David Baxter PhD
Late Founder
Although this article is about medical rather than psychiatric diagnosis, I think there are enough parallels to make it of interest to Psychlinks members. ~ DJB
Doctor and Patient: The Comfort of a Diagnosis
By PAULINE W. CHEN, M.D., New York Times
October 8, 2009
I was covering the emergency room the morning that Sarah (not her real name) presented with excruciating abdominal pain. Married, in her late 40s and otherwise healthy, she had come to our clinic a few weeks earlier with a benign blood vessel tumor in her liver. Because of the risk of spontaneous rupture, her surgeon, the most senior member of our department, suggested she have the grapefruit-sized tumor, a hemangioma, removed electively and as soon as possible. They settled on a date, but as Sarah left the clinic, he offered one cautionary piece of advice. ?If you develop pain in your belly, come in right away. It may be a sign that the tumor has ruptured.?
In the emergency room that morning, we all assumed the tumor was at least leaking if not already in the early stages of rupture. Sarah lay on the narrow emergency room gurney, her face pale and covered with a patina of cold sweat. In the few minutes that it took for her surgeon to arrive in the E.R., the operating room personnel had prepared a room and warned the blood bank that she might need an emergency transfusion.
The surgeon asked Sarah several questions: how her pain started, where it was, and how she might describe it. He put his hand against her belly, gently palpating the area of her liver, around her belly button and near her pelvis. His hand rested for a moment in the bow of her pelvis, and he lowered his head and closed his eyes. Slowly he began moving his hand in small circles, as if feeling for something below.
?I don?t think her diagnosis is hemangioma,? he said as he emerged from Sarah?s room. ?I think she?s got dead bowel.?
That diagnosis, usually seen in the elderly or in those with rare clotting disorders, had never crossed my mind that morning. It, too, would require an emergency operation, but there would be no life-threatening hemorrhage and an entirely different set of issues to consider post-operatively. Caring for Sarah with dead bowel would not be the same as caring for Sarah with a ruptured hemangioma.
Later that morning in the operating room, Sarah?s surgeon would peel free a perfectly intact hemangioma from her liver. But deeper down in her belly, he would find what only he had felt in the emergency room, the cause of her excruciating pain ? a two-inch segment of dead intestine, telescoped so tightly on itself that it had kinked off its own blood supply.
That Sarah?s surgeon could make such a specific and accurate diagnosis still mystifies me, and her story has become one of several diagnostic mysteries I find myself recounting over and over again. Like doctors everywhere, I relish anecdotes like hers because they are evidence of extraordinary medical sleuthing and intuition.
But, as Dr. Lisa Sanders shows in her thought-provoking new book, Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis (Broadway Books, 2009), my fascination, our fascination, with diagnoses may have more to do with the importance of having a diagnosis than with the robustness of the process itself.
Few individuals have considered the diagnostic process as extensively as Dr. Sanders. For the last seven years in The New York Times Magazine, she has offered readers a new diagnostic dilemma every month, a peek into the way doctors think about disease.
Her new book is filled with similar fascinating patient stories ? the young woman who turns ?highlighter yellow,? the medical student who suddenly becomes inarticulate, and the muscular man who suddenly can no longer hold a coffee cup or walk straight. But unlike her column, where each story is the focus of discussion, the patients who appear in the book are springboards for a discussion of how methods of diagnosis, or lack thereof, ultimately drive patient care. With a diagnosis, the doctor-patient relationship has direction, a purpose, a common goal. Without it, both the patient and physician are unmoored, cast in a sea of overwhelming and often paralyzing possibilities.
With an understated but unwaveringly clear narrative voice, Dr. Sanders takes readers on an examination of the tools of diagnosis, touching upon the obvious and the not-so-obvious ? the physical exam, the effect of physician biases, and even the reliability of computers and Dr. Google.
Over the course of one chapter, for instance, Dr. Sanders explores the role of sight in diagnosis. She brings us on a visit to the office of Dr. Stanley Wainapel, a busy rehabilitation medicine physician, and describes his interaction with a patient complaining of knee pain. It is, she writes, ?a perfectly ordinary encounter? with one exception: the doctor is blind. Later, she recalls a patient she had cared for soon after graduating from medical school. While she recognized that the patient was sick, she needed to look to more senior doctors for help. ?I saw ? it?s probably how I knew she was sick ? but I didn?t recognize what I saw and so was unable to figure out what to do.? Finally, toward the end of the chapter, she brings us into a neuroscience laboratory, where she describes participating in an experiment in which she must watch a video and count the number of basketball passes between players. Dr. Sanders finishes the video but is so intensely focused on the ball that she fails to notice a gorilla ambling across the screen.
But by this part of the chapter, her failure to ?see? the gorilla comes as no surprise. Dr. Sanders has already convinced us that diagnosis is more than seeing; it?s perceiving and placing those perceptions within the context of a patient?s clinical experiences.
As Dr. Wainapel, the blind physician, later tells her, ?[Patients] want me to help them see what?s going on. They want me to help them understand. That?s really my job. Same as any doctor.?
I spoke to Dr. Sanders recently about diagnoses and their role in the patient-doctor relationship.
?Making a diagnosis was almost inconceivable 100 years ago,? Dr. Sanders said. ?Now it?s inconceivable not to have one.?
And while lack of a diagnosis can be frustrating for a doctor, not having one can make seeking treatment particularly difficult for patients and add to their sense of suffering. ?The need to have some kind of identity for your illness is very human,? she said, citing poorly defined syndromes like chronic fatigue and chronic Lyme. ?Something is wrong with them, but many of us are eager to parcel these patients out to psychiatry. While there may be psychiatric issues for some of them, they shouldn?t be suffering because we cannot name what they have. We have to acknowledge that we don?t know but that their suffering is real.?
Over the years, Dr. Sanders has received e-mails from individuals who read her column and are ?desperately in search of a diagnosis.? Often, these patients already have a diagnosis ?but they haven?t bought it yet, so I think they continue to suffer,? she said. ?When people are unable to make sense of what is happening to them, they are not really healed, even if they have been diagnosed. Diagnoses depend on the fundamental collaboration that is the doctor-patient relationship.?
Dr. Sanders sees that collaboration as a two-part process. ?Our first job as doctors is to take the story from the patient,? she said, ?but then our job is to give the story back to the patient.? This second part is particularly critical to patient care. ?The patient has the hard job of dealing with the story and the diagnosis we have given them. Often they have to take medications or have surgery. If doctors can present the story ? the diagnosis ? to patients in a way that they can accept and recognize, I think a lot of the work is done.
?Diagnoses can be a part of the healing process and a building block for an ongoing doctor-patient relationship.?
Doctor and Patient: The Comfort of a Diagnosis
By PAULINE W. CHEN, M.D., New York Times
October 8, 2009
I was covering the emergency room the morning that Sarah (not her real name) presented with excruciating abdominal pain. Married, in her late 40s and otherwise healthy, she had come to our clinic a few weeks earlier with a benign blood vessel tumor in her liver. Because of the risk of spontaneous rupture, her surgeon, the most senior member of our department, suggested she have the grapefruit-sized tumor, a hemangioma, removed electively and as soon as possible. They settled on a date, but as Sarah left the clinic, he offered one cautionary piece of advice. ?If you develop pain in your belly, come in right away. It may be a sign that the tumor has ruptured.?
In the emergency room that morning, we all assumed the tumor was at least leaking if not already in the early stages of rupture. Sarah lay on the narrow emergency room gurney, her face pale and covered with a patina of cold sweat. In the few minutes that it took for her surgeon to arrive in the E.R., the operating room personnel had prepared a room and warned the blood bank that she might need an emergency transfusion.
The surgeon asked Sarah several questions: how her pain started, where it was, and how she might describe it. He put his hand against her belly, gently palpating the area of her liver, around her belly button and near her pelvis. His hand rested for a moment in the bow of her pelvis, and he lowered his head and closed his eyes. Slowly he began moving his hand in small circles, as if feeling for something below.
?I don?t think her diagnosis is hemangioma,? he said as he emerged from Sarah?s room. ?I think she?s got dead bowel.?
That diagnosis, usually seen in the elderly or in those with rare clotting disorders, had never crossed my mind that morning. It, too, would require an emergency operation, but there would be no life-threatening hemorrhage and an entirely different set of issues to consider post-operatively. Caring for Sarah with dead bowel would not be the same as caring for Sarah with a ruptured hemangioma.
Later that morning in the operating room, Sarah?s surgeon would peel free a perfectly intact hemangioma from her liver. But deeper down in her belly, he would find what only he had felt in the emergency room, the cause of her excruciating pain ? a two-inch segment of dead intestine, telescoped so tightly on itself that it had kinked off its own blood supply.
That Sarah?s surgeon could make such a specific and accurate diagnosis still mystifies me, and her story has become one of several diagnostic mysteries I find myself recounting over and over again. Like doctors everywhere, I relish anecdotes like hers because they are evidence of extraordinary medical sleuthing and intuition.
But, as Dr. Lisa Sanders shows in her thought-provoking new book, Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis (Broadway Books, 2009), my fascination, our fascination, with diagnoses may have more to do with the importance of having a diagnosis than with the robustness of the process itself.
Few individuals have considered the diagnostic process as extensively as Dr. Sanders. For the last seven years in The New York Times Magazine, she has offered readers a new diagnostic dilemma every month, a peek into the way doctors think about disease.
Her new book is filled with similar fascinating patient stories ? the young woman who turns ?highlighter yellow,? the medical student who suddenly becomes inarticulate, and the muscular man who suddenly can no longer hold a coffee cup or walk straight. But unlike her column, where each story is the focus of discussion, the patients who appear in the book are springboards for a discussion of how methods of diagnosis, or lack thereof, ultimately drive patient care. With a diagnosis, the doctor-patient relationship has direction, a purpose, a common goal. Without it, both the patient and physician are unmoored, cast in a sea of overwhelming and often paralyzing possibilities.
With an understated but unwaveringly clear narrative voice, Dr. Sanders takes readers on an examination of the tools of diagnosis, touching upon the obvious and the not-so-obvious ? the physical exam, the effect of physician biases, and even the reliability of computers and Dr. Google.
Over the course of one chapter, for instance, Dr. Sanders explores the role of sight in diagnosis. She brings us on a visit to the office of Dr. Stanley Wainapel, a busy rehabilitation medicine physician, and describes his interaction with a patient complaining of knee pain. It is, she writes, ?a perfectly ordinary encounter? with one exception: the doctor is blind. Later, she recalls a patient she had cared for soon after graduating from medical school. While she recognized that the patient was sick, she needed to look to more senior doctors for help. ?I saw ? it?s probably how I knew she was sick ? but I didn?t recognize what I saw and so was unable to figure out what to do.? Finally, toward the end of the chapter, she brings us into a neuroscience laboratory, where she describes participating in an experiment in which she must watch a video and count the number of basketball passes between players. Dr. Sanders finishes the video but is so intensely focused on the ball that she fails to notice a gorilla ambling across the screen.
But by this part of the chapter, her failure to ?see? the gorilla comes as no surprise. Dr. Sanders has already convinced us that diagnosis is more than seeing; it?s perceiving and placing those perceptions within the context of a patient?s clinical experiences.
As Dr. Wainapel, the blind physician, later tells her, ?[Patients] want me to help them see what?s going on. They want me to help them understand. That?s really my job. Same as any doctor.?
I spoke to Dr. Sanders recently about diagnoses and their role in the patient-doctor relationship.
?Making a diagnosis was almost inconceivable 100 years ago,? Dr. Sanders said. ?Now it?s inconceivable not to have one.?
And while lack of a diagnosis can be frustrating for a doctor, not having one can make seeking treatment particularly difficult for patients and add to their sense of suffering. ?The need to have some kind of identity for your illness is very human,? she said, citing poorly defined syndromes like chronic fatigue and chronic Lyme. ?Something is wrong with them, but many of us are eager to parcel these patients out to psychiatry. While there may be psychiatric issues for some of them, they shouldn?t be suffering because we cannot name what they have. We have to acknowledge that we don?t know but that their suffering is real.?
Over the years, Dr. Sanders has received e-mails from individuals who read her column and are ?desperately in search of a diagnosis.? Often, these patients already have a diagnosis ?but they haven?t bought it yet, so I think they continue to suffer,? she said. ?When people are unable to make sense of what is happening to them, they are not really healed, even if they have been diagnosed. Diagnoses depend on the fundamental collaboration that is the doctor-patient relationship.?
Dr. Sanders sees that collaboration as a two-part process. ?Our first job as doctors is to take the story from the patient,? she said, ?but then our job is to give the story back to the patient.? This second part is particularly critical to patient care. ?The patient has the hard job of dealing with the story and the diagnosis we have given them. Often they have to take medications or have surgery. If doctors can present the story ? the diagnosis ? to patients in a way that they can accept and recognize, I think a lot of the work is done.
?Diagnoses can be a part of the healing process and a building block for an ongoing doctor-patient relationship.?
