It's now about two weeks till the book comes out. As an appetizer, I'll be writing brief posts almost every day till then about topics relevant to each chapter. Today, it's chapter 1, where I talk about the most frequent procedure - the medical interview.

The conversation between the doctor and the patient is the most common opportunity for the doctor to try and heal. As I point out in the book, there are many ways in which this conversation is often suboptimal, overlooked, and given short shrift in medical education: both in the training of medical students and in the continuing education of medical professionals.

On the way to what we hope will be systematic reform in both professional practice and medical education, which will privilege personal interaction over the quick fix of reflex procedure or lab test, it is - unfortunately - mostly up to the person adrift in our health system to find the doctor it is actually possible to talk to.

Which kind of doctor should that be, though? Ideally, you find a combination of skill, knowledge, personality, and sympathy, someone you can stick with for a while. Like as not, that person does not exist.

But if we stick it out with the imperfect person who inhabits the exam room, perhaps we can train them to be a better doctor (or nurse, or PA). Yes, part of our role is to improve matters even if we are the patient, even in the midst of our pain and illness.

The doctor has to measure up but we have to help them do it.

Monday, August 5th, 1pm
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 Some thoughts of mine from 3 years ago - when I was still a resident - about the "whole physical exam" promoted by Abraham Verghese have stood up pretty well. 

Abraham Verghese's essay "Culture Shock" (pdf) made a lasting impression when I came upon it last night during a quiet period at work. He writes beautifully about the real patient, with all his spots and signs - as opposed to what Verghese calls the "iPatient," the simulacrum found inside the electronic medical record but nowhere else.

I do realize that we residents, no matter where we train, hone our skills on the iPatient's indices ("The iPatient's blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed") while getting ever farther away from the bedside physical exam done on the real patient. This article makes as powerful a case as any I've read for the re-centering and re-honing of my skills, and it comes at just the right time, when I have the chance to make a transition to be the kind of doctor I want to be.

But Verghese is confused in his defense of the physical exam - he doesn't know what rationale he wants to focus on, or how he feels about physical diagnosis as justified (or questioned) by evidence-based medicine. Here he is in one place:

"If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered."

This is the argument from efficiency, or maybe from diagnostic rigor - exceeded somewhat by Verghese's clear affection for the physical exam as a pedagogic and maybe, even, an esthetic, cultural, and moral tool. But it's not clear whether Verghese believes that the physical exam does improve diagnosis or efficiency. Just paragraphs later, Verghese takes another turn:

"Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a large pleural effusion is worthwhile in and of itself."

The physical exam's actual use in diagnosis is again feinted toward, but without making a real case one way or the other ("we need continued study in this area," the academic physician's classic copout that I know I use at the end of every article I write).

Near the end of the essay, and most confusingly, Verghese takes yet another tack when describing with understandable pride the teaching of the bedside physical exam he coordinates with his chief residents:

"We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart."

But this comparison is double-edged. If a finding on the physical exam is like a biomarker, then it is like any other diagnostic test, which can be ignored, re-interpreted, or even not tested at all based on the prior probabilities the physician approaches the patient with. Perhaps - given the patient - I might prefer the information given by X-ray to my own physical exam. Or maybe, given the vagaries of varying echocardiography reads, I might privilege my own cardiac exam.

This is why I find Verghese's essay, though moving and personally challenging to my own too-ingrained love of EHRs, to be ultimately unsatisfying. If medicine is a culture, it changes. If the physical exam is to be a practical part of the diagnostic art, and not a relic, it too must change. Let's find out which parts of the diagnostic exam work, and why. We know that no physician does the "head-to-toe exam" for more than a fraction of his or her patients, so which parts should be done when? When is it useful to look for Roth's spots as a diagnostic adjunct rather than as a fascinating bedside pedagogical tool of limited clinical import? (Probably rarely.) Given our limited time with patients, should we not build rapport and understanding by asking more detailed histories at the bedside, rather than indulging in percussion of parts which have no diagnosis to yield up?

I take Verghese's wisdom and his eloquence but I look for rigor elsewhere, trying to spend my time with the patient in ways that build our therapeutic relationship and find a true diagnosis efficiently.

In Talking To Your Doctor, I close with an exhortation: we should base our health care system on the relationship of the patient and the primary care provider. We should provide incentives for that relationship to be sustained and developed. That's easy for me to say. What are some practical ways to make this happen?

Although I refrained from making this comparison in the book, since it would have been complicated to outine and defend and I don't really know about much literature on the subject, the obvious comparison is to marriage, which the state - for good, I think - encourages and incentivizes. Perhaps, just like there is a cultural supposition of monogamy and some sort of civil union for many people (with exceptions, obviously), there should be the same supposition for the provider-patient relationship.

What kinds of incentives are in place for civil unions or marriage? Plenty, ranging from the financial (tax credits) to the sociological (name changes, fancy parties) to the recognition in various contexts, including health-care related, that the partner/spouse has a special place in the hierarchy of information sharing or decision making.

The same could, or should, be said of the place of the PCP in the health care relationship. There should be incentives for patients and providers to maintain that relationship; requirements that specialists communicate, and run major decisions by, the PCP-patient dyad, and perhaps even social recognition (parties? name changes? maybe not - but something ceremonial) when that relationship is cemented.

There is something else that happens in relationships: mistakes can be made, and, providing they are not so serious, negligent, or ill-intentioned as to be inexcusable, the relationship survives. There is plenty written about the best way to come clean, ask for forgiveness, and correct the processes that led to a mistake, whether in a relationship between two adults or in the setting of health care. Just as a relationship - in the best of cases - provides a cushion for a mistake, the special connection between the PCP and patient can sometimes withstand serious error.

Reposted from 2012.

I have read several articles in leading journals - most recently in the Annals of Internal Medicine about tailoring mammography recommendations to patient risk - which come to the same conclusion: no matter what physicians’ recommendations are, we must respect patient preferences. There are various difficulties with this:

1. Patients, in fact anyone, are often hard-pressed to state just what their preferences are. There are a number of reasons for this: the fact that information is often not adequately conveyed; the tyranny of choice from the overabundance of medical information; and, at bottom, the truth that some situations are not ones we are prepared to state preferences about. “Would you rather die in a nursing home or in a hospital?” is, for those not yet in such a situation, equivalent to asking, “Would you rather perish by Dalek or Vader?”

2. We don’t actually respect patients’ preferences, much of the time. We try to make them do things which they would not ordinarily do. Which leads us to...

3. Preferences change. Many change their desires and even their approach to life over time. When we “respect a preference,” whose preference, at what stage of life, are we respecting, and how much respect are we really supposed to show?

“I don’t know if I want to take this pain medicine,” people have told me more than once. “I want to know what’s really wrong with me and not just cover it up.” Or: “I don’t want to treat the symptoms. I want an MRI because I want to figure out the underlying problem.”

There is a dichotomy often used – especially by the people who asked me these questions – between “knowing what’s going on” and “not knowing what’s going on.” The more you think about these categories, of course, the more you realize that these conceal as much as they reveal. If we can determine that someone’s lower back pain is not dangerous, but (as in most cases) we will never figure out to what specific tendon or muscle the pain is due to, what does it matter that we might always be in the dark about the cause?

Or take chronic kidney disease, which has recently been reclassified: the cutoffs in kidney function have been changed for some of the categories. Not significantly, but now there are new routes to become diagnosed with the conditions, and new guidelines to treat it. If you had one kind of kidney disease before, and were told – after some tests – you actually had the other one, what was known before and what wasn’t? And what difference did it make? 

You can never know everything. Treatment has to start sometime. And, since treatment can lead to a better picture of the underlying condition, it’s never just covering up what is going on. Treatment and diagnosis always live in the creative ambiguity that is the organic muck of medicine. Sometimes I know what’s going on even before a word has been spoken. Sometimes I won’t know what’s going on even when the patient feels 100% better because of something I did.

On the webpage of the Society of General Internal Medicine, I am starting a series of blog posts to introduce internists/primary care doctors, and any other interested parties, to cancer research from the perspective of general internal medicine (GIM). Much of this research is interested in health care services - how health care is delivered, and how to optimize the quality, accesssibilty, equity, and cost of care. Below is the first post - keep your eye out for more!

Cancer Researcher in Focus: Larissa Nekhlyudov, MD, MPH

Dr. Nekhlyudov is an Associate Professor at Harvard Medical School and a general internist at Harvard Vanguard Medical Associates. Her work, which has generated numerous publications, centers on the quality of life and quality of care of cancer survivors.  One recent paper published this year highlights the use of integrated healthcare delivery systems as platforms for cancer survivorship research.  Another reports on patients' communication experiences during cancer care and provides a foundation for the design and testing of patient reporting systems. 

Dr. Nekhlyudov is particularly interested in the interplay between primary care and oncology providers in the care of cancer survivors.  In addition to research, she is leading efforts to promote the education and training of providers caring for cancer survivors.  She has built an impressive online collection of resources for primary care providers caring for survivors. These include links to guidelines of care, educational programs, resources for patients and families and links to granting organizations.  This year, she served as a key contributor to the development of a cancer survivorship curriculum for primary care providers, a program of the National Cancer Survivorship Research Center (https://cancersurvivorshipcentereducation.org). 

Two questions for Dr. Nekhlyudov

What is a research question that currently interests you?

How do we improve the care of cancer survivors in oncology and primary care settings?

What are the difficulties in researching this question?

Cancer is not a single disease. There are different types of cancers, stages, and treatments. It is therefore difficult to study the impact of any intervention and make generalizable conclusions.

1. Should I take an aspirin?

2. Should I take a medication for osteoporosis?

3. How often should I get a DEXA scan?

4. Should I see a specialist about this?

5. What's the best test to keep me from getting cancer?

6. Can you write me a prescription for an antibiotic?

7. Can't I just get an MRI?

8. What's the difference between you and a family medicine doctor?

9. What diet can help me live longer?

10. Can't you just order me some baseline bloodwork?

And a bonus:

11. Why is your hospital better than any other?

It's commonplace now to say that medical care needs to be patient-centered. But what does that mean? How do we make sure that the doctor's advice is tailored to the person in front of them? Part of what I argue in my book is that true patient-centered medical care has to be based on a relationship with the primary care provider, which in turn is dependent on good communication. But there's another dimension: the medical care proferred has to be modified based on the person's individual, unique needs. Medicine is not one size fits all. Every rule can be bent, every guideline can be remixed based on the person talking to the doctor at the moment.

But how are we to get there? And does it make a difference?

In a recent article in the Annals of Internal Medicine, Saul Weiner and caolleagues, from Duke and the University of Illinois at Chicago, defined this necessity, calling it "context-dependent care." In their study, patients surreptitiously recorded physicians, and the resultant recordings were analyzed to identify whether doctors appropriately modified their care based on contextual clues provided by the patient. For example, a patient with presumed hypothyroidism might also have depression; a patient who needs insulin may be unemployed and homeless, needing some creative solutions to getting them their medication. 

The result of their study? Such modification of care plans according to context actually improved care outcomes. This is an interesting finding, but I think the bigger-picture advance is to recognize what patient-centered care actually is: not a mere elicitation and application of "preferences" (Ms. Gomez, do you prefer X or Y?), but a translation of the care plan into the patient's world, with all the complications and nuance that entails.