Every Patient Tells A Story Part 2

"Sure." She quickly called out tests she'd like to order and the results were provided. A spinal tap was normal, there was no elevated white blood cell count, her liver and kidneys were working fine.

"So basically what you're telling me is that we have here a woman with a rapidly progressive dementia but a completely normal physical exam otherwise and no sign of infection or laboratory abnormalities?" Fitzgerald asked. She then turned to the audience. "I am not at all offended if people shout out the answer at any time," she called out to the audience. "Anyone? Well, at least it's not obvious to anyone else out there either."

It certainly wasn't obvious to me. As Fitzgerald considered the data available on the patient, she started to describe how she was thinking about what she'd heard. "At this point I like to develop some kind of structure on which to hang my ideas. To help me put together a thorough differential diagnosis, I often just start with the different areas of medicine. So, could this be some kind of congenital disease that causes dementia-like early Alzheimer's? Maybe. Or could this be infectious? Did she have a life of adventure that would put her at risk for some colorful, s.e.xually transmitted diseases like syphilis or HIV?"

As she reviewed her thinking, she developed a list of possible causes of these symptoms. Voices called out from the audience offering additional diseases to add to the differential. "Parkinson's dementia" a man called from the end of my row. "Jakob-Creutzfeldt" (mad cow disease) offered a woman in front.

"Get a head CT," called out still another voice.

"Hmmm-a head CT." Fitzgerald considered the suggestion. "This lady has no neurological findings-right?" She turns to Nasir, who again nods his confirmation. "No weakness, no seizures, no tremor-nothing except confusion. Given that, I don't think a CT scan will show me much. In my hospital it's almost impossible for a patient with mental status changes to come through the ER without getting a head CT. And yet the odds are that hers will be normal, so ..." She paused thoughtfully. "I say we skip it."

Once the case had been presented completely, it was time for Fitzgerald to make her diagnosis. She went through her differential. "Well, common things being common, this would most likely be multi-infarct dementia or maybe Alzheimer's. But this is stump-the-professor time and so it's never the common thing. Hmmmm." She turned to the audience. "Can I talk to a really old doctor?" Chuckles from the audience were followed by a few more suggestions.

"Any other ideas?" Fitzgerald conceded. "Okay, I give up. Let's hear it."

"Maybe you should have gotten the head CT after all," quipped the medical student, pleased that he actually stumped the professor. He projected the final slide onto the large screens at the front of the room. An image from a CT scan of the head revealed a huge, white, irregularly shaped circle bulging into and distorting the familiar spaghetti swirls of the brain. It was a brain tumor.

"d.a.m.n. It's big too," conceded Fitzgerald, shaking her head. "It's really amazing that it didn't announce itself more clearly. Oh well, you can't win them all, now can you?" she said, facing the audience with a roguish smile. The audience applauded enthusiastically.

I turned to the young woman sitting next to me, still clapping. "Aren't you disappointed that she got it wrong?" I asked. She shook her head. "No way. This is about the process-hearing the story and putting it all together. I started off wanting to be a surgeon, but I realized that it was internal medicine that would keep me on my toes intellectually."

The man sitting next to her leaned over and added, "I didn't come here for the answer. I come to see the thinking."

Getting the right diagnosis is, of course, what you always want-and will usually get on TV and in the movies. But doctors are hungry to hear how others think a case through. Translating the big, various, complicated, contradictory story of the human being who is sick into the spare, stripped-down, skeletal language of the patient in the bed, and then making that narrative reveal its conclusion-that is the essence of diagnosis. Like a great Hitchc.o.c.k film, the revelation at the end is not nearly as interesting as the path that gets us there. So despite her wrong answer, it was exciting to watch Fitzgerald work her way through this complicated case. And, in the other two cases presented that afternoon, she was right. I caught up with Fitzgerald later that day. "Oh, I'm wrong a lot, but my audience seems to forgive me." Fitzgerald laughed, then added, "It's a form of entertainment. A lot of the appeal of internal medicine is Sherlockian-solving the case from the clues. We are detectives; we revel in the process of figuring it all out. It's what doctors most love to do."

The kind of story Javed Nasir told to Fitzgerald is at the very heart of that Sherlockian process. It is one of the fundamental tools of diagnosis. Doctors build a story about the patient in order to make a diagnosis. It is a story based on the patient's story but it is freed of most of the particular details of the individual, and structured to allow the recognizable pattern of the illness to be seen. In the last chapter I looked at the process of getting the story from the patient and the final task of giving it back to the patient. Here I want to look at just what it is that doctors do with that story to make it yield the diagnosis.

Done well, the doctor's version of the story often holds the key to recognizing the pattern of an illness, leading to a diagnosis. Much of the education doctors get in their four years of medical school and subsequent years of apprentices.h.i.+p training is focused on teaching this skill of identifying and shaping those aspects of a patient's life and symptoms, exams and investigations that contribute to the creation of a version of the patient's story that makes a diagnosis possible. Indeed, the ability to create this spare and impersonal version of the patient's story is the the essential skill in diagnosis. essential skill in diagnosis.

It's also one of the aspects of medicine that can seem most dehumanizing. It's how the elegant retired schoolteacher who mesmerized three generations of her students with stories of the Roman Empire as she inspired them to master noun declensions in Latin is quickly reduced, in diagnosis-speak, to the seventy-three-year-old woman with rapidly progressive dementia in room 703.

How doctors apply general medical knowledge to the particular patient has been an area of intense interest and research for decades. Current thinking focuses on stories as the key. The basic sciences of anatomy, physiology, biology, and chemistry are linked to a patient at the bedside through very specific stories that doctors learn and eventually create. These stories, what researchers now call illness scripts, contain key characteristics of a disease to form an iconic version, an idealized model of that particular disease. For any individual disease, the illness script will be a loosely organized aggregate of information about the typical patient, about the usual symptoms and exam findings-with an emphasis on those that are unique or unusual-as well as information about the pathology and biology of the disease itself. It is the story that every doctor puts together for herself with the knowledge she gains from books and patients. The more experience a doctor has with any of these illnesses, the richer and more detailed the illness script she has of the disease becomes.

Development of a large library of these illness scripts has been the goal of medical training since long before it was described this way. When I was a student and then a resident in the 1990s, you'd hear older doctors tell you that the only bed you couldn't learn from was your own. That's why residency programs exist. Seeing more patients helps you learn more medicine and become a better doctor.

One of the ways doctors are taught to think about disease, one of the ways that these illness scripts get structured, is through the use of what are known as clinical pearls-observations and aphorisms containing nuggets of information about patients and likely diagnoses. This is a teaching technique that dates back to the days of Hippocrates, who published several volumes simply t.i.tled Aphorisms Aphorisms. Modern medical students are drilled on the five Fs of gallbladder disease-female, fat, forty, fertile, and fair-the characteristics of the most typical patient. They are pumped on Charcot's triad-fever, jaundice, and right upper quadrant pain (the diagnostic trio of a gallbladder infection that is spreading to the liver).

Clinical pearls are often cleverly worded to make it easier for students to remember them. When taking care of a patient who came in with a paralyzed arm and a facial droop I was told: a stroke is only a stroke after 50 of D50-a reminder that low blood sugar (which can be treated with 50 mg of 50 percent dextrose, or D50) can cause symptoms that imitate those of a stroke. When I was seeing a patient in the ER brought in after being found in a s...o...b..nk, a patient who had no detectable heart rate or blood pressure, I was told: a man isn't dead until he's warm and dead. That is, in conditions of extreme hypothermia (low body temperature), vital signs may be undetectable until the body temperature is brought up to a near normal range. And in fact this patient recovered fully. These pearls are little snippets of the illness script, snippets that help doctors connect a patient to a diagnosis.

Doctors create stories about patients that are organized like these illness scripts. Using the barest most generalized recounting of the patient's characteristics, his symptoms, his exam and test results, the doctor tries to match that story to an illness script in order to make a diagnosis, or at least build a differential. A well-constructed story might even help a doctor who has never seen a patient to come up with the right diagnosis.

Tamara Reardon is alive today because a doctor-not her her doctor-was able to make a diagnosis based on a one-line description of her illness. Tamara was forty-four years old, a mother of four, and healthy until one day in early spring when she woke up with a sore throat and a fever. She took some Advil, got her children off to school, and went back to bed. She was still there when the kids got home that afternoon. She roused herself enough to get them started on their homework, then returned once more to bed. Her entire body ached; she alternated between shuddering chills even under a half dozen blankets and waves of heat marked by drenching sweats. Her husband made dinner that night but she couldn't eat. The next day she could barely drag herself out of bed to see her doctor. She still had a fever, her throat was on fire, and she had a new symptom: her jaw hurt, mostly on the right, so that talking and eating were excruciating. When the doctor had her open her mouth so he could look at her throat, it hurt so much she cried. doctor-was able to make a diagnosis based on a one-line description of her illness. Tamara was forty-four years old, a mother of four, and healthy until one day in early spring when she woke up with a sore throat and a fever. She took some Advil, got her children off to school, and went back to bed. She was still there when the kids got home that afternoon. She roused herself enough to get them started on their homework, then returned once more to bed. Her entire body ached; she alternated between shuddering chills even under a half dozen blankets and waves of heat marked by drenching sweats. Her husband made dinner that night but she couldn't eat. The next day she could barely drag herself out of bed to see her doctor. She still had a fever, her throat was on fire, and she had a new symptom: her jaw hurt, mostly on the right, so that talking and eating were excruciating. When the doctor had her open her mouth so he could look at her throat, it hurt so much she cried.

Tonsillitis was his diagnosis. Probably strep throat. An outbreak had roared through her household a few weeks before, so the doctor didn't even send a culture. He simply sent her home with a prescription for an antibiotic called Biaxin. After a couple of days of antibiotics Tamara began to feel better. The fever came down and her throat was less painful, but now she noticed a lump in her neck that had her worried. She went back to her doctor. He looked down her throat. It was much easier this time-her jaw was no longer painful. Her tonsils looked fine-the fiery red color was gone and they no longer looked swollen. But across the back of her throat the doctor saw patches of white that hadn't been there before. And her neck was swollen and tender on the right. The doctor thought the swelling was probably just a lymph node still inflamed from her recent infection, but he was a little puzzled about the white patches. He gave Tamara a week's worth of prednisone-a steroid-to reduce the inflammation since it was bothering her. And he made an appointment for her to see an Ear, Nose, and Throat doctor about those white patches.

The steroids reduced the swelling in her neck almost immediately. And the fatigue and achy feeling she'd had since she'd first gotten sick started to ease up. Whatever she'd had, it was gone now.

The day after she'd taken her last dose of prednisone, she woke up with a fever. And the swelling on her neck was back-and even worse than it had been before she'd taken the steroids. She could hardly open her mouth. She could not move her neck. She had an appointment with the ENT the next day, but Tamara felt too sick to wait. Her husband drove her to the emergency room and after waiting a couple of hours she was given some Darvocet (a painkiller) and advised to see her ENT the next day.

She did, but he wasn't certain what was going on either. She had a fever and her neck was swollen and red on the right. It seemed too extensive to simply be her lymph nodes. He worried she might have an abscess hidden in her tonsils. The white patches her doctor had been worried about were gone. He looked into her throat using a tiny camera embedded at the end of a slender tube. He couldn't find any evidence of an abscess, so he gave her a few more days of steroids and another round of antibiotics. And he got a CT of her neck.

That night the ENT went to a meeting of his local medical society. He ran into an old friend, Dr. Michael Simms, a specialist in infectious disease. As they made their way to their seats, the ENT thought of this baffling case. "Hey Mike, let me run something by you. I've got a forty-four-year-old woman with a history of tonsillitis who now has fever, jaw pain, and swelling on the right side of her neck. I got a CT scan and there's no abscess, just a clot in the jugular vein. Do you know what this is?" Simms looked at his friend. He ticked through the facts the ENT had related: "She had a recent case of tonsillitis, and now has fever and pain in the right side of her neck and a clot in her jugular vein?" The ENT nodded. "I think she has Lemierre's disease," Simms told him, instantly.

Dr. Andre Lemierre, a physician in Paris, first described this disease in 1936. It's rare, and seen most often in adolescents and young adults. Lemierre wrote up several cases of this illness, which begins with a fever and tonsillitis and progresses to a painful and often swollen neck as the infection moves into the jugular vein. Once there, the bacteria induce the formation of blood clots, which then shower the rest of the body with tiny bits of infected tissue.

Before the discovery of penicillin the disease was usually fatal. The widespread use of penicillin to treat all severe sore throats during the 1960s and 1970s virtually wiped out the disease. But over the past twenty years, Lemierre's has staged something of a comeback-an unintended consequence of a more cautious use of antibiotics and the development of new drugs-like Biaxin, which is what Tamara was given-that are easier to take but far less effective than penicillin against this potentially deadly infection.

Simms saw Tamara the next day. Since starting the medications she felt much better-hardly sick at all-so she was surprised when Simms recommended that she go to the hospital that very day. She went, and just in time. The infection had already moved into her lungs. She had a rocky course, and ended up spending nearly two months in the hospital-but she survived.

With only a couple of sentences, and a handful of facts about the case, Michael Simms was able to diagnose this woman he had never seen, a patient whose diagnosis had already been missed by two primary care doctors and a doctor specializing in diseases of the head and neck. That is the power of these little stories.

Clearly, knowledge is an important part of this. Simms was able to make this diagnosis because he knew this disease. It's rare, so it's likely that the patient's primary care doctor and the ER doctor had never heard of it. But the ENT knew about this disease. When Simms mentioned Lemierre's, he'd recognized it. But somehow he hadn't been able to connect the knowledge of the disease with its cla.s.sic clinical presentation. Somehow he hadn't created a story or illness script for this ent.i.ty. Maybe he'd never seen it before either. I doubt he'll miss it again.

Doctors are constantly adding to the number and richness of the illness scripts in their heads. Every patient contributes. Lectures can too. Most speakers start off with a cla.s.sic patient story before presenting their research on a disease or topic. Medical journals often present difficult cases in their pages. Like those presented to Fitzgerald, these cases teach doctors about a particular disease, and about the construction of the story that can help the doctor link the patient to the diagnosis.

These stripped-down stories, while useful to the diagnostic process, bear little resemblance to the stories a patient tells the doctor. Doctors strip away the personal and specific to make their version of the story and in doing so sometimes forget that the reason we do this is to help the person in the bed. That person is more than their disease, but sometimes that seems to get forgotten. When doctors confuse the story they have created about the patient's disease with the patient himself, this contributes to a sense that medicine is cold and unfeeling and indifferent to the suffering of patients-the opposite of what medicine should be.

Dr. Nancy Angoff is the dean of students at Yale Medical School. She watches over the one hundred students of each cla.s.s as they wend their way from student to doctor. She's concerned that medical education spends too much time on focusing the students' attention on the disease and not enough time on the patient. She cringes when she overhears a student refer to a patient by his disease and location, or when the discussion of a cool diagnosis overlooks the potentially tragic consequences for the person with the diagnosis. She worries that the doctors they will become will forget how to talk to the patient, to listen to the patient, to feel for the patient. For years she worried that in the excitement of mastering the language and culture of medicine they might lose the empathy that brought them to medical school in the first place.

When Angoff became the dean of students, she decided to see if she could do something to prevent that transformation. And she wanted to do it right from the start, right from the very first day of school. "Students come here and they are very excited about medicine. They want to help the sick patient, and medicine is the tool that makes that possible. That's why they are here. But medical schools don't teach you about the patient, they teach you about the disease. I wanted to emphasize the patient right from the very first day."

As part of that effort, Angoff has shaped that first day at Yale Medical School to try to "vaccinate" the students against the focus on the disease and the depersonalization of the patient that is part and parcel of current medical education. To do this, she focuses on the difference between the patient's story and the story the doctors create from it.

So on a warm September morning, I returned to the cla.s.sroom in which I had spent most of my first two years as a medical student to see what a new generation of med students is taught about the stories we hear and those we tell as doctors.

As Angoff, a small and slender woman in her mid-fifties, stepped onto the stage, the nervous chatter of these brand-new students quickly died. She said a few words of welcome and then outlined the events of the morning. We would hear two versions of a patient's story, first as the patient told it and then as it might have been written up by a doctor caring for the patient in the hospital.

The stories were to be performed by Dr. Alita Anderson. Anderson is a young black woman in her early thirties. A Yale Medical School graduate (cla.s.s of 2000), Anderson spent a year interviewing patients about their experiences in the health care setting. All of the patients she interviewed were African American, most were poor; many were poorly educated as well. All had multiple encounters with a medical system that was only sometimes responsive to their needs. She now travels around the country performing the stories she collected from this often unheard population.

Anderson gave Angoff a hug and then walked slowly across the stage. She began to sing a slow sad song in a husky alto. I couldn't quite understand the words and I didn't recognize the song, but it sounded like some kind of spiritual.

Anderson settled in a lonely chair on the stage and finished the song. She sat quietly for a moment and then said in a rumbly southern voice, "In June 1967, I went to Vietnam. I was a member of the First Infantry Division. My first evening there, they sent me out on an ambush." She didn't have any props, nor a costume, but through her voice and expressions she became this middle-aged black man who never recovered from the battlefields and bars of his year in the Vietnam War. She portrayed this man, clearly destroyed by an almost lethal dose of post-traumatic stress disorder, drugs and liquor. It was a compelling performance.

Anderson, still speaking as this sad middle-aged man, described a particularly difficult episode in his life. "I had been drinking. I was very loud and belligerent that night and my sister, who is probably the closest person to me, walked off and said that she was never going anywhere with me again. Afterward, I went out to the Dumpster and I threw the bottle in that Dumpster and I said that I was never going to drink anymore. I tried to stop on my own, but the next morning when the liquor store was open I was right there buying another bottle. A lot of times, people-they want off but they have no control. That is what the bondages of Satan do, using alcohol and drugs."

When she finished this man's monologue, Anderson sang a reprise of the sad song that she'd started with. As she sang, a slide appeared on a screen behind her. Anderson seamlessly switched into a professional voice, with crisp diction and shorn of any accent as she read a re-creation of what a hospital admission note from any of his many hospital admissions might have read. "Chief complaint-a thirty-four-year African American male brought in by police; a question of a drug overdose.

"The history of the presenting illness: The patient was found unresponsive and brought to ER. He was intubated in the field to protect his airway since he was actively seizing, which caused respiratory depression when he was found. In the ER, the patient was minimally responsive to pain. Per police, he had 3 grams of cocaine in pocket. He has been identified by his driver's license as Mr. R. Johnson whose prior medical records indicate multiple past admissions for drug overdose."

The students sat in rapt silence throughout the hour-long performance. The contrast between the rich, detailed life portrayed by the young doctor-reporter and the spare, cold language with which it was portrayed in the imagined, but realistic, admission note could not have been stronger. Afterward the students sat in small groups discussing the morning's event. They were moved by the patient's story and horrified by its translation into the coolly impersonal language of medicine.

Angoff sees this as an opportunity to demonstrate what patients see all the time: the cold and depersonalizing language and process of medicine. "I want to remind our students that there's a real person here." Medical students fall in love with what the doctor's story can do, what medicine can do, she tells me. The morning's performance is there to remind them of what a patient's story can do and how the infatuation can look and sound to the patient they are trying to help.

At the end of the morning Angoff said a few words to the students, summarizing what she hoped they have learned. "You're starting out on the journey across this bridge, this education, and right now you are on the same side as your patients. And as you get halfway over the bridge you'll find yourself changing and the language the patient had and you had is being replaced by this other language, the language of medicine. Their personal story is being replaced by the medical story. And then you find yourself on the other side of that bridge-you're part of the medical culture. When you get there, I want you to hold on to every bit of your old self, your now self. I want you to remember these patients."

CHAPTER THREE.

A Vanis.h.i.+ng Art.

Here's a story I read not long ago in the New England Journal of Medicine: New England Journal of Medicine: A man in his fifties comes to an emergency room with excruciating chest pain. A medical student is told to check the blood pressure in both arms. He checks the closer arm and calls out the blood pressure. He moves to the other side of the patient but is unable to find a blood pressure. Worried that this is due to his inexperience rather than a true physical finding, he says nothing. No one notices. Overnight the patient is rushed to the operating room for repair of a tear in the aorta, the vessel that carries blood out of the heart to the rest of the body. He dies on the operating table.

A difference in blood pressure between arms or the loss of blood pressure in one arm is strong evidence of this kind of tear, known as a dissecting aortic aneurysm. The student's failure to speak up about his inability to read the blood pressure on one side of the patient's body prevented the discovery of this evidence.

Here's another story-this one from a colleague of mine: A middle-aged woman comes to the hospital with a fever and difficulty breathing. She'd been treated for pneumonia a week earlier. In the hospital she's started on powerful intravenous antibiotics. The following day she complains of pain in her back and weakness in her legs. She has a history of chronic back pain and her doctors give her painkillers. They do not examine her. When her fever spikes and her white blood cell count soars, the team gets a CT scan of the chest, looking for something in her lungs that would account for a worsening infection. What they find instead is an abscess on her spinal cord. She is rushed to surgery.

Had the team examined her, they would have found a loss of sensation and reflexes, which would have alerted them to the presence of the spinal cord lesion.

This story was recently presented at Grand Rounds, a high-profile weekly lecture for physicians, at Yale: A man has a heart attack and is rushed to the hospital, where the blocked coronary artery is reopened. In the ICU, his blood pressure begins to drop; he complains of feeling cold and nauseated. The doctors order intravenous fluids to bring up his dangerously low blood pressure. They do not examine him. When, after several hours, his blood pressure continues to drop, the cardiologist is called and she rushes back. When she examines him she sees that his heart is beating rapidly but is barely audible. The veins in his neck are distended and throbbing. She immediately recognizes these as signs that the man has bled into the sac around his heart-a condition known as tamponade. It is a well-known complication of the procedure she'd done just hours before. She rushes him back to the OR and begins draining the blood, which by now completely fills the sac, preventing the heart from beating. Despite her efforts, the man dies on the table. Had the doctors in the ICU examined the patient, rather than paying attention only to the monitors tracking his vital signs, they would have been able to diagnose this potentially reversible complication.

This is another kind of story doctors tell one another in hospital hallways and stairwells-cautionary tales from the pages of our best journals, cases presented at the weekly Grand Rounds or Morbidity and Mortality Conferences, where medical errors are traditionally discussed. These are the tragic stories of patients who worsen and sometimes die because clues that could have and should have been picked up with a simple physical examination were overlooked or ignored. We repeat them to one another as lessons learned-a prayer and talisman. We tell them with sympathy because we fear that any one of us might have been that doctor, that resident, that medical student.

These anecdotes reveal a truth already accepted by most doctors: the physical exam-once our most reliable tool in understanding and diagnosing a sick patient-is dead.

It wasn't a sudden or unantic.i.p.ated death. The death of the physical exam has been regularly and carefully discussed and doc.u.mented in hospital hallways and auditoriums and in the pages of medical journals for over twenty years. Editorials and essays have posed once unthinkable questions like: "Physical diagnosis in the 1990s: Art or artifact?" or "Has medicine outgrown physical diagnosis?" and "Must doctors examine patients?" And finally in 2006, the flat announcement of the long-antic.i.p.ated death was carried in the pages of the New England Journal of Medicine New England Journal of Medicine. In "The Demise of the Physical Exam," Sandeep Jauhar tells the story of that inexperienced medical student-himself-who couldn't find a blood pressure on a man with chest pain and an aortic dissection who dies as a result. It is the tasty opening anecdote in an obituary-not for the patient but for this once valued part of being a doctor.

The physical exam was once the centerpiece of diagnosis. The patient's story and a careful examination would usually suggest a diagnosis, and then tests, when available, could be used to confirm the finding. These days, when confronted with a sick patient, doctors often skip the exam altogether, instead shunting the patient directly to diagnostic imaging or the lab, where doctors can cast a wide net in search of something they might have found more quickly had they but looked. Sometimes a cursory physical examination is attempted but with few expectations as physicians, instead, eagerly await results of a test they hope will tell them the diagnosis.

Many doctors and researchers are troubled by this s.h.i.+ft. They complain about the overuse of expensive high-tech tests and decry the decline of the skills needed to conduct an effective physical exam. Yet despite this uneasiness, doctors and even patients increasingly prefer what they perceive to be the certainty of high-technology testing to a low-tech, hands-on examination by a physician.

Measuring the Loss of Skills In the early 1990s Salvatore Mangione, a physician and researcher at Thomas Jefferson University Medical Center in Philadelphia, began studying how well doctors were able to recognize and interpret common findings on one fundamental component of the physical exam, the examination of the heart. He tested 250 medical students, residents, and postgraduate fellows specializing in cardiology from nine different training programs. The investigation was straightforward enough: students and doctors were given an hour to listen to twelve important and common heart sounds and answer questions about what they heard.

The results were stunning and controversial. A majority of the medical students could identify only two out of the twelve sounds correctly. The other ten were recognized by only a handful of the students. Surprisingly, the residents did no better. Despite their additional years of experience and training, they were able to correctly identify only the same two examples. Perhaps most disturbing of all, most of the doctors holding a post-residency fellows.h.i.+p in cardiology were unable to identify six out of the twelve sounds.

In a similar test on lung sounds, Mangione again found that students and residents couldn't identify many of the most common and most important sounds of the body. If letter grades were being handed out, all but a handful of these partic.i.p.ants would have gotten a big fat F.

In the years since Mangione first published his studies, editorials and lecturers have bemoaned this loss of skills and warned that if action isn't taken to remedy the problem, we'll end up with teachers who know no more than their students, a case of the blind leading the blind. A recent study suggests that that day has already come. Jasminka Vukanovic-Criley, a physician at Stanford, compared cardiac exam skills of practicing physicians to those of medical students and residents. First-year medical students correctly answered just over half of the questions. Graduating medical students were a little better-correctly answering nearly 60 percent of the questions. But after graduation from medical school, all improvement stopped. Residents, their teacher-physicians on the faculty, and doctors in the surrounding community did no better than graduating medical students.

How did we get here? How can we have generations of doctors who make it through residency and sometimes subspecialty training without improving their skills in the physical exam? Mangione surveyed medical training programs about their curriculum in these areas and found that only one in four offered structured teaching of basic physical examination skills. Routine observations of trainees performing the physical exam were rarely done. Perhaps, Mangione suggests, doctors don't learn this because programs don't teach it.

Historically, residency and fellows.h.i.+p programs rarely taught these skills outright, as a separate course of instruction, because this kind of teaching happened informally, throughout the day, while taking care of patients. At one time, a "resident" actually lived in the hospital, literally resident, so that he might learn his skills via total immersion, like a Berlitz language cla.s.s of the body. Part of the total immersion was to pick up the physical examination skills of the older doctors as the resident watched the pros working from room to room.

After every call night, teaching physicians would see each newly admitted patient along with the resident, the interns, and the students. Together they would review the story of the patient's initial presentation and then examine the patient, reviewing significant physical findings noted (or not) by the team. In addition, three times a week, the attending met with residents and medical students for a ninety-minute educational session. During these cla.s.ses attending physicians were expected to incorporate instruction in the nuances of the physical exam-at the bedside, with the patient.

These types of unstructured, informal teaching sessions, based on the pathology of the patients, were the princ.i.p.al methods of teaching the physical exam along with other aspects of patient care.

Several trends completely unrelated to education have eroded these traditions. First, the rising cost of hospitalization has focused efforts on shortening patients' time in the hospital. Those with significant heart murmurs, the kind that make good teaching cases, are in and out of the hospital within days. In 1980 the average length of stay in a U.S. hospital was more than a week. In 2004 that had dropped to just over three days. So there is less opportunity to do bedside teaching-a triumph of medical economy that only slowly has been recognized to have come at the expense of education. Patients zip in and out of the hospital too quickly for residents to learn from their exams.

These days, the residents who care for the patients also zip in and out of the hospital. The eighty-hour workweek, mandated in 2004 by the Accreditation Council of Graduate Medical Education (ACGME), the organization that oversees medical education, means that the time that doctors-in-training are allowed to spend in the hospital is limited. Eighty hours may seem like a long workweek, but there's plenty to fill it; the amount of work hasn't decreased, only the time available to do it in. What this usually means is that residents spend less time with their patients. In a recent study done at Yale, interns were found to spend less than ten minutes a day with each of their patients.

As an intern, I used to allow two hours to see my patients first thing in the morning, before work rounds when I presented the patient to my resident and the attending. This gave me plenty of time to talk with the patient, examine him, check his labs. With the eighty-hour workweek, interns in our program are not permitted to come into the hospital any earlier than one hour before work rounds. Given the dual demands of patient care and education-which are, after all, the purpose of residency-something had to give. Unfortunately, what's given up is the time doctors spend with the patient.

Our successes in medicine have taken their toll as well. Many diseases are caught early, before the severe consequences are manifested. In the 1990s when I did my training, I was exposed to far fewer types of murmurs and other heart sounds than the generations of doctors who preceded me. Rheumatic heart disease used to be commonplace. In this disease, a strep infection of the throat or skin can cause the immune system to attack the heart, destroying the valves. The unexpected link between this painful but not life-threatening infection and potentially lethal destruction of the valves of the heart was recognized in the early twentieth century. Now physicians routinely check for strep when patients come in with a fever and sore throat. Those with positive tests are treated with antibiotics. The drugs don't do much to shorten the illness or lessen the pain of the infection, but they prevent the development of rheumatic heart disease.

It's been a very successful strategy. Rheumatic fever was one of the most common diseases in America through the 1940s. In 1950 approximately 15,000 people died of rheumatic heart disease; in 2004, that number had dropped to just over 3,200. It's a dramatic decline, but we didn't wipe out the disease, so doctors still have to recognize it when they see it. It's just that now there are a lot fewer patients to learn the symptoms from-an unintended consequence of good medicine.

There are many diseases that are now routinely treated early, often before patients ever need to come into the hospital. It's a success story in medicine and a blessing for patients, but a problem for education based on chance patient encounters in the hospital. The old system of informal teaching, based on learning at the bedside, doesn't work anymore. And medical education has been slow to come up with alternate ways to teach doctors the critical skills necessary for a thorough physical exam.

This loss of skills has resulted in a loss of faith in what the physical exam can do. The official line in medicine is that the physical exam is important. But what you quickly pick up in the "hidden curriculum"-the values and beliefs of medicine as it's practiced-is that the physical exam is mostly a waste of time. On rounds in the hospital, as a student or intern, you might proudly describe a murmur you picked up on exam, but it doesn't take long to realize that it's only the report of the "echo" (shorthand for echocardiogram -an ultrasound of the heart) that anyone pays attention to. And because the physical exam is not valued, you soon learn not to pay attention to it and all further learning stops-replaced by the kind of learning you know those who are in charge will will value. What did the newest high-tech test say? What is the most current research on a particular therapy? These are the questions physicians are now being trained to ask-not the more traditional questions, such as, What did you see when you looked at the patient? What did you feel? What did you hear? value. What did the newest high-tech test say? What is the most current research on a particular therapy? These are the questions physicians are now being trained to ask-not the more traditional questions, such as, What did you see when you looked at the patient? What did you feel? What did you hear?

These structural changes in modern medicine-where doctors and their patients zip in and out of the hospital with an ever changing variety of diseases-are expressed at the practical level in this hidden curriculum. But I suspect there is one more reason that the exam has lost its once central position in the evaluation of the patient. In contrast to the cool answers provided by technology, the physical exam feels primitive, intimate-even intrusive. Even when the patient is available and willing, conducting such an exam is psychologically daunting for the physician. It's a truth I learned early in my own medical education.

Palpable "Do you want to feel my cancer while it's still here?" Joan asked me one wintry afternoon as we sipped coffee in her kitchen. "You're going to be a doctor. Shouldn't you know what a breast cancer feels like?"

My husband and I were visiting his oldest sister one February weekend in 1993. It was spring break at the Yale Medical School, where I was in the middle of my first year. The week before, Joan had gone for her regular mammogram. As she was getting dressed after the test, the radiologist, an old friend, burst into the room. "She looked at me and I could tell something was wrong," Joan told me.

The radiologist arranged for her to see an oncologist, who, in turn, sent her to a surgeon for a biopsy. Our visit caught her before she'd heard the results of the biopsy but well after Joan had accepted the likelihood of the diagnosis.

Joan sighed and tucked a wayward blond curl behind her ear. "Wouldn't it be helpful to know what to look for? Wouldn't it?" she persisted. After the needle biopsy, she'd located the tiny nodule that was going to change her life and found herself touching it several times a day, the way you sometimes can't stop fingering a painful sore or replaying a difficult conversation in your head-acting on some need to remember where the pain was coming from.

I didn't know what to say. I had no idea what a breast cancer would feel like and she was right-it would be useful for me to know. And I was wildly curious.

But I knew immediately that I couldn't do it. Touching my sister-in-law's breast was inconceivable. Joanie was able to imagine me in the role of a physician-a group given permission to ignore the traditional zones of privacy when necessary. But it wasn't a mantle I was ready to put on. At that point in my training, I had not yet examined anyone. Until that moment I hadn't really envisioned how strange and unnatural it would to be to violate the zone of privacy each of us occupies. I couldn't touch my sister-in-law. In fact, I wasn't sure I could touch anyone.

The act of placing your hand upon another's body is, in many ways, the hallmark of the physician. And yet, though simple, it is an act riddled with complications. Who are the people we touch in our lives? Our lovers, certainly; our children, naturally. And as a sandwich generation, perhaps even our parents, eventually. No one else. I don't count the hug and cheek-peck h.e.l.lo, the hand on the shoulder, the slap on the back. This is touch as a form of communication-it speaks of fellows.h.i.+p and affection, support and concern. This type of physical contact lies well within our expectations of social intercourse. It is by convention brief, by practice un.o.btrusive. A hug or touch that lasts a little too long or is a little too close sets off alarms because we understand the rules of social conduct.

In medicine, at the bedside, on the examination table, we touch those we care for-but it's a different form of touch, and a different kind of care. Medicine requires intimacy but one characterized by an intellectual and emotional distance. You don't expect your friends and loved ones to a.s.sess you with a knowing and impartial eye. We allow them to occupy an intimate s.p.a.ce physically and emotionally because we know they see us through a filter of love.

The intimacy of the physical exam is far removed from that between friends and family. In the physical exam, that filter is gone. Doctor and patient are often strangers to each other. It can be uncomfortable-for the patient, and often for the doctor as well. And there is, at the heart of this sometimes awkward intimacy, a fiduciary relations.h.i.+p, an implicit bargain: the patient will let the doctor see him and touch him and in return the doctor will share her knowledge for the benefit of the patient. When Joan had her cancer, I knew I wasn't ready to live up to my end of the deal. I had nothing to offer: I knew a lot of anatomy, some cell biology, a good deal of genetics, but I didn't know anything about medicine. Not then.

Moreover, I didn't know how to do it. Literally. I hadn't been taught. That was something I would learn in my second year. Perhaps even more important, I hadn't yet learned how to occupy that permitted s.p.a.ce between physical intimacy and intellectual distance that is fundamental to touching as a doctor. That part isn't on the written curriculum; there weren't any lectures on it (or at least not in my medical school), and yet you can't be a doctor if you don't learn how to negotiate this deeply personal territory. Medicine-to the extent that it can be called a science-is a sensual science, one in which we collect data about a patient through touch and the other senses according to a systematic method in order to make a diagnosis. Most patients are willing to be touched by their doctor. They expect it. I certainly expected to touch patients. But, as I realized that afternoon in my sister-in-law's kitchen, first you have to learn how.

In medical school, starting with anatomy cla.s.s, doctors are taught to understand the body by taking it apart, one piece at a time. What you walk away with, at the minimum, is an uncanny ability to objectify the h.e.l.l out of even the most intimate body parts. For anyone else, this might be considered disrespectful, but for doctors, a clinical and objective view of, say, a female breast offers us the chance to see it isolated from its other, often s.e.xual, contexts. We are taught to handle a breast as a separate object.

And so when you examine a breast, you notice that the smooth skin and soft layer of fat beneath give way under your fingers to reveal highly organized, dense layers of glandular tissue below. Beneath the skin, trapped by the investigating hands, the breast is so much more orderly than the wildly mobile appendage it appears. I learned how to examine the breast in the middle of my second year. A patient-instructor-a layperson trained in the techniques of this exam-walked me and the three other students who made up my physical exam group through the methodical examination using her own b.r.e.a.s.t.s as the models on which we learned.

As the cla.s.s began, I felt again that same discomfort I'd felt in Joanie's kitchen. We were four medical students, dressed in our still creased short white coats, our s.h.i.+ny name tags pinned to our lapels, and brand-new stethoscopes folded into our pockets, trying hard to appear relaxed as we sat in a semicircle around a half-naked middle-aged woman. The teacher sat comfortably on the exam table. The robe she had worn when we entered the room was pushed down around her waist to reveal the subject of this cla.s.s, her b.r.e.a.s.t.s. I tried to relax my face-to at least appear at ease. I wasn't quite sure where to look. I pulled out a notebook to take notes as she talked about the exam. I could feel the tension emanating from the students on either side of me. None of us said anything at all. Greg, the earnest, well-meaning liberal from New York's Upper West Side, appeared to be studying his shoes. Lillian, the exuberant effusive life force in our cla.s.s, fidgeted quietly with her hair. No one made eye contact with the teacher or one another. The four of us silently struggled to figure out a way to manage our discomfort. I knew then that those skills were part of what the cla.s.s was supposed to teach us.

"First you inspect," she told us. "The b.r.e.a.s.t.s should be symmetric." She raised her hands above her head, and her breast stretched upward as well. Then she placed her hands down on her hips, spreading her elbows wide to stretch the chest muscles and the b.r.e.a.s.t.s. "This gives you a chance to see any abnormalities that affect the shape of the breast or the texture of the skin."

As she ran through her orderly presentation the tension in the room began to fade. Her matter-of-fact demonstration communicated an ease with her role as a patient and her expectations of us as doctors. I realized later that she was not only teaching the basics of the breast exam, she was demonstrating a technique we could use in our own encounters to bring a naturalness to the awkward physical intimacy between a doctor and a patient.

"I'm going to demonstrate how to examine my b.r.e.a.s.t.s and then each of you will do it."

We crowded around the table as she lay with one hand over her head and the other performing the examination.

"Start at the midline. Use the pads of your fingers. Press them lightly on the breast and make a circle. I like to anchor my fingers to each spot and move the skin along with my fingers so that I know that I'm examining the same spot. You do that three times at each spot, each time applying just a little more pressure so that you can feel all the different structures under the skin."

We watched with interest as she repeated this motion up and down her chest in overlapping stripes from her sternum all the way over to her side and up into the dome of her underarm.

"Now you try it."