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Questions: Where The Rubber Meets The Road

Posted Aug 26 2008 4:08pm

For all the policy talk and all the problems of managing physicians and designing efficient delivery systems, the rubber has to meet the road some time. This happens where a provider of health care is working with a patient with the door closed. Beyond the door is the maddening world of what we call the health care system. There was once a time that the things that passed behind the closed door were sacrosanct; they are no longer. But like it or not, behind the closed door is the crux of the health care system, it is the place where every health care consumption decision must take place. And it is a mystery to every policy wonk, manager and patient who is not a physician.

Some years ago I used to teach residents at a large city university hospital and I was called to see a patient in the ER.

I was asking his wife some questions, when I noticed a look of pained irritation on his face. They were tired, I could tell. It didn’t take much imagination; she had had these pains for two days. They were in a frantic emergency room, waiting for a bed and had just finished with the emergency physician who decided she needed to stay and called our service. My medical student and intern had visited and when they called me, it was my turn. I too was tired, having been rounding all afternoon on the sickest patients we had in the hospital.

I pressed on hesitatingly and then he scowled and asked, “Why all the questions?”

How to explain, I wondered. The magic of medicine reduced to the most basic process, one of conversation. It is here, in the flow of questions and answers that I would find out for myself if someone missed anything important. We didn’t have a diagnosis, just stomach pains. Physicians are all trained to doubt the answers another has related to us. We go back to the patient and ask all the same questions, scouring the story for an inaccuracy. "Do it yourself or it wasn't done at all," is how I was taught.

Maybe the history just wasn’t as clear in my mind from the documentation the emergency physician left for me? After all, he jots down a few cursory notes, just enough to support his decision to call the admitting team and dictated the details. My intern is good, but relies on the medical student’s mindless repetition of every possible question . This is how they learn to distinguish critical information form all the other stuff in the medical history. As teachers we test their skill at organizing the relevant and discarding the questionable. My job, as most doctors would see theirs to be, is to be the final adjudicator of the plan. Funny how everything -- policy, management, insurance, consumer groups -- everyone impinges on this moment; the one where a patient and a physician put together a plan that makes sense to both the doctor and the patient.

As a student, I was taught that 90 percent of the diagnoses you make are made on the history alone and merely confirmed by the examination and laboratory. Diagnosis takes place far from the moment of the laying on of hands, which can almost be redundant in certain circumstances. We have no Star Trek tricorder to see deep into the body’s workings. We decide by talking, sifting through the peculiar tales filtered through a unique experience and told according to history, education and levels of understanding.

The tests we use are not as reliable as we think when used indiscriminately, like a shotgun. Statistics describe the limitations in their usefulness; sensitivity and specificity, positive and negative predictive values, to rule-in or rule-out any specific condition we may have in mind. Without the thought that precedes the study, whether it is a simple blood test or a sophisticated scan, tests can lead you to the wrong place. It is worse than a red herring which is unexpected and not created by the inherent uncertainty of the situation.

“I need to ask,” I find myself saying. “I know a lot of people have seen you, but at least for tonight, I’m the guy who’s in charge. Tomorrow I may ask another doctor or two to see you. I’m afraid they will want to get the story from you themselves.”

I waited for the question about the tests. “When are you going to find out what’s going on?” he asked. “We’ve been here three hours and nobody’s told us what the tests showed.”

“Not much, I’m afraid. At least nothing you’d want to hang your hat on. The hemoglobin is normal, so there hasn’t been any bleeding. The white count is normal, so it doesn’t look like a bad infection, you know, like an abscess or an appendix or something serious like that. She could still have a stone, but those results aren’t back yet. We may need to do an ultrasound in the morning.”

“What about the X-ray? Couldn’t you see anything on the X-ray?”

“It was normal.”

“So what’s causing the pain.”

I shrug my shoulders. “We have to take it one step at a time. Sometimes we can’t give you an answer right away. Sometimes, we can’t give you an answer at all, except that it isn’t anything bad.”

Tests are funny that way sometimes. They only show you something if a disease is there, but they don’t always tell what’s wrong, especially if the condition is not what it was designed to detect. Most tests are only meant to confirm the presence of one or two conditions, or else they just tell you something is wrong, without telling you what. It’s frustrating, but then you go back to the questions and check out you own skills this time. This time, maybe the patient tells the same story just a little different, not realizing that it is all the difference. The headache came before the throwing up, not after. Maybe it was a migraine, after all. We ask our questions and impatiently order more tests, falling into the trap of being indiscriminate. We ignore the possibility of remaining in the dark, because it is impossible not to understand everything that can happen to a human being.

Illness is fear, for the patient that he or she may suffer; for the physician that he or she may miss something and be blamed. In the end, it is the basic human skill of conversation that will save you.

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