Every Patient Tells a Story (8 page)

When Angoff became the dean of students, she decided to see if she could do something to prevent that transformation. And she wanted to do it right from the start, right from the very first day of school. “Students come here and they are very excited about medicine. They want to help the sick patient, and medicine is the tool that makes that possible. That’s why they are here. But medical schools don’t teach you about the patient, they teach you about the disease. I wanted to emphasize the patient right from the very first day.”

As part of that effort, Angoff has shaped that first day at Yale Medical School to try to “vaccinate” the students against the focus on the disease and the depersonalization of the patient that is part and parcel of current medical education. To do this, she focuses on the difference between the patient’s story and the story the doctors create from it.

So on a warm September morning, I returned to the classroom in which I had spent most of my first two years as a medical student to see what a new
generation of med students is taught about the stories we hear and those we tell as doctors.

As Angoff, a small and slender woman in her mid-fifties, stepped onto the stage, the nervous chatter of these brand-new students quickly died. She said a few words of welcome and then outlined the events of the morning. We would hear two versions of a patient’s story, first as the patient told it and then as it might have been written up by a doctor caring for the patient in the hospital.

The stories were to be performed by Dr. Alita Anderson. Anderson is a young black woman in her early thirties. A Yale Medical School graduate (class of 2000), Anderson spent a year interviewing patients about their experiences in the health care setting. All of the patients she interviewed were African American, most were poor; many were poorly educated as well. All had multiple encounters with a medical system that was only sometimes responsive to their needs. She now travels around the country performing the stories she collected from this often unheard population.

Anderson gave Angoff a hug and then walked slowly across the stage. She began to sing a slow sad song in a husky alto. I couldn’t quite understand the words and I didn’t recognize the song, but it sounded like some kind of spiritual.

Anderson settled in a lonely chair on the stage and finished the song. She sat quietly for a moment and then said in a rumbly southern voice, “In June 1967, I went to Vietnam. I was a member of the First Infantry Division. My first evening there, they sent me out on an ambush.” She didn’t have any props, nor a costume, but through her voice and expressions she became this middle-aged black man who never recovered from the battlefields and bars of his year in the Vietnam War. She portrayed this man, clearly destroyed by an almost lethal dose of post-traumatic stress disorder, drugs and liquor. It was a compelling performance.

Anderson, still speaking as this sad middle-aged man, described a particularly difficult episode in his life. “I had been drinking. I was very loud and belligerent that night and my sister, who is probably the closest person to me, walked off and said that she was never going anywhere with me again. Afterward, I went out to the Dumpster and I threw the bottle in
that Dumpster and I said that I was never going to drink anymore. I tried to stop on my own, but the next morning when the liquor store was open I was right there buying another bottle. A lot of times, people—they want off but they have no control. That is what the bondages of Satan do, using alcohol and drugs.”

When she finished this man’s monologue, Anderson sang a reprise of the sad song that she’d started with. As she sang, a slide appeared on a screen behind her. Anderson seamlessly switched into a professional voice, with crisp diction and shorn of any accent as she read a re-creation of what a hospital admission note from any of his many hospital admissions might have read. “Chief complaint—a thirty-four-year African American male brought in by police; a question of a drug overdose.

“The history of the presenting illness: The patient was found unresponsive and brought to ER. He was intubated in the field to protect his airway since he was actively seizing, which caused respiratory depression when he was found. In the ER, the patient was minimally responsive to pain. Per police, he had 3 grams of cocaine in pocket. He has been identified by his driver’s license as Mr. R. Johnson whose prior medical records indicate multiple past admissions for drug overdose.”

The students sat in rapt silence throughout the hour-long performance. The contrast between the rich, detailed life portrayed by the young doctor-reporter and the spare, cold language with which it was portrayed in the imagined, but realistic, admission note could not have been stronger. Afterward the students sat in small groups discussing the morning’s event. They were moved by the patient’s story and horrified by its translation into the coolly impersonal language of medicine.

Angoff sees this as an opportunity to demonstrate what patients see all the time: the cold and depersonalizing language and process of medicine. “I want to remind our students that there’s a real person here.” Medical students fall in love with what the doctor’s story can do, what medicine can do, she tells me. The morning’s performance is there to remind them of what a patient’s story can do and how the infatuation can look and sound to the patient they are trying to help.

At the end of the morning Angoff said a few words to the students, summarizing
what she hoped they have learned. “You’re starting out on the journey across this bridge, this education, and right now you are on the same side as your patients. And as you get halfway over the bridge you’ll find yourself changing and the language the patient had and you had is being replaced by this other language, the language of medicine. Their personal story is being replaced by the medical story. And then you find yourself on the other side of that bridge—you’re part of the medical culture. When you get there, I want you to hold on to every bit of your old self, your now self. I want you to remember these patients.”

CHAPTER THREE
A Vanishing Art

H
ere’s a story I read not long ago in the
New England Journal of Medicine:

A man in his fifties comes to an emergency room with excruciating chest pain. A medical student is told to check the blood pressure in both arms. He checks the closer arm and calls out the blood pressure. He moves to the other side of the patient but is unable to find a blood pressure. Worried that this is due to his inexperience rather than a true physical finding, he says nothing. No one notices. Overnight the patient is rushed to the operating room for repair of a tear in the aorta, the vessel that carries blood out of the heart to the rest of the body. He dies on the operating table.

A difference in blood pressure between arms or the loss of blood pressure in one arm is strong evidence of this kind of tear, known as a dissecting aortic aneurysm. The student’s failure to speak up about his inability to read the blood pressure on one side of the patient’s body prevented the discovery of this evidence.

Here’s another story—this one from a colleague of mine:

A middle-aged woman comes to the hospital with a fever and difficulty breathing. She’d been treated for pneumonia a week earlier. In the hospital
she’s started on powerful intravenous antibiotics. The following day she complains of pain in her back and weakness in her legs. She has a history of chronic back pain and her doctors give her painkillers. They do not examine her. When her fever spikes and her white blood cell count soars, the team gets a CT scan of the chest, looking for something in her lungs that would account for a worsening infection. What they find instead is an abscess on her spinal cord. She is rushed to surgery.

Had the team examined her, they would have found a loss of sensation and reflexes, which would have alerted them to the presence of the spinal cord lesion.

This story was recently presented at Grand Rounds, a high-profile weekly lecture for physicians, at Yale:

A man has a heart attack and is rushed to the hospital, where the blocked coronary artery is reopened. In the ICU, his blood pressure begins to drop; he complains of feeling cold and nauseated. The doctors order intravenous fluids to bring up his dangerously low blood pressure. They do not examine him. When, after several hours, his blood pressure continues to drop, the cardiologist is called and she rushes back. When she examines him she sees that his heart is beating rapidly but is barely audible. The veins in his neck are distended and throbbing. She immediately recognizes these as signs that the man has bled into the sac around his heart—a condition known as tamponade. It is a well-known complication of the procedure she’d done just hours before. She rushes him back to the OR and begins draining the blood, which by now completely fills the sac, preventing the heart from beating. Despite her efforts, the man dies on the table. Had the doctors in the ICU examined the patient, rather than paying attention only to the monitors tracking his vital signs, they would have been able to diagnose this potentially reversible complication.

This is another kind of story doctors tell one another in hospital hallways and stairwells—cautionary tales from the pages of our best journals, cases
presented at the weekly Grand Rounds or Morbidity and Mortality Conferences, where medical errors are traditionally discussed. These are the tragic stories of patients who worsen and sometimes die because clues that could have and should have been picked up with a simple physical examination were overlooked or ignored. We repeat them to one another as lessons learned—a prayer and talisman. We tell them with sympathy because we fear that any one of us might have been that doctor, that resident, that medical student.

These anecdotes reveal a truth already accepted by most doctors: the physical exam—once our most reliable tool in understanding and diagnosing a sick patient—is dead.

It wasn’t a sudden or unanticipated death. The death of the physical exam has been regularly and carefully discussed and documented in hospital hallways and auditoriums and in the pages of medical journals for over twenty years. Editorials and essays have posed once unthinkable questions like: “Physical diagnosis in the 1990s: Art or artifact?” or “Has medicine outgrown physical diagnosis?” and “Must doctors examine patients?” And finally in 2006, the flat announcement of the long-anticipated death was carried in the pages of the
New England Journal of Medicine
. In “The Demise of the Physical Exam,” Sandeep Jauhar tells the story of that inexperienced medical student—himself—who couldn’t find a blood pressure on a man with chest pain and an aortic dissection who dies as a result. It is the tasty opening anecdote in an obituary—not for the patient but for this once valued part of being a doctor.

The physical exam was once the centerpiece of diagnosis. The patient’s story and a careful examination would usually suggest a diagnosis, and then tests, when available, could be used to confirm the finding. These days, when confronted with a sick patient, doctors often skip the exam altogether, instead shunting the patient directly to diagnostic imaging or the lab, where doctors can cast a wide net in search of something they might have found more quickly had they but looked. Sometimes a cursory physical examination is attempted but with few expectations as physicians, instead, eagerly await results of a test they hope will tell them the diagnosis.

Many doctors and researchers are troubled by this shift. They complain
about the overuse of expensive high-tech tests and decry the decline of the skills needed to conduct an effective physical exam. Yet despite this uneasiness, doctors and even patients increasingly prefer what they perceive to be the certainty of high-technology testing to a low-tech, hands-on examination by a physician.

Measuring the Loss of Skills

In the early 1990s Salvatore Mangione, a physician and researcher at Thomas Jefferson University Medical Center in Philadelphia, began studying how well doctors were able to recognize and interpret common findings on one fundamental component of the physical exam, the examination of the heart. He tested 250 medical students, residents, and postgraduate fellows specializing in cardiology from nine different training programs. The investigation was straightforward enough: students and doctors were given an hour to listen to twelve important and common heart sounds and answer questions about what they heard.

The results were stunning and controversial. A majority of the medical students could identify only two out of the twelve sounds correctly. The other ten were recognized by only a handful of the students. Surprisingly, the residents did no better. Despite their additional years of experience and training, they were able to correctly identify only the same two examples. Perhaps most disturbing of all, most of the doctors holding a post-residency fellowship in cardiology were unable to identify six out of the twelve sounds.

In a similar test on lung sounds, Mangione again found that students and residents couldn’t identify many of the most common and most important sounds of the body. If letter grades were being handed out, all but a handful of these participants would have gotten a big fat F.