Medical students are taught that the evaluation of a patient should proceed in a discrete, linear way: you first take the patients history, then perform a physical examination, order tests, and analyze the results. Only after all the data are compiled should you formulate hypotheses about what might be wrong. These hypotheses should be winnowed by assigning statistical probabilities, based on existing databases, to each symptom, physical abnormality, and laboratory test; then you calculate the likely diagnosis. This is Bayesian analysis, a method of decision-making favored by those who construct algorithms and strictly adhere to evidence-based practice. But, in fact, few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression in the waiting room, and with the tactile feedback gained by shaking a persons hand. Hypotheses about the diagnosis come to a doctors mind even before a word of the medical history is spoken. And in cases like Annes, of course, the specialist had a diagnosis on the referral form from the internist, confirmed by the multitude of doctors notes in her records.
Falchuk ushered Anne Dodge into his office, his hand on her elbow, lightly guiding her to the chair that faces his desk. She looked at a stack of papers some six inches high. It was the dossier she had seen on the desks of her endocrinologists, hematologists, infectious disease physicians, psychiatrists, and nutritionists. For fifteen years shed watched it grow from visit to visit.
But then Dr. Falchuk did something that caught Annes eye: he moved those records to the far side of his desk, withdrew a pen from the breast pocket of his white coat, and took a clean tablet of lined paper from his drawer. Before we talk about why you are here today, Falchuk said, lets go back to the beginning. Tell me about when you first didnt feel good.
For a moment, she was confused. Hadnt the doctor spoken with her internist and looked at her records? I have bulimia and anorexia nervosa, she said softly. Her clasped hands tightened. And now I have irritable bowel syndrome.
Falchuk offered a gentle smile. I want to hear your story, in your own words.
Anne glanced at the clock on the wall, the steady sweep of the second hand ticking off precious time. Her internist had told her that Dr. Falchuk was a prominent specialist, that there was a long waiting list to see him. Her problem was hardly urgent, and she got an appointment in less than two months only because of a cancellation in his Christmas-week schedule. But she detected no hint of rush or impatience in the doctor. His calm made it seem as though he had all the time in the world.
So Anne began, as Dr. Falchuk requested, at the beginning, reciting the long and tortuous story of her initial symptoms, the many doctors she had seen, the tests she had undergone. As she spoke, Dr. Falchuk would nod or interject short phrases: Uhhuh, Im with you, Go on.
Occasionally Anne found herself losing track of the sequence of events. It was as if Dr. Falchuk had given her permission to open the floodgates, and a torrent of painful memories poured forth. Now she was tumbling forward, swept along as she had been as a child on Cape Cod when a powerful wave caught her unawares. She couldnt recall exactly when she had had the bone marrow biopsy for her anemia.
Dont worry about exactly when, Falchuk said. For a long moment Anne sat mute, still searching for the date. Ill check it later in your records. Lets talk about the past months. Specifically, what you have been doing to try to gain weight.
Copyright © 2007 by Jerome Groopman. Reprinted by permission of Houghton Mifflin Company.
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No Man's Land
by Simon Tolkien
Inspired by the experiences of his grandfather, J. R. R. Tolkien, during World War I.
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