How Doctors Think (12 page)

Moreover, McEvoy is leery about attaching a label to a child, because once that label is fixed, "it's as though the child is changed forever," she said. "It almost borders on cruelty to raise the idea of a serious problem that might not be there." For that reason, she doesn't begin by introducing a specific diagnosis to the family; rather, she might say, "I am not sure, but this may just be the way your child is developing and will soon catch up. So let's schedule the next visit sooner. That will give me the opportunity to see him again." When to follow up is a judgment call. "You don't want to have the visit too soon, because it's like watching the grass grow," she said. "So you may see the kid in two or three months instead of six months," and then assess the child again for language and interpersonal interaction. This time frame also is a signal to the parents that the doctor does not believe the situation is an emergency.

The process of assessing developmental milestones is complicated by narrowing definitions of what is psychologically normal: moodiness is labeled as depression, shyness as social affective disorder, a drive to precision as obsessive-compulsive disorder. "There are so many diagnoses put on children these days," she said. "But all of human behavior is a continuum." For that reason, again, she refrains from raising a psychiatric issue with the family until she has had an adequate opportunity to observe the child herself and navigate the shoals of parental overconcern and parental denial. "Psychiatric labels can be shattering," McEvoy said, "so I try to move the parents away from focusing on the label and tell them that the key is to take an activist approach, to figure out what kind of learning style and social environment is best for their child."

McEvoy's approach reminded me of Jane Holmes-Bernstein, a neuropsychologist at Boston's Children's Hospital whom I met several years ago. Holmes-Bernstein emphasizes that what is normal or abnormal is highly related to the context of the behavior. She assiduously refrains from fixing ready rubrics to a child's condition, and instead seeks to describe the ways she gathers and assesses information through cognitive testing and play. Holmes-Bernstein develops a descriptive profile of how the child functions in different settings. She can then customize her recommendations for how to overcome particular obstacles, whether they be difficulties in decoding written text, organizing speech and language, or controlling emotional and antisocial behaviors.

Of course, some children do suffer well-recognized psychological syndromes. McEvoy bemoaned the current difficulty in referring such children for psychiatric evaluation. Pediatric psychiatrists generally have long waiting lists, and much of their work has been reduced to a relatively brief evaluation followed by the prescription of a psychotropic medication. This is because insurers reimburse poorly for psychotherapy.

Many primary care physicians find their practices taking on a similar frenetic quality, and for similar reasons. Insurance compa nies seriously underreimburse doctors for primary care, a legacy of the period when surgeons headed the medical societies that negotiated with insurers about what was a "customary" payment for services. A specialist who performs a procedure—a bronchoscopy, say, or a surgical operation—gets a substantial payment from the insurance carrier. But if a pediatrician or another primary care provider, a general practitioner or internist, spends an hour with a complex set of medical problems trying to arrive at a diagnosis, or probing the emotional fallout from an illness or its treatment, the payment is meager. For this reason, many general pediatricians "feel like they are running up a hill of sand," McEvoy said.

In fact, a recent study showed that over the past decade, taking inflation into account, the incomes of physicians like pediatricians have fallen. Many doctors have reacted by truncating visits to ten or fifteen minutes and increasing the volume of patients they see in a given day. This speeds up the train and fosters the kinds of errors that Pat Croskerry and Harrison Alter fear when the ER doctor is spinning plates. Working in haste can not only increase cognitive mistakes but impair the communication of even the most basic information about treatment. A study of 45 doctors caring for 909 patients found that two thirds of the physicians did not tell the patient how long to take a new medication or what side effects it might cause. Nearly half of the doctors failed to specify the dose of the medication and how often it should be taken.

Sometimes the frenetic pace overwhelms the doctor and estranges the patient and family. Friends of mine who live in a Dallas suburb had adored their pediatrician until they came to feel that she was not paying close attention during routine visits. "She had four rooms going at once," the mother told me, with the doctor and her nurses shuttling among them. Often my friends' visit was interrupted by a nurse entering to ask the doctor a question about another child. Then, one evening after a yearly checkup, the pediatrician called my friends at home. "She apologized and told us that she had injected saline and forgotten to mix in the vaccine." My friends took their children in the next day for the vaccination and then decided to find another doctor. "We really liked her, but she just became too busy and too distracted, and we worried that she would miss something important about the kids."

My wife and I searched for, and found, a pediatrician who, despite a busy practice, focuses squarely on our children during their visits. We met him first on the sidelines of a soccer field where both of our children were playing. He had a warm and outgoing manner, as many pediatricians do. We asked colleagues their opinion of him, and each said he was highly competent. Pam found some fellow mothers who were not doctors, and again heard notes of praise. His waiting room is usually packed, but his secretary and nurses know our children by name. Sometimes we sit awhile in the waiting room, but we know he is running late because another family has needs that take longer than the allotted time. He often thinks out loud as he ponders our questions, and raises issues that we did not consider. He doesn't talk to us while typing his note on his computer. His eyes engage ours, not the clock.

Years ago, the mother of one of my patients said, "I want you to take care of my son like he is the only one in your practice." At first I was taken aback by what seemed a selfish demand. But then I realized what she meant: that my mind should be entirely on his case when we are together. That required me to manage my time so I could hear his problems and consider them. It also prompted me to encourage him to organize his concerns in advance of his visits. But one day, after going through his list and preparing to end the appointment, he mentioned in passing that he had a "stitch" in his groin. It was probably nothing, he continued, since he had been rearranging the furniture in his apartment and proba bly just pulled the muscle. But we went back to the examining room and I found a large, hard lymph node that heralded the return of his lymphoma.

Lists are useful, and like algorithms can make care more efficient in certain circumstances, yet they also pose the same risks, that the doctor will not ask the kinds of open-ended questions that Debra Roter and Judith Hall had shown in their research as yielding the most information. In addition, as McEvoy pointed out about developmental disorders, and as I saw with my patient with lymphoma, we often push from our minds the concern that is most frightening. In pediatrics, parents may ask themselves in advance what it is that scares them the most about their child's condition. This question is an echo of the one that we posed before: What is the worst diagnosis that this could be? If fear still inhibits a parent's or patient's mind from recognizing this, then the pediatrician should budget time to allow the concern to come to the surface, drawn out through a dialogue.

A good physician learns how to manage time. Symptoms that are straightforward can be accurately defined and explained to a patient and loved ones in clear and accessible language within a twenty-minute visit. Families leave the office feeling informed and satisfied. Complicated problems cannot be solved so quickly. A discerning doctor will recognize when more time is needed to ask questions and explain his thinking. In such instances, the appointment may need to be extended or a follow-up visit scheduled as soon as feasible. Cogent thinking and clear communication cannot be conducted like a race being run. Despite all the pressures to limit time in managed care and the pursuit of putative efficiency, doctors and patients should push back. Finding the right answer often takes time. Haste makes cognitive errors.

Dr. JudyAnn Bigby is also a gatekeeper. We met some thirty years ago when she was a student and I was a resident. She is an inter nist and the director of Community Health Programs and the Center for Excellence in Women's Health at Boston's Brigham and Women's Hospital. She divides her time between caring for patients as their general internist and administering the hospital's program, which tries to improve care in underserved communities, mainly among African-American and Latino women. After her internship and residency, Bigby took a fellowship in general internal medicine, and during that period received didactic instruction in certain forms of clinical decision-making. "We learned how to be critical, particularly how to apply Bayesian analysis when considering different tests and procedures." The curriculum was meant to teach young doctors how best to use resources like sophisticated imaging techniques, and how far to pursue a particular diagnosis given a set of initial findings. Bigby was not taught about different modes of cognition and the various types of cognitive errors that physicians can make. I wondered how much of this theoretical grounding she applies in her day-today clinical practice. "I don't use Bayesian analysis routinely," she told me, "but I do use it at times to help explain to patients why I think a particular test that they want won't really help them. In my mind, I see the probabilities and try to translate them into language that a patient will understand."

The day we spoke, Bigby had seen one of her longtime patients, a healthy middle-aged white man. He wanted to have an exercise test as a part of his routine yearly physical. "We talked about what value it would add, based on its prediction of cardiac disease in his case," she said. "And he got it. He understood that the test wasn't valuable for him." She recalled another patient, an African-American woman in her eighties, who had coronary artery disease and renal failure and had had numerous negative mammograms over the past decades. In this instance, she used probabilities to explain to the woman why another mammogram was unnecessary, given how unlikely it was that further screening would find an abnormality. Even if a tumor were found, she told the patient, it would take so long to develop that it would probably never threaten her.

JudyAnn Bigby is a compact woman with a round face, alert eyes, and a lilting, almost musical voice that often breaks into laughter. She was raised in Hempstead, Long Island. When she was a child, hers was one of the first African-American families in town; by the time she graduated from high school, Bigby told me, the school was more than 80 percent black. Her father worked as a mechanic for United Airlines, and only later in life did her mother, a homemaker, return for a high school equivalency degree.

Although Bigby devotes only about a third of her time to direct clinical care, she is not immune to the pressures that all primary care physicians now feel. "We are supposed to see patients every fifteen minutes," she told me. "And I probably don't meet my target numbers. That's largely because I put blocks in my schedule. I simply cannot see patients every fifteen minutes." She doesn't like to keep patients waiting, and because many of the people she cares for require extended thinking about their problems, she has set her schedule to accommodate this style of practice. "I have to have some leeway in each clinical session," she said. I asked whether anyone from the hospital administration ever expressed disapproval of this leeway, which is, of course, not reimbursed by insurance and would be considered unproductive by a bean counter. She laughed. "Not anymore," she said. "I think if I were a fulltime clinician, someone might. But I've reached a point in my career where this is simply the way I want to doctor.

"A lot of primary care is about getting people to recognize and change certain behaviors," she said. Whether it be smoking, overeating, failing to exercise, or missing a mammogram appointment, Bigby tries to think about how to make her patients' behavior healthier given their particular social context.

For example, two weeks before we spoke, Gloria Manning, a seventy-four-year-old African-American woman, was admitted to the hospital. Manning had diabetes, hypertension, and coronary artery disease, in addition to advanced rheumatoid arthritis. Her rheumatologist had been seeing her as an outpatient, and Manning had told him that her ankles were increasingly painful and swollen. She had been treated with a number of medications for her arthritis, including methotrexate and Plaquenil. The rheumatologist decided to give her Remicade, a new antibody used in autoimmune diseases like rheumatoid arthritis that works by blocking an inflammatory protein called TNF. When Bigby examined Manning, she had gained more than twenty pounds and was tired and short of breath. "It was clear that she was in heart failure," Bigby told me, "all the weight being retained water." And, Bigby suspected, the Remicade therapy could have made her condition worse.

Years before, Manning had been admitted to the Brigham and Women's Hospital with poorly controlled hypertension and bouts of angina. "At that time, she was labeled as noncompliant," Bigby said—that term we saw earlier, fraught with meaning for both doctors and patients. Physicians dislike patients who don't follow their advice. During a hospitalization, it is not easy to determine the optimal dose of medications to control blood pressure, facilitate blood flow to the atherosclerotic vessels of the heart, and keep blood sugars within an acceptable range, and then discharge such a patient with a regimen that will sustain the progress made during her hospitalization. When a patient after discharge seems to be ignoring the prescribed diet and not reliably taking her medicines—being noncompliant—physicians, as Toronto's Donald Redelmeier said, react with anger and disgust. "She had been lectured time and again by other doctors that she was not taking her medications, and that's why she kept being readmitted to the hospital," Bigby continued.