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.
Yes, the supposed creed that insists on disease centered medicine rather than “patient-centered medicine” will fail to perform truly scientific medicine (that is the knowledge-full kind). Truly respecting the patient has to be part of a physician’s work. This entry makes it clear that the patient belongs in the picture. A doctor who fails to perceive that the patient is there to be observed and respected should change professions, or make a change in his/her basic view of doctoring.
With her quotations from Dr. Meador’s book and her example of the patient whose problem was hunger, not something “wrong” with his stomach, Maggie Mahar creates an important vision of what’s important for healing and health.
It serves to illustrate a very important proximal node where dissection of the disease of the health care system ought to begin: the consulting room. This is where I have seen the worst medicine practiced…and 17 years of teaching clinical medicine reinforced this for me.
Good histories and physicals are the exception, and there are many reasons for this, but it does not negate this truth.
Also (I repeat this many times), doctors *really* need to understand, in much greater detail, what it is like to be a very sick patient in this system. Unfortunately, I do.
I am also amazed how seemingly threatened several doctors have felt when confronting me. I really prepare for the encounters. The risk is always capitulation to the needs of ‘the system’…which is easy when you are badly compromised and absolutely need help. Advocacy is paramount.
Good to see Balint mentioned in a current blog! I’ve attended some Balint groups in London but have found things have moved on a bit from there. Balint was a very strict Freudian and saw things that way. He did bring the doctor-patient relationship to the fore of course. I guess that is partly about what you are writing about here.
75% of medical diagnoses should be made by talking to the patient. ie before physical examination and certainly before investigations. The human relationship between doctor and patient is essential. For me affection and humour are essential too. To be a foot soldier for MEDICAL SCIENCE is not why I became a doctor.
Gertrude, Ruth, Brian
Yes, you put it so well: “Disease-centered medicine” is quite
different from “patient-centered medicine.” As you suggest, it lacks the wisdom of medical practice that truly respects the patient.
Thank you ,
Good to hear from you.
Doctors who have also been patients know more than most of us. (Though I would add that nurses who also have been patients probably know more than all of us! I am convinced that nurses know more than anyone about what goes on in hospitals.)
And, as you say, in the face of the “system” patient “advocacy” is paramount.
Yes, Ballint was writing in at a time when Freud was
accepted without skepticism.
Much of what Freud said was, I think, true–and as he knew, not even oriiginal. (As Freud said: “the poets have been here before me.” Much of what Shakespeare shows us about human beings in his plays woud be codified by psychiatrists a few decades later.)
You write: “75% of medical diagnoses should be made by talking to the patient. ie before physical examination and certainly before investigations. The human relationship between doctor and patient is essential. For me affection and humour are essential too.”
You are the doctor many of us have been lookng for.
Thanks for the compliment, Maggie! I wish I could live up to it most of the time. On the positive side there are some good things going on in medicine which have yet to affect the mainstream. One doctor who has done a lot in New Zealand is Robin Youngson. I recently heard him speak in London on his recent book: Time to Care: How to love your patients and your job. His whole movement (which can be seen here http://www.time-to-care.com) is well worthy supporting in any way.
I totally agree with what you say about nurses. Nurses have always known more about the human side of medicine than doctors. Dr Youngson’s book makes great reading for nurses because it must be so easy to ‘burn out’ as a nurse – esp. in these times of recession (‘depression’ is too negative a word to use)
My main focus these days is using reverse psychology and humour to get people to see the truth about themselves as early as possible. Only they have the map of their journey in life. Humour and reverse psychology can be used to satirise behaviour patterns in them that are not helping them reach their own inner goals and thus preventing them from finding their own way to fulfilment in life. We can talk about this approach more if you want, but do keep up the good work on this blog.
Thanks for the link via Jonathon Tomlinson at the Medicine Unboxed conference in Cheltenham (just finished)
I see the problem here, well analysed from the perspective of the medic needing to understand the person sitting opposite them. I still feel as though there is a further, additional, move to make – whereby the person is just that, and not a patient.
“affection and humour” – absolutely right – because this is how we build relationships.
Medics, social workers, nurses, and therapists of all kinds in the statutory sector, have been inspected, monitored, bribed, blackmailed, bureaucratised and hounded into objectifying people…
and taught that it is uneconomical to treat the person as a brother or sister in humanity who needs empowering so that you can proportionately use your skills only where they really help…
This is a disaster and has to change.
the strengths based approach – which comes naturally to some loving practitioners – is a way to go. It requires us to see people as primarily a container of skills/strengths/knowledge, first, and not the collection of needs, or deficit that we do currently.
Taking this approach is not easy. It does require that we actively put a block in, at all levels, to more than just the culture of targets and box ticking – it means we have to REBEL against them.
This requires CEOs and senior managers to provider “air cover” as practitioners tear up the useless measure forms, redesign the system around the quality of life of the citizen (NOT “patient”, please let go of this demand for professional distance) and develop the culture of becoming the person’s “friend in service” who will enable them to stay out of the system as much as possible, and walk a quick and gainful path through it when it is required.
In Gloucestershire we have some agreement from key leaders in NHS and GCC that we can do this, take what looks like a huge risk.
But the tide is turning and we have friends in low and high places who see that this is the only way forward…
watch this (Listening Well, Living Well) space for how we turn the system around in Gloucestershire
“becoming the person’s ‘friend in service’ who will enable them to stay out of the system as much as possible, and walk a quick and gainful path through it when it is required.” I like that– it sounds very much like what patient-centered (as opposed to physician centered or hospital-centered) medicine is supposed to be all about.
I had never thought about it, but I agree referring (and thinking of) the person as “the patient” is condescending, and
ignores what is unique about each person. I’ve heard doctors use the term with some distaste — conveying that “the patient” is a layman, and thus ignorant.