billing codes, make a template for consultation letters, learn which procedures got reimbursed (six-minute walk, sleep apnea screening, external counterpulsation), and tap into community resources (support groups, visiting nurse service, home hospice). A doctor I'd met at a conference for graduating cardiology fellows told me that since I likely wasn't going to generate even a fraction of the revenue of procedure-based cardiologists in my department, I should at least keep track of downstream earnings on catheterizations and pacemakers I ordered for my patients, so I came up with a scheme to do that, too. Then there was the actual work of patient care. Should I document every abnormality in that stack of EKGs? Should I try to master the specifics of this particular case or cede turf to the residents? As an attending you had to know how to toggle back and forth between a bird's-eye view and the details. Delegation was the key. Sometimes it helped to ask, What would I do if this were my father? It was always interesting to note which insights—such as
Do we really need another test to make this diagnosis?
—would pop into your head when you asked yourself that basic question.

I had manifold responsibilities at the hospital. As the director of the heart failure program I was accountable for the overall care the hospital provided to patients with this disease. Though it is often difficult to treat, heart failure has a characteristic physiology. In most cases it begins with an acute decrease in the heart's pumping function. The weakened heart is unable to propel blood out of the lungs, resulting in plasma leakage into the air spaces, which causes decreased oxygen tension and shortness of breath. At the same time, blood pressure drops, as the heart is unable to maintain a normal cardiac output, resulting in fatigue and damage to vital organs, especially the kidneys. Heart failure treatments, such as diuretics for removing excess salt and bodily fluid, attempt to counteract, however inadequately, these effects.