Unheard Hearts – A Metaphor, by Clifton K. Meador

Below, a guest-post by Dr. Clifton. Meador.

Many  HealthBeatt readers  know Meador as the author of a popular HealthBeat guest-post “The Art of Diagnosis,” drawn from his book True Medical Detective Stories  (“A Young Doctor and a Coal Miner’s Wife.”)

Long-term readers will recognize Meador both as one of the stars in  the film,, Money-Driven Medicine,  and as the author of well-known satirical writings on the excesses in our  medical system. They  include “The Art and Science of Nondisease (the New England Journal of Medicine, 1965) and  “The Last Well Person,” an essay he published as an “Occasional Note” in NEJM  in 1994. 

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Unheard Hearts – A Metaphor 

                                                      Clifton K. Meador, M.D

A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder Continue reading

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Breakfast with Atul Gawande

Sunday, Boston Surgeon Dr. Atul Gawande spoke at the New Yorker Festival about the importance of a hospital being able to “Rescue Success from Profound Failure.”   (Long-time Health Beat readers will recognize Gawande as the author of Complications: A Surgeon’s Notes On An Imperfect ScienceThe Checklist Manifesto  and a number of brilliant New Yorker articles that I have written about in the past, including: “Letting Go: What Should Medicine Do When it Can’t Save Your Life?”,  “It Will Take Ambition It Will Take Humility,” and  “The Fight for the Soul of American Medicine”  (Hat-tip to the New Yorker for publishing so many stellar articles illuminating an extraordinarily complicated subject: healthcare and healthcare reform.)

Before Gawande’s talk began, IBM, the event’s sponsor, hosted a small breakfast where Gawande spoke informally to a group of doctors, health plan executives, hospital administrators and people from IBM who are in the vanguard of healthcare reform. The New Yorker was kind enough to invite me to attend the breakfast and blog about the conversation.

                              Less Expensive Medical Care Can Mean Better Care   

At Sunday’s breakfast Gawande began by observing that “in just the past four or five years we have seen a huge shift in the national conservation about health care.” Since 2007 or 2008 many have come to realize that when it comes to medical care in the U.S., “there is no direct relationship between the amount of money spent and positive results.”  In other words, although we spend twice as much as many other developed countries on health care, medical care in the U.S. is not twice as good. In some ways it is worse.

Yet this epiphany is not as discouraging at it sounds. As Gawande pointed out, “Recognizing that expensive care does not necessarily equal top-quality care has enabled a decoupling of the two issues in the public mind, and opened up the possibility for real beneficial change in the system. The Affordable Care Act’s goal” of securing high quality care for everyone is, in fact, affordable. “We don’t have to ration care.”
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The Pressure to Diagnose: Meador and Balint on The Physician’s Creed

The doctor who treated the Coal Miner’s Wife in the story above solved the mystery both because he listened to his patient–and because he didn’t rush to diagnose. 

As Dr. Jerome Groopman, author of How Doctors Think, has told us:   “Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what’s wrong.   And too often, we make what’s called an anchoring mistake — we fix on that snap judgment.”

Meador has taken that insight a step further: Sometimes doctors diagnose a “non-existent disease.”

Not long ago, Meador posted a comment on Health Affairs that sums up his doubts diagnosis: “The fact a patient is experiencing ‘symptoms’ does not necessarily mean that he are suffering from a disease. After 50 years in teaching and practice, I have come to see that not every symptom or set of symptoms has a medical diagnosis to fit. What I am sure about is that every symptom has a cause.”

 The symptoms are real. Meador does not assume that because he can’t crack the case, the patient must be a hypochondriac. Something is triggering the pain. It’s just not something that a doctor will find on a list of known maladies. For example, the coal-miner’s wife wasn’t suffering from a rare disease; she was “dusting” her cat. 

“Most patients in primary care have stressors causing their symptoms either from home or work,” Meador adds. “I agree with the old dictum that says ‘what the mind cannot absorb goes to the body.’’

Ultimately, he believes, “the insistence on a diagnosis” –i.e. the pressure to find a disease –“is at the heart of medical excesses and false diagnoses.”

Doctors Must Remain Open, Doubting Their Own Diagnoses

Groopman agrees that false assumptions lead to misdiagnosis: “Usually doctors are right,” he says, “but conservatively about 15 percent of all people are misdiagnosed. Some experts think it’s as high as 20 to 25 percent . . .

“The reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab,” he adds. “Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.”

The initial “snap judgment “could be based on the first thing the patient says,” he points out. “It could be based on something on their chart or in their file that somebody else has concluded in the past. It could be anything.” At that point, a doctor is likely to order tests that he believes will confirm his diagnosis. Often those tests do just that–or at least they seem to, in part because the physician expects that they will.

But Groopman warns, “each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.”

How can a doctor avoid misdiagnosis?

                  Not All Patients Fit On a “Decision Tree”

Groopman believes that when trying to assess complex cases, today’s physicians are too quick to trust “the preset algorithms and practice guidelines” that form so-called “decision trees.” 

 “The trunk of the clinical decision tree is a patient’s major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes,” he explains. “For example, a common symptom like ‘sore throat would begin the algorithm, followed by a series of branches with ‘yes’ or ‘no’ questions about associated symptoms. Is there a fever or not? Are swollen lymph nodes associated with the sore throat? Have other family members suffered from this symptom?

“Similarly, a laboratory test like a throat culture for bacteria would appear farther down the trunk of the tree, with branches based on ‘yes’ or ‘no answers to the results of the culture. Ultimately, following the branches to the end should lead to the correct diagnosis and therapy.”

He is quick to acknowledge that “clinical algorithms can be useful for run-of-the-mill diagnosis, distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases — the kinds of cases where we most need a discerning doctor — algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.”

If the doctor attends to the patient in front of him, not just by listening to him, but by observing him–perhaps even laying hands on him– he may realize that the patient just doesn’t fit on the tree.

In the course of his clinical practice, this is just what Clifton Meador discovered.

Symptoms of Unknown Origin

Before writing True Medical Detective Stories, Meador published Symptoms of Unknown Origin: a Medical Odyssey (2005).  

The book describes Meador’s own Odyssey. “For years after graduating from medical school, Dr. Clifton K. Meador assumed that symptoms of the body, when obviously not imaginary, indicate a disease of the body–something to be treated with drugs, surgery, or other traditional means,” his publisher explains.

Experience would teach Meador that he was wrong. “Over several decades, as he saw patients with clear symptoms but no discernible disease, he concluded that his own assumptions about diagnosis were too narrow. In time he came to reject a strict adherence to the prevailing bio-molecular models of disease and its separation of mind and body.”

He studied other theories and approaches–for instance “George Engel’s biopsychosocial model of disease.” (Engel recognized the effect that our social environment has on our body/minds; he believed that physicians treating the body must also take notice of “psycho-social issues.)  

 “Meador also came to recognize Michael Balint’s studies of physicians,” his publisher reports. (Balint coined the term “patient-centered medicine” and stresses the importance of the doctor-patient relationship. In “The Doctor, His Patient and the Illness.” Balint concludes that once a doctor and a patient agreed on a diagnosis, the “non-disease” becomes incurable.) 

As a result, his publisher notes Meador came to recognize “the defense mechanisms that physicians use to cope when encountering their  patients’  distress” –and adjusted his practice accordingly to treat what he called ‘nondisease’.”  He had to “retool” his publisher reports, “learn new and more in-depth interviewing and listening techniques, and undergo what Balint termed a ‘slight but significant change in personality.’”

        Defense Mechanisms: the “Physicians’ Creed”

When a patient visits a doctor complaining of symptoms, he expects the doctor to diagnose what ails him. If he doesn’t, the patient is likely to view the visit a failure.

For his part, the physician presented with a patient in pain quite naturally wants to solve the problem. His medical training has taught him that the resident who names the disease wins the gold star. Thus, both patient and doctor conspire to “insist” on a diagnosis.

If the doctor cannot find a satisfactory answer, or the patient does not respond to treatment for the diagnosed disease, the physician may become testy–and ultimately blame the patient. In Symptoms of Unknown Origin, Meador quotes Michael Balint:

 “every doctor has a set of fairly firm beliefs as to which illnesses are acceptable and which are not; how much pain, suffering, fears and deprivations a patient should tolerate, and when he has a right to ask for help and relief: how much nuisance the patient is allowed to make of himself and to whom, etc., etc.

“These beliefs are hardly ever stated explicitly but are nevertheless very strong. They compel the doctor to do his best to convert all of his patients to accept his own standards and to be well or to get well according to them.”

This, of course, is the opposite of what Dr. Donald Berwick has famously described as “patient-centered” medicine.

Balint then goes on to describe a hypothetical “physician’s creed” based on a conventionally narrow biomolecular model of illness.  The creed reads: “I believe my job as a physician is to find and classify each disease of my patient, prescribe the proper medicine, or recommend the appropriate surgical procedure. The patient’s responsibility is to take the medicine I prescribe and follow my recommendations. I believe that man’s body and mind are separate and that disease occurs either in the mind or in the body. I see no relationship of the mind to the disease of the body.

“Medical disease (‘real,’or  ‘organic’ disease) is caused by a single physicochemical defect such as by invasion of the body by a foreign agent (virus, bacterium or toxin) or from some metabolic derangement  arising within the body. I see no patient who fails to have a medical disease.” (Hat Tip to “The Renaissance Allergist” for posting Balint’s comments on his blog

One wonders how many students graduate from medical school today believing some rough version of this doctrine. At least one reader commenting on Meador’s book suggests that the “Creed” remains part of our medical culture:

“Although the biomolecular model of Dr. Meador’s day has since been supplanted by the biopsychosocial model in academic circles, in actual clinical practice this transition has yet to occur. Instead of searching for root causes, we learn to blame our patients for their refractory illnesses by characterizing them as “problem patients”, “difficult”, or “noncompliant”. Those labels are often true, but they don’t encourage or help us to address the underlying problems. Dr. Meador’s book does.”

Or, as another reader puts it, “Meador not only pulls the rabbit out of the hat, he shows us where the rabbit was hiding.”

As we struggle to reduce that amount of overtreatment in our medical system, I hope that medical educators will begin to warn young doctors against the “insistence” on finding a single organic “defect.” Very often, behind human suffering, a wise physician and compassionate physician will find  multiple causes–biological, psychological and sociological–that cannot be easily separated.

 I recall a post I published on HealthBeat in May of 2011 quoting a doctor who mistook poverty for disease: “I diagnosed ‘abdominal pain’ when the real problem was hunger. . . .  My medical training had not prepared me for this ambush of social circumstance. Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.”  She was able to help her young patient only when she realized that he was going to bed with an empty stomach. 

 

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How to Avoid Avoidable Care–by George Lundberg

Below, a  guest-post by Dr. George Lundberg, Editor-at-Large of MedPageToday; Editor in Chief of Collabrx; President and Board Chair of the Lundberg Institute.  (Full disclosure: I am a member of the Lundberg Institute’s Board)

What Lundberg says is not meant to be news.  Today, physicians tend to agree that many of the tests that patients undergo are unnecessary. Three years ago, one hospitalist shared a story on HealthBeat, describing how he warned his residents about over-testing His hospital may not have been happy about his disclosure: tests boost revenues.

But in some cases, we have solid medical evidence showing that for certain patients, these tests do more harm than good– though vested interests may try to bury that evidence. (See Dr. Hoffman’s post below.)

Yet doctors continue to order the tests– why?  

George Lundberg brings a unique perspective to this problem. Drawing on his wealth of experience, both as a practitioner and as a teacher, he puts it in a historical context.  For 40 years, he has asked physicians why they perform so many tests. The frankness of their responses is matched only by Lundberg’s own candor as he diagnoses the excesses in our medical system . 

How to Avoid Avoidable Care 

George Lundberg

Why do physicians order laboratory tests?  The traditional reasons are: diagnosis 37%, monitoring 33%, screening 32%, previous abnormal result 12%, prognosis 7%, education 2%, and medicolegal 1%.

In  order to confirm these data, I began to ask the same question of many groups of clinical and laboratory workers over three continents in the 1970s, ‘80s and ‘90s during  Socratic teaching sessions on how to use the clinical laboratory correctly. And I began to get very different answers.  

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