When Falchuk told me that the picture didnt fit, his words were more than mere metaphor. Donald Redelmeier, a physician at Sunnybrook Health Sciences Centre in Toronto, has a particular interest in physician cognition and its relation to diagnosis. He refers to a phenomenon called the eyeball test, the pivotal moment when a doctor identifies something intangible yet unsettling in the patients presentation. That instinct may, of course, be wrong. But it should not be ignored, because it can cause the physician to recognize that the information before him has been improperly framed.
Doctors frame patients all the time using shorthand: Im sending you a case of diabetes and renal failure, or I have a drug addict here in the ER with fever and a cough from pneumonia. Often a doctor chooses the correct frame and all the clinical data fit neatly within it. But a self-aware physician knows that accepting the frame as given can be a serious error. Anne Dodge was fitted into the single frame of bulimia and anorexia nervosa from the age of twenty. It was easily understandable that each of her doctors received her case in that one frame. All the data fit neatly within its borders.
There was no apparent reason to redraw her clinical portrait, to look at it from another angle. Except one. Its like DNA evidence at a crime, Falchuk explained. The patient was saying I told you, Im innocent. Here is the art of medicine, the sensitivity to language and emotion that makes for a superior clinician.
Falchuk almost rose from his chair when he showed me the pictures of Dodges distorted small intestine taken through the endoscope. I was so excited about this, he said. He had the sweet pleasure of the detective who cracks the mystery, a legitimate pride in identifying a culprit.
But beyond intellectual excitement and satisfaction, he showed his joy in saving a life.
Intellect and intuition, careful attention to detail, active listening, and psychological insight all coalesced on that December day. It could have been otherwise. Anne Dodge, with her history of anorexia nervosa and bulimia, may then have developed irritable bowel syndrome. But Falchuk had asked himself, What might I be missing in this case? And what would be the worst thing that could be missed? What if he had not asked himself these questions? Then Anne Dodge, her boyfriend, or a family member could have asked them perhaps many years earlier. Of course, a patient or a loved one is not a doctor. They lack a doctors training and experience. And many laymen feel inhibited about asking questions. But the questions are perfectly legitimate. Patients can learn to question and to think the way a doctor should. In the chapters and epilogue that follow, we will examine the kinds of errors in thinking that physicians can make, and the words that patients and their loved ones can offer to prevent these cognitive mistakes.
In Anne Dodges case, it was Falchuk who asked simple but ultimately life-saving questions, and to answer them he needed to go further. And Anne Dodge needed to agree to go further, to submit to more blood tests and an invasive procedure. For her to assent, she had to trust not only Falchuks skill but also his sincerity and motivations. This is the other dimension of Roters and Halls studies: how language, spoken and unspoken, can give information essential to a correct diagnosis, and persuade a patient to comply with a doctors advice. Compliance can have a negative connotation, smacking of paternalism, casting patients as passive players who do what the all-powerful physician tells them. But according to Roters and Halls research, without trust and a sense of mutual liking, Anne Dodge probably would have deflected Falchuks suggestions of more blood tests and an endoscopy. She would have been noncompliant, in pejorative clinical parlance. And she would still be struggling to persuade her doctors that she was eating three thousand calories a day while wasting away.
Copyright © 2007 by Jerome Groopman. Reprinted by permission of Houghton Mifflin Company.
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