How Doctors Think (8 page)

One of the most celebrated statements in clinical medicine comes from a lecture delivered by Dr. Francis Weld Peabody of Harvard Medical School in 1925: "The secret of the care of the patient is in caring for the patient." This is undoubtedly true, but less obvious than it may seem. Peabody cautioned doctors about the way their training conditions them. Of necessity, we learn to suppress our emotions, to block our natural reactions to many of the awful things we see and the brutal things we must do.

Consider what happens in the ER when we try to save the life of a person smashed by a car or burned in a fire. If a doctor thought too much about the person before him, he couldn't insert his gloved hands into a hemorrhaging abdomen or maneuver a breathing tube past charred flesh. Even in less desperate circumstances—giving chemotherapy to a young woman with widespread breast cancer, say, or inserting a dialysis shunt into the arm of a blind diabetic whose kidneys have failed—we have to detach ourselves from anguish that could impede our work. But to become immune to feeling, as Peabody indicated, is to diminish the full role of the physician as a healer and relegate him to a single dimension of his job, that of a tactician. If we feel our emotions deeply, we risk recoiling or breaking down. If we erase our emotions, however, we fail to care
for
the patient. We face a paradox: feeling prevents us from being blind to our patient's soul but risks blinding us to what is wrong with him.

I asked Dr. Karen Delgado about this paradox. Delgado is an acclaimed specialist in endocrinology and metabolism at a large urban teaching hospital who cares for patients with hormonal and metabolic disorders such as diabetes, infertility, and hypothyroidism. To my mind, she is the very model of a doctor, deeply knowledgeable about medical science and compassionate, empathetic, and generous with her patients. When I asked Delgado whether she had ever made an attribution error, she readily recalled a patient from her training in the 1970s. A young man was brought to the emergency ward of the hospital in the wee hours. The police had found him sleeping on the steps of a local art museum. He was unshaven, his clothes were dirty, and he was uncooperative, unwilling to rouse himself and respond with any clarity to the triage nurse's questions. Dr. Delgado was busy that night attending to other patients, so she "eyeballed" him and decided that he could stay on a gurney in the corridor, another homeless hippie who would be given breakfast in the morning and returned to the streets. Some hours later, she felt a nurse tugging at her sleeve. "I really want you to go back and examine that guy," the nurse said. Delgado was reluctant, but she had learned to respect an ER nurse who felt that something was really wrong with a patient.

"His blood sugar was sky-high," Delgado told me. The young man was on the brink of a diabetic coma. He had fallen asleep near the art museum because he was weak and lethargic and unable to make it back to his apartment. It turned out that he was not a vagrant but a student, and his difficulties giving the police and the triage nurse information reflected the metabolic changes that typify out-of-control diabetes.

"The hardest thing about being a doctor," Delgado said, "is that you learn best from your mistakes, mistakes made on living people." Chastened by the experience, she conjured up the picture of that young man whenever she was called to the ER to evaluate other disheveled and uncooperative people. But, Delgado continued, that was a single experience corresponding to a single stereotype. "It is impossible to catalog all of the stereotypes that you carry in your mind," she said, "or to consistently recognize that you are fitting the individual before you into a stereotypical mold. But you don't want to have to make a mistake to learn with each stereotype." Rather, Delgado believes, patients and their families should be aware that a doctor relies on pattern recognition in his work and, understandably, draws on stereotypes to make decisions. With that knowledge, they can help him avoid attribution errors.

Is this really possible? I asked.

"Sure, it's not easy for laypeople to do," Delgado said, "because patients and their families are especially reluctant to question a doctor's thinking when their questioning suggests his thinking is colored by personal prejudice or bias." Still, Delgado thinks lay-people can diplomatically direct a doctor's attention to his reliance on stereotypes, because one of her patients had done this with her.

Ellen Barnett had recently sought out Dr. Delgado for help with a multitude of vexing symptoms. Many people who see Delgado have symptoms that are difficult to pin down—low energy, for example, or abrupt weight gain—and assume they have a hormonal or metabolic imbalance. Usually they don't. Ellen Barnett had already consulted five physicians and felt all five had shunned her. "I'm having what I call explosions, feeling hot all over, which make my skin crawl. I mean really crawl, like ants all over, and sometimes they come with terrible headaches," she told Delgado. "Really, it's like a bomb going off in my body. I know I am in menopause, and all five doctors told me that that's the cause of my problems. And two told me that I'm crazy. And, frankly, I
am
a little crazy," Barnett said with a wry smile. "Okay, I know menopausal women have hot flashes. But I think this is something else, that what I'm feeling is more than just menopause."

As Delgado listened, she recognized how easy it would be to make an attribution error with a persistently complaining, melodramatic menopausal woman who quite accurately describes herself as kooky. So she stopped herself from casting Ellen Barnett as a stereotype and assumed for a minute that her patient was telling her something important, something meaningful, that these "explosions" were indeed different from run-of-the-mill menopausal hot flashes and hormonal migraines.

"I evaluated her very extensively," Delgado said, "and it turned out that, yes, she was menopausal, and yes, she was a strange person with lots of weird ideas, but what turned up in her urine was not from menopause or being kooky. Her catecholamine levels were through the roof. A CT scan showed a pheochromocytoma above her left kidney." A pheochromocytoma is a relatively rare endocrine tumor that produces catecholamines, chemicals like adrenaline that can cause wild swings in blood flow and blood pressure. The changes in circulation may mimic menopausal hot flashes and precipitate severe migraine-like headaches. The catecholamines can also cause psychological symptoms such as anxiety, despair, and even aggression. If untreated, the patient may have a stroke or heart or kidney failure.

"She had surgery and the tumor was removed. Now her hot flashes are much less severe, as are her headaches, at the level you would expect during menopause," Delgado said. "But Ellen is still kooky, by her own admission."

Delgado believes that patients or family members can adopt Ellen Barnett's approach. With a disarming sense of humor, she communicated that she understood she fit a certain social stereotype, and that stereotype had caused her doctors to fail to fully consider her complaints. "I didn't feel like Ellen was being obnoxious or patronizing," Delgado said, "and I didn't react and become alienated or annoyed with her. What she said enhanced her credibility and helped me avoid an attribution error."

Negative feelings that patients like Ellen Barnett trigger in a physician are usually close to the surface. But positive feelings, like the ones Croskerry had for Evan McKinley, Falchuk had for Joe Stern, and I had for Brad Miller, are more difficult to recognize as dangerous. Since Delgado is a physician who has genuine affection for many of her patients, I asked whether she had ever fallen into that trap, the trap of affective error. She thought she had. "I had an elderly patient with thyroid cancer and considered treating him with radioactive iodine. There are difficult logistics involved with the therapy, and it really can disrupt the person's life. I was just about to refrain from treating this man when he said to me: 'Don't save me from an unpleasant test just because we're friends.'" At best, in severe circumstances, the family or friends of patients who realize that a doctor's affection may stay his hand at times can address this concern by saying: "You should know how deeply we appreciate how much care you show. Please know also that we understand you may need to do things that cause discomfort or pain."

Only a layman aware of how such feelings can color a doctor's judgment in subtle but significant ways could make such a remark. In pondering Delgado's vignette, I realized it would have been impossible for Brad Miller to muster the energy to think about our prior interactions and warn me this way when I saw him that morning on rounds. It was my job to be complete in my exam, and my charge to monitor my feelings when they might break my discipline.

Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents.

Chapter 3

Spinning Plates

T
UBA CITY, ARIZONA,
lies 3,246 miles west of Halifax, Nova Scotia. Halifax was the first British town in Canada, founded in 1749; most of its 360,000 inhabitants still trace their roots to the British Isles. Tuba City has a population of just 6,000, but it serves as the central town for more than 100,000 members of the Navajo and Hopi nations. Modern glass-and-steel skyscrapers ring the Halifax harbor, and a sharp northern light reflects off the sea. Tuba City sits on high mesa, the surrounding country highlighted by scrub and the soft pastels of ancient sedimentary rock. Halifax's Dalhousie University Medical School is renowned for its academic departments and cadres of researchers. The hospital in Tuba City is a cluster of low-slung dun-colored buildings housing the Indian Health Service; the nearest MRI scanner is an hour's drive away. Despite these differences in geography, size, resources, and culture, an emergency room physician in Tuba City, like Dr. Harrison Alter, has to recognize the same clinical patterns and avoid the same cognitive errors as a counterpart in Halifax like Pat Croskerry.

Alter, who is forty-three, did not initially see himself as a physician. He studied comparative literature at Brown and only four years later attended medical school at the University of California at Berkeley. Following his residency at Highland Hospital in Oakland, he went to the University of Washington in Seattle as a Robert Wood Johnson scholar to study medical decision-making. After two years on the faculty at UW, he wanted to work with dedicated doctors in an underserved community, so he moved with his wife and three young children to a small yellow stucco house in Tuba City.

One day in April 2003, while Alter was working in the emergency department, an ambulance brought in a ten-year-old boy named Nathan Talumpqewa from the local Hopi school. The fourth graders had just ended recess and were lining up to return to class when another student jumped on his back, expecting a piggyback ride. Nathan was a hefty boy, four feet eight inches tall and 140 pounds, and reveled in rough-and-tumble play. But this time he screamed in pain and fell to the ground. "Nathan came in on a backboard in full spinal immobilization," Alter recalled, describing how a patient is kept in a fixed supine position to prevent any stress on potentially injured nerves. "He was terrified, sobbing and moaning." Alter quickly took the history and asked Nathan several key questions. "He said that he could move his arms and legs, that there was no tingling or electric shocks going down his spine or into his buttocks, only that he had this terrible pain in the middle of his back." Alter concluded that it was safe to move the child off the backboard onto a bed.

When Alter examined him and pressed on the lower thoracic spine, Nathan cried out. "I sent him off for x-rays, and, sure enough, right at the tender spot he had a wedge compression fracture of the tenth thoracic vertebra. This was a ten-year-old boy with the kind of fracture that I am accustomed to seeing in an eighty-year-old woman. And I thought to myself, This just isn't supposed to happen."

Alter told me that with each patient he recites the ABCs he learned during his training. (In fact, the alphabet of emergency care includes D and E as well.) "
A
stands for airway, meaning that the mouth, throat, trachea, and bronchi are all open;
B
is breathing, that the patient's lungs are able to get enough oxygen and pass it into the bloodstream;
C
is circulation, that the heart is pumping, the blood pressure is adequate for the blood to reach vital organs like the liver, kidneys, and brain.
D
stands for disability, a reminder to check neurological function, not only muscle strength and reflexes but also mental responses; and finally,
E
is for exposure, not to neglect any part of the body just because you are focusing on a problem in one area." In Nathan's case, he concluded, each letter was satisfactory.

Alter ordered tests, including a complete blood count, calcium level, and bone enzymes. All were normal. He then went further and got a CT scan, which was transmitted digitally to a bone radiologist at the University of Arizona. Shortly, a report came back to the emergency department: "Normal, except for a compression fracture at the tenth thoracic vertebra." Alter still was uneasy. He put Nathan in an ambulance and transported him for an MRI scan to Flagstaff, an hour and a half away. Later that day, Alter learned that an MRI confirmed what the CT scan showed: the single collapsed vertebra and no other abnormalities.

Alter called a local pediatrician. The specialist reassured him that nothing serious was going on, nothing to be concerned about. "We just see this sometimes," the pediatrician assured him. "I had to accept the data," Alter said, but still was worried. He made sure the pediatrician saw Nathan a few days later. At that appointment, Nathan was feeling better, with only minor discomfort in his back. The pediatrician told the family not to worry; it was just a freakish playground accident.