Lose the forest for the disease: Part I
I finally started 3rd year of medical school – where we rotate through the various branches of medicine for 1-2 months at a time – and I am continually struck by the formulaic approach to health that seems ingrained in both the practice and training of medicine. Medicine, as it is currently taught, centers around the development of a “differential diagnosis” – a list of all possible diagnoses based on the patient’s symptoms – and the consequent treatment plan. To develop this mental workflow, we don’t pour over monolithic medical treatises. Instead, we resort to review books (of the BluePrints or Board Review Series variety), which distill man’s current knowledge of the human body into easily digestible factoids of the form “ABC Disease is characterized by (insert rash here) and (insert cardiac abnormality here), commonly found among (insert ethnicity, gender, and/or age group here). It is diagnosed by (insert 2-3 symptoms and laboratory test here). First line of treatment is (insert medication here); second line of treatment is (insert surgical intervention here).”
It is mindnumbing. Worse still, I suspect that this educational paradigm inhibits patient-centered healthcare.
You can imagine how the average medical student approaches a patient: nervous, yet eager, she hangs back while her attending physician exams the patient. Suddenly, the physician lifts up the patient’s leg, and asks the student, “What is unilateral swelling of the leg associated with?” The student stares blankly at this leg, which is now conceptually dismembered from the rest of the patient, grasping for shreds of a differential diagnosis. In the end, she manages to recall a few catch phrases from her review book (lymphadenopathy, DVT, etc.), and her attending fills in the rest.
Now, this model for education is arguably necessary, for, when we enter a patient’s room, we need to rapidly sort and file all the data that we collect, and, more importantly, we need to know what we are looking for. The problem is that, more often than not, we lose the patient for the disease. Instead of interacting with the patient as we would our uncle or our neighbor, we interact with them as a bag of possible diseases. We have all experienced this kind of medical care (for it is the most common): the doctor comes in, asks you how you’re doing, ignores your response, asks you a few questions, listens to your heart, and – poof – diagnosis made, pills prescribed, medicine done. This sounds a bit extreme, but I have seen variants of it already – and I’m only 2 months into my medical school rotations. Recently, I worked with a pediatric gastroenterology fellow whose patient interview looked more like canned, well-rehearsed acting than genuine human interaction. She would ask her patients how they felt, and then, while avoiding eye contact, drop in the timely “Hmm” or “I see” for reassurance. After blatantly ignoring every complaint they had, after ignoring the rash covering their body head to toe, after ignoring their attempts at conversation, she would then procede to ask about belly pain… and nausea, and vomiting, and bloody stools, etc., effectively turning this person into a grabbag of gastrointestinal symptoms. After going fishing for GI complaints, she would then pull out one of her GI tools, be it an endoscopy or a CT scan or perhaps a recommendation to eat more fiber.
This GI fellow never rose above her formulaic medical training. She memorized her board review textbooks, and, along the way, she also memorized the patterns of speech – the Hmm’s and I-see’s – characteristic of her revered teachers. To her, each patient was merely a variant of the same gastrointestinal grabbag. Her attending physician, however, seemed to pay more attention to what the patient said, taking into account what they ate, how they felt, where they’ve been, etc., commingling his intel with light-hearted conversation. The seemingly disparate bits of information buried in genuine conversation have their own place is assessing a patient’s health, and the value of this kind of interaction seems to become more appreciable with experience (as older physicians tend to listen- or are perceived as listening - to their patients more).
