Below, a guest-post by Dr. Clifton K. Meador, the author of well-known satirical writings on the excesses in our medical system, including “The Art and Science of Non Disease,” (the New England Journal of Medicine, 1965) and “The Last Well Person,” an essay he published as an “Occasional Note” in NEJM in 1994. HealthBeat readers may remember past guest-posts by Meador including “The Art of “Diagnosis” drawn from his book True Medical Detective Stories, and “The Unheard Heart: A Metaphor,”
In this guest-post Meador writes about the importance of listening to patients—something that often doesn’t happen in a 15 minute office visit. I’m hopeful that under reform, more and more doctors will be able practice medicine full-time, leaving billing, hiring and firing of support personnel ,and all of the other time-consuming details of running a business to others. Telemedicine also should open up some time: rather than coming in for a 15 minute appointment, patients who don’t have questions could ask for refills of routine prescriptions on the phone or via e-mail.
Eventually Health IT will be good enough that doctors will no longer spend hours tracking down lost Faxes. Finally, more physicians will be dividing their work with nurse-practitioners. In some cases, the nurse-practitioner might be especially effective when dealing with chronically ill elderly patients; in other cases he or she might excel in treating adolescents.
Ideally, restructuring how care is delivered will lead to longer appointments with some patients, giving the doctor the opportunity to truly listen—particularly when the cause of physical symptoms remains a mystery.
If a doctor had more time, what would he discover? Here, Meador offers what some may consider a radical thesis: 55 years of experience as a primary care physician, combined with studying the medical literature, has convinced him that “between 30 and 40 percent of first contact primary care visits are stress- related or are psychological in nature.”
I’m particularly intrigued by his description of “psychosomatic disorders” as described by Dr. John E. Sorno in The Divided Mind.
I haven’t yet read the book, but look forward to doing so. The reviews are impressive. As Meador makes clear, to say that an ailment is “psychosomatic” does not mean that “it’s all in your mind.”
Finally, Meador mentions that at this time, the medical profession denies the existence of psychosomatic illnesses. I’m baffled. Both life experience and years of reading have convinced me that mind and body cannot be separated. I’d be interested in hearing from other physicians on this point. — MM
The High Cost of Not Listening to Patients
by Clifton K. Meador, M.D.
Author: True Medical Detective Stories and Symptoms of Unknown Origin
Before we can understand the high cost of not listening, we need to examine in detail the diagnostic process. I am limiting my discussion to patients with chronic or recurring symptoms lasting several months. I am not discussing acute illnesses. They fall into completely different category.
At the front line of medical care, at the first contact between a patient and a doctor, the patient describes physical symptom. Whatever the real underlying cause, a physical symptom is the required ticket to see a physician. (Michael Balint, Lancet. Pp 683-88, 1955).
The physician, on first contact, has no idea what the underlying nature of the patient’s chronic complaint really is. At the risk of oversimplifying, there are five broad categories of the causes for complaints. These are:
1. There is a definable medical disease in one or more organs.
2. There is no definable medical disease but the patient is in contact with an unknown toxic substance causing the symptom (inhaled, ingested, or from skin contact).
3. The patient is in a stressful or toxic relationship at home or work producing physical symptoms or even a definable medical disease. (“What the mind cannot process is relegated to the body.” Dr. William Mundy, psychiatrist, personal communication. )
4. The patient or a companion is inflicting harm. Here, there are several categories:
— Factitial disease (in these cases the patient or someone else creates physical symptoms)
— Malingering to gain money or drugs,
— Munchausen syndrome—a serious mental disorder in which someone with a deep need for attention pretends to be sick or gets sick or injured on purpose. People with Munchausen syndrome may make up symptoms, push for risky operations, or try to rig laboratory test results to try to win sympathy and concern.
— Munchausen by proxy — a parent or another caretaker exaggerates symptoms that a child is suffering. (For both forms of this disease see Marc Feldman, “Playing Sick”, Brunner-Rutledge, NYC, 2004. )
5. There is no definable medical disease but the patient has assumed a chronic illness role in life with multiple symptoms (i.e.hypochondriasis).
6. There is a sixth category; patients with psychosomatic disorders. Time and space does not permit a full discussion of this important and very common set of disorders. I suspect they represent more than fifty percent of patients seeking primary medical care. The book “The Divided Mind” explains and defines these disorders and the successful treatment applied to thousands of patients at NYU by Dr. Sorno and his colleagues. At present the medical profession denies the existence of this category. The epidemic emergence of pain clinics comes from lack of knowledge about psychosomatic disorders and their proper treatment.
Of course, the patient can have any of these, and also be suffering from a definable medical disease.
But my experience in primary care over the past 55 years –combined with studies in the medical literature–suggest that between 30 and 40 percent of first contact primary care visits are stress related or are psychological in nature (#3 and #6 in above list).
It should be obvious that the only way to sort out these causes of symptoms requires very careful listening to the narrative of the patient’s life. Some of these causes can be determined only by listening.
Let’s now trace a hypothetical patient and a hypothetical physician, who does not have the time or inclination to listen carefully.
The hypothetical patient is 48 years old, married, and the mother of two teenage daughters. The husband is a severe alcoholic and often physically beats up the patient.
The sixteen year old daughter just told her mother that she is pregnant. The patient’s mother, with Alzheimer’s, wanders in and out of the house at night, often getting lost. None of this story is revealed to or explored by the doctor.
The patient complains of abdominal pains, headaches, fatigue, insomnia, and constipation. The doctor, in the first 15 minute appointment, focuses in on the abdominal pain and orders an endoscopy of the upper GI tract and a full battery of blood chemistry screens.
The endoscopy is normal. Chemistries reveal a slightly elevated alkaline phosphatase, suggesting liver or gall bladder disease (later found to be a false positive). The physician then orders as abdominal ultrasound, suspecting gall bladder disease. The gall bladder exam is normal, but there is a suspicious looking mass in the left upper quadrant. The physician then orders a CT scan of the abdomen. And the work up continues over several weeks, including a colonoscopy.
The cost of the workup exceeds $5000 and reveals no abnormality.
The physician tells the patient “it is all in your head” and prescribes Xanax and a sedative at bedtime.
This story is only slightly exaggerated. With the increasing shortage of primary care physicians, this tale will become more common as more patients are fed into the high technological workup prematurely, without the sorting process and without being heard. Though if , under health care reform, we make greater use of nurse practitioners—who are trained to spend time with patients, and listen to what they have to say-– we may find that more diagnoses are based on the patient’s oral history.
Feeding the Patient Into the Specialist System
But today, too often, the primary level is by- passed. The patient is fed directly into the specialist system. The job of the specialist is not to sort out the real causes of the symptoms. The job of the specialist is to discover if the patient does or does not have a disease related to his specialized organ.
Does the patient have (for examples) heart disease or GI disease or chest disease or joint disease or blood disease or the disease of whatever specialist is being seen? The chance to sort out the influences of the lived life of the patient has been lost in this process.
There is one other element leading to the high cost of not listening to the patient. It is the false positive problem. Here I must digress a bit into some details of the diagnostic process.
The accuracy of any test (i.e. true positive or false positive test result) depends on how common or how rare the tested disease is. If the probability of the disease being tested is low (rare), there will be a large number of false positive results.
The physician who listens carefully can be selective in ordering tests. This step of being selective actually increases the accuracy of the test. If this step is bypassed, there is a high chance of getting a false positive test result.
This is the case when patients are seen directly by specialists who automatically order the definitive test of their specialty. The false positive test result must then be chased down by another test, and on and on, creating large unnecessary costs and anxiety for the patient or even a false diagnosis of a nonexistent disease.
In the end, not listening to patients generates higher costs on two levels:
1. At the primary care level, failures to hear the life stresses and explore them leads to premature testing and high rates of false- positive test results. This, in turn, leads to unnecessary costs and even false diagnoses of nonexistent diseases.
2. At the specialty referral level (by- passing primary care) the automatic unfiltered testing creates high costs and the increased chance of false positive test results. In the worst case scenario, this leads to false diagnoses of nonexistent disease.
The magnitude of the costs of “not listening” is unstudied and unknown. The medical literature that we all rely on does not attempt to measure the number of false diagnoses.
But given the large numbers of patients suffering from stress or psychologically determined symptoms, it is likely that a large percentage of the national high cost of healthcare comes from the fact that too many doctors are not listening to their patients.
Let me suggest that there are two questions that any physician should ask of each patient, no matter what the complaint:
–Are you happy with your life?
— Do you like your work?