Diagnosis

Our patient had become increasingly socially withdrawn, emotionless, and impulsive. He had started falling with increasing frequency, not even bothering anymore to put out his hands to break his fall. And he had been taken to specialist after specialist, undergoing test after test. But each doctor was stumped as to what disease (or diseases) might be responsible. The patient had been referred to the clinic where I was observing, desperately seeking answers.

I largely watched as a more senior medical student conducted a lengthy and thorough interview and exam. By the end, both of us were leaning towards the same diagnosis: progressive supranuclear palsy. It is a progressive degenerative brain disease, and an insidious one at that. It causes dementia and impairs motor function, slowly paralyzing the muscles involved in gaze, talking, and swallowing, and causing frequent, spectacular falls. There is neither a cure nor an effective treatment (although some therapies are currently in development). Most patients die of complications from it within years. Very few doctors know about the disease or know how to pick up on the disease's subtle signs, often misdiagnosing it as Parkinson's. To be fair, the patient's condition was less advanced when she saw her previous physicians, which would have made the disease harder to recognize then.

The medical student presented to the attending physician, who became even more certain than we were that the patient had progressive supranuclear palsy. It was time to broach the news to the patient and his family. I thought that this would be a devastating moment: learning that you (or your loved one) are afflicted with an incurable, progressive, and tragic disease. In large part, the patient and his family responded as though a burden had been lifted. They had finally gotten a satisfying conclusion to their quest for a diagnosis, and now they could predict what might happen to the patient in the coming years. Above all, they were relieved that something finally explained what was going on: that a known disease was responsible for the befuddling combination of behavioral and motor problems that were increasingly affecting the patient. Within this tiny snapshot of time, the family responded bravely to the news of the diagnosis.

Getting the diagnosis here was a help for the family. Had the correct diagnosis been given earlier, the family could have avoided a lot of hassle, expense, and anxiety.

I'm considering neurology more seriously as a specialty, fully aware that many of the conditions I would be dealing with are largely incurable and untreatable. Where I think I could make a difference is in making the right diagnosis where others might stumble.

Where Are Today's Philosopher-Physicians?

I recently finished "The Man Who Mistook His Wife for a Hat", by neurologist and popular author Oliver Sacks. It is about the philosophical ramifications of his patients' diseases. 

• A patient with Korsakoff's Syndrome (severe damage to the memory-forming regions of the brain, due to a vitamin deficiency) lacks the ability to create new explicit memories. Decades after World War II has ended, he does not realize that time has passed beyond the year 1945. He knows himself only as a young man, and has entirely lost his own adult identity. Can someone really "live" if they don't know who they are, and if they have no ability to gain new knowledge or modify their personal narrative and sense of self?

• One patient with Tourette Syndrome finds that his nervous tics enhance his talent as a session drummer, forming the basis of wild improvisations that bring him musical acclaim. Since it is benefiting the patient, should Tourette Syndrome here be considered a disease? Should the Tourette Syndrome be treated? To what extent does Tourette Syndrome define the patient's personality?

• Another patient is mentally retarded but displays a remarkable spiritual and poetic wholeness that gives her life substance. Is it fair to consider her mental faculties as diminished? Are our psychological and neurological tests able to capture her strengths? 

• An elderly patient's new-onset seizure disorder makes her to see vivid flashbacks of her forgotten early childhood, unearthing pleasant memories that had long been buried. During her seizures she can accurately picture her parents, who died when she was age 4, as never before. The memories of her halcyon days of youth put her at ease in her waning days. Her case, among others, suggests that humans have a virtually unlimited faculty for storing memory. We seem to be limited only in our ability to recall those memories, an ability that can be paradoxically enhanced by debilitating diseases.

Sacks discusses these cases as a neurologist, as a historian, and as a student of philosophy. He uses his fascinating patients to try to make sense of the human condition.

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Sacks attended medical school in England and graduated in the late 1950s. I wonder, is my medical education engendering scholarly thought in a way that might produce writer-thinkers like Prof. Sacks? The answer is no. There are notable physician-writers of the present day (Atul Gawande, Danielle Ofri, Abraham Verghese, and Siddartha Mukherjee come to mind), but they strike me as an exception to the rule.

Part of the problem is medical education. We learn the mechanisms of disease and of treatment in thorough detail. But there is little discussion of the wider consequences of what we're learning. The humanities are virtually divorced from my medical education. My school spends about 2 hours of lecture on clinical ethics, with no opportunity to receive further instruction. We are not taught about the history of medicine, or of the philosophy of the mind-body problem, or of the mathematical underpinnings of diagnostic medicine. We learn little about the laws, corporations, and political systems that govern the practice of medicine, about other countries' medical systems, about ways to implement population-scale interventions that prevent disease in the first place. There is so much medicine to learn that we are reduced to learning it in a vacuum, isolated from the fascinating scholarly fields that border, affect, and inform medicine. In many respects, medical school feels like trade school, like learning how to repair cars. We are expected to be learners, but not scholars.

Aren't we missing something substantial? Authors, poets, and philosophers have spent millennia grappling with death and illness, understanding how to make sense of the human experience and how to understand our interactions with others and with ourselves. It offers something that science cannot (and I say this as an undergraduate science major): it offers resiliency, insight, and perspective. When our medical education teaches science at the expense of the humanities, doesn't it also untether itself from humanity? Is it wise for our healers to be ignorant in literature and philosophy? Indeed, can those ignorant of literature and philosophy even be healers?

Part of the problem too is the medical admissions process. Getting into medical school demands that one excel at conventionality. Prerequisites are science and math classes, and applicants are strongly encouraged to net publications and shadow physicians. It demands that an applicant check boxes well, and that they be a scientific kind of thinker. Yet the pre-med process boxes out creative and compassionate thinkers that could innovate the field. The medical profession is beginning to recognize this problem, and is retooling the MCAT to emphasize ethics and social sciences. At the end of the day, though, the MCAT is just a multiple-choice test. Multiple-choice tests demand uniformity of thought, which is the exact opposite of creative thought. Fittingly, virtually every exam I've taken as a medical student has been multiple-choice.

The question really comes down to our identity: what do doctors believe a physician should strive to be? I think most doctors would say, a physician works in a medical setting in the care and treatment of patients. Medical school is structured around this particular mission, and it tends to accept those applicants that abide by it.

My view of medicine's aims is more expansive. I believe that physicians should improve the plight of man, using a knowledge of science as well as whatever other tools are available to them. This could be through patient care, through politics, through education, through research—anything. If medical schools were to adopt this far-reaching mission, and to teach students through that lens, medical education would necessarily look dramatically different. I think our country would look dramatically different, too, and for the better.

I'm hardly the first to believe that medicine should broaden its "scope of practice". The field of pathology, a branch of medicine that involves little patient interaction, was partly founded by Rudolf Virchow. Virchow also founded "social medicine," a nearly nonexistent branch of medicine that studies and addresses the societal determinants of disease (like famine, war, and public policy). In his words, "The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction." Though written over 150 years ago, I believe they hold quite true today.

Card-ology

Although I've only played poker once in the past three years, I entered a (free) campus Texas Hold'em poker tournament and won handily. It was shocking. My competitors were devoted poker fans who spoke in poker lingo and followed the competitive poker scene. I, on other hand, was so rusty that I had to ask players to remind me of the order of poker hands. As of writing, I still don't recall if a straight is worth more than a flush. And yet, everything worked. I accurately predicted when to fold, succeeded every time I bluffed, and subtly pressured my opponents into making unwise decisions that I ultimately collected on.

My performance differed from how I fared the few times I had ever played poker, and I wonder if my victory can be attiributed to my transformation into a medical student. Medicine and poker involve managing uncertainty, and most elements of my poker strategy involve skills that I have been honing in medical school.
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Anchoring: One of the most common pitfalls in making a diagnosis is that we tend to anchor ourselves too strongly to our initial hunches, even in the face of data to the contrary. It's not just physicians who anchor.

For example, you might ask someone: "How many calories are in an apple?"

You might ask a second person: "How many calories are in an apple? 250? 300?"

The second person will tend to give a higher number than the first. An apple actually has about 100 calories. But by suggesting caloric values of 250 and 300, you have subconsciously anchored them to values near those numbers.

Fast-food chains and stores like Walmart use this trick all of the time. The Subway chain prominently advertises how certain subs on its menu are low in fat. But many of their other subs are actually quite high in fat. By advertising that some of their subs are low-fat, they anchor people to the unwarranted belief that Subway subs generally are low in fat. The effect of Subway's advertising is explored in the wonderful book "Mindless Eating", which I previously reviewed.

Doctors must make sure not to follow their initial hunch too doggedly. While playing poker, I was cognizant of how I mustn't get too attached to my hand, even if I've already bet a substantial amount on it. Several times I resisted the urge to keep betting and folded.

Probability and Bayesian inference: In an intriguing case mentioned in a New England Journal of Medicine case report, a neurologist examined a patient who had been diagnosed with multiple sclerosis. Upon questioning, the patient mentioned that both of his brothers had been diagnosed with multiple sclerosis (MS) as well. The neurologist immediately doubted that the disease was MS, because MS is not a very heritable disease. The neurologist knew that if one's sibling has multiple sclerosis, one's odds of having it are only 1 in 25. For all three brothers to have MS was virtually impossible. Sure enough, the neurologist found that what the brothers had was not MS, but instead a rare (autosomal dominant) genetic disease called CADASIL. Probability led to the correct diagnosis.

In poker, if I am one of eight players at the table, I know that in each round there is a 1/8 chance that I have been dealt that round's best hand. This knowledge makes me fold often.

During each round, I ask myself: probabilistically, how strong are my cards relative to the others'? If someone had been dealt a better hand than me, what is the likelihood that they have folded by now? If there were still a person in this round who has better cards than me, what is the likelihood that I could make them fold? Is the way that a particular person is acting consistent with their having a better hand than me?

These same types of conditional probability questions are what underpin Bayesian inference, a branch of statistics that impacts decision-making. The best diagnosticians use Bayesian inference, consciously or unconsciously, to arrive at the correct diagnoses.

Reading people and interacting with people: Interacting with patients in clinic is helping me with reading people generally. When I ask a patient if they smoke tobacco and they hesitate, I know that no matter what they say afterwards, they smoke tobacco. I'm learning how to make a patient feel more calm, which means that, by extension, I'm learning how I could make them feel bothered.

In poker, I frustrated one of my opponents by intentionally placing a needlessly high bet against her early in a round. I correctly predicted that she wasn't confident enough in her cards to call my bet, and she angrily folded. Her reaction suggested to me that she would want retribution, and that the next time I placed a large bet she would call. Sure enough, when I placed another large bet against her, she called and lost on a weak hand. A few hands later, she went "all-in" against me to try to get me to fold. I suspected that her hand was probably weaker than mine, and I called. She lost and had to give me all of her chips. Her frustration in the face of mounting pressure got the better of her.

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I've mentioned some of the ways that becoming a physician seems to be changing me, and not always for better. At the same time, though, medical school is maturing and strengthening some parts of my personality and my thinking. Strange that it was a poker tournament that reminded me of that.

Trying patients

While shadowing a headache specialist in clinic:
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Patient: All you neurologists keep saying the same thing about my headaches. I mean, there has to be someone who actually specializes in headaches. Maybe I need to go see them instead.

Headache specialist: I am a headache specialist.

Patient's wife: Yeah, but I'll bet you only see people with migraines. Not real headaches like his.