Authors: Jerome Groopman
It was at this admission that Bigby met Manning and recog nized what the other physicians had overlooked. "An African-American woman of her age, from Mississippi—you have to consider the high likelihood that she never learned to read or write. The reason that Gloria Manning could not take her medications correctly was not a matter of being noncompliant but was explained by her inability to read the labels on the medicine bottles." So Bigby made sure that Manning's daughter, who works as a manager at a local corporation, was present when her mother was discharged and the outpatient plan was presented. "I just saw her in clinic yesterday," Bigby said. "She has lost seven more pounds, which is great, because so often people put back the weight and retain fluid after they leave the hospital. Everything is in order, and the daughter, this time, is making sure that the medications are being taken properly."
Bigby is trying to relay this sort of thinking about context to the interns and residents at the Brigham and Women's Hospital. That institution is one of the premier academic centers in the country and boasts cutting-edge technologies in fields like cardiology and surgery. It resembles the hospitals where I trained as a student, resident, and fellow. But I cannot recall a single instance when an attending physician taught us to think about social context. When an elderly patient was noncompliant, you generously considered whether this was a sign of early dementia or psychological depression, not a reflection of the severe disadvantages of being a black woman in the rural Mississippi of the 1930s.
Bigby, like all clinicians who have practiced for decades, made a diagnosis that had been missed by others and, in a moment, reversed the apparent fortunes of a patient. She recalled the case of Constance Gardner, who had developed a persistent cough and went to a local emergency room where a chest x-ray was ordered. The ER physician told Mrs. Gardner that she had metastatic cancer, since her lungs were studded with multiple masses. "I saw her the next day," Bigby said. After listening to her story and examining her, Bigby reviewed the chest x-ray. "I don't think this is metastatic cancer," she said to Mrs. Gardner. "It looks like a rare autoimmune disease called Wegener's granulomatosis." This malady can cause inflammatory masses in the lungs as well as other parts of the respiratory system. "It wasn't that brilliant, really," Bigby said, "just a matter of developing a complete differential diagnosis and thinking beyond the immediate possibility."
And, like all doctors after years in practice, Bigby had a patient who stopped coming to see her. Harriet West was an elderly African-American woman whom Bigby had cared for over several years and with whom she felt she had a good relationship. West had long-standing hypertension and heart disease and came to the emergency room at the Brigham and Women's Hospital complaining of shortness of breath. "She was in heart failure," Bigby said. Fluid was backing up in her lungs because her heart could not pump effectively. Harriet West had no evidence of an infection, Bigby continued, no fever, and no elevation of her white blood cell count. Nonetheless, Bigby recounted, "someone decided to obtain blood cultures." This was done to rule out a systemic infection, particularly one called endocarditis, which can affect the valves of the heart and contribute to heart failure.
Not only was the test unnecessary, it started a chain of events that led to West's leaving Bigby's practice. "One of the three blood cultures grew out staph epidermidis," Bigby said. This bacterium is commonly found on skin and usually has no significance if it appears in a single blood culture. "In a spirit of full disclosure, one of the residents said to Mrs. West, 'Oh, one of your blood cultures grew out this bacteria, but don't worry. It was contaminated.'"
After West's heart failure was treated in the hospital, she went to see Bigby, to follow up as an outpatient. West was very agitated. "I want to know
exactly
what my medical records say," she said to Bigby, who was taken aback by this change in her demeanor. "After many, many conversations and much back-and-forth, I still couldn't figure out what was the matter," Bigby said. "She couldn't remember the exact words that the resident had said in the ER. But finally I realized that she thought she had been told that she had 'bad blood.'" "Bad blood" is an old euphemism, particularly in the South, where West was raised, for syphilis. West was convinced that the resident had asserted this, and, understandably, she was very insulted. "I was married for more than forty years, and now I am a widow, and I am a churchgoing woman," West told Bigby. "What does this say about me, a Christian woman?" She demanded that it be removed from her medical records. "I attempted to explain to her what 'contaminated' meant in this setting, that when he took the blood, the resident contaminated it." But West was not consoled. In fact, she then concluded that the resident in the emergency room had put a contaminated needle into her vein, and so had tainted her.
"It was the biggest divide in communication that I've experienced," Bigby said. "It was as though the two of us were speaking a completely different language. And that was the last time I ever saw her." Bigby now uses this case in teaching young doctors. "The irony was that it was a set of blood cultures that she didn't need," Bigby told me. "She was insulted, deeply insulted, by the institution."
Bigby is familiar with the work of Roter and Hall on doctor-patient communication, and emphasized to me that sensitivity to language, while particularly important with patients like Harriet West, should be considered with every patient. This is a challenge for the primary care physician, since so much of what she deals with is labeled routine in medicine. "One woman I cared for had knee pain," Bigby said. Her x-rays showed degenerative changes, common findings as we age. "I called her up and told her that she had osteoarthritis. I was ready to go on with my next phone call, but then I realized that she was devastated. To me it seemed to be no big deal, and I stated the x-ray findings in a matter-of-fact way. But to her, arthritis meant severe pain and being crippled."
Pediatricians like McEvoy learn how to talk to parents about the possibility of a developmental or psychological disorder, and general internists like Bigby craft phrases to deliver clearly bad news, such as a cancer diagnosis. But both McEvoy and Bigby emphasized to me that in the hurly-burly of primary care, a physician must not lose sight of the fact that what may seem mundane to the doctor can strike the patient as tragic.
Several years ago, I was speaking at medical grand rounds at Tufts—New England Medical Center when the chairman of the Department of Medicine, Dr. Deeb Salem, posed a difficult question for which I had no easy answer. I'd been discussing the importance of compassion and communication in the art of doctoring, and Salem asked the following: There are primary care physicians in every hospital who speak with great sensitivity and concern, and their longtime patients love them, but clinically they are incompetent—how is a patient to know this?
Salem's words resonated with me. There had been a cadre of such doctors who practiced on Beacon Hill and admitted their patients only to the Phillips House at the Massachusetts General Hospital when I was a resident there in the 1970s. A few of them were highly skilled, but several were, at best, marginal in their clinical acumen. Nonetheless, their patients were devoted to them. It was the job of the residents to plug the holes in these marginal doctors' care. "Just as a physician has to be wary of his first impression of a patient's condition, as a patient you have to be careful of your first impression of a physician," I said, particularly in choosing who will coordinate your care, or your children's care. Thankfully, fewer students are admitted to medical school now because of social standing and family connections than at the time of my training. America has become more of a meritocracy in the professions. Medical school admissions committees no longer accept a record of gentlemen's C's at an Ivy League college. At best, I said to Salem, a layman should inquire of friends and, if possible, other physicians as well as nurses about the clinical quality of a doctor beyond his personality. His credentials can be found on the Internet or by contacting the local medical board. Ultimately, I realized that Salem's query required a much more comprehensive answer, which I hope this book will help provide.
Dr. Bigby has experienced the flip side of a patient's positive first impression. "As a black woman, I have had patients arrive, take one look at me, and walk out of my waiting room," she said. Bigby mentors many residents, and has a special message for those who are African American or Latino. "I tell them, Always wear your white coat, always wear your name badge, and always have a stethoscope visible in your pocket," she said. "Despite all that, they will still sometimes be asked if they have come to take the meal tray. People focus on your being black and don't pay attention to the uniform that indicates you are a doctor."
Bigby, who covers weekend call with several prominent physicians on the staff, has also experienced situations when their patients looked askance at her when she entered the hospital room on a Saturday morning. Not subtly, they quizzed her about her credentials. "Wellesley College, Harvard Medical School, Mass General," she recites. Although there has been a significant increase in the number of women in medicine—now more than 50 percent in many parts of the country—as well as in the number of minorities, prejudice remains. Bigby believes this prejudice factors into her doctoring. She still feels, some thirty years after her residency, that she has to prove herself as a black woman, that she has to strive to be flawless, because some people still assume that she arrived at her senior post because of affirmative action and political correctness. "I...,"she said, her voice faltering briefly, "feel that I have to do everything better just to be judged as okay. It is something I wish I could let go of. It's something that I wish just wasn't there."
In 1997, Dr. Eric J. Cassell wrote an insightful and illuminating book,
Doctoring: The Nature of Primary Care Medicine.
Cassell is a clinical professor of internal medicine at Weill Medical College of Cornell University in New York and has a thriving Manhattan practice. In the 1990s, the train had begun to pick up considerable speed, because its controls had been increasingly taken over by insurance companies, HMOs, and hospital-based administrators. Cassell believed that many of the practice guidelines put forth by these organizations were designed to foster cost control rather than the best interests of the patient. "From this perspective ... physicians themselves can be seen as interchangeable commodities in a marketplace."
This statement reminded me of a remark by an eminent academic physician-scientist who led a department around that time: "Anyone can take care of patients." His arrogance, like much arrogance, was a product of narrow vision and ignorance. University hospitals and medical schools prize research most highly, because it brings attention from medical journals and money from grants. Similar arrogance and ignorance about medical care persist among the businesspeople who design and enforce many of the healthcare delivery constraints that dictate the fifteen-minute office visit. "A common error in thinking about primary care is to see it as entry-level medicine ... and, because of this, rudimentary medicine—for mostly (say) the common cold and imaginary illnesses. This is a false notion," Cassell writes. The great challenge is not only identifying serious illness but often being unable to decide if something is serious or not. "Everyone knows, however, that knowing when you don't know requires sophisticated knowledge ... From the perspective of training physicians and the knowledge bases required for adequate performance, the higher we go on the scale of a specialist training, the
less
complex the medical problem becomes."
This conclusion, Cassell acknowledges, is the opposite of that usually drawn. "One should not confuse highly technical, even complicated, medical knowledge—special practical knowledge about an unusual disease, treatment (complex chemotherapy, for example), condition, or technology—with the complex, many-sided worldly-wise knowledge we expect of the best physicians." Moreover, "The narrowest subspecialist, the reasoning goes, should also be able to provide this range of medical services. This naïve idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations—for example, ordering tests or x-rays when waiting a few days might suffice—thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor."
Recently, patient templates were proposed as a solution to organizing clinical information so that data are not overlooked. These templates, like clinical algorithms, are based on a typical patient with a typical disease. All that is required of the doctor is to fill in the blanks. He types in the patient's history, physical examination, lab tests, and the recommended treatment.
Not long ago, one of my neighbors told me that she had returned from a visit to her internist, who is a member of a large practice in a Boston hospital. I know the internist, and he recounted to me that he had recently been instructed by the prac tice's administrator to cut thirty-minute visits for follow-up to fifteen minutes, and sixty-minute appointments for new patients down to forty. When the doctor protested, the administrator told him that there was an electronic solution to make this all possible—a template would be on his computer screen. As he spoke with a patient, he would fill in the form. This would help, the administrator added, not only in economizing his time but also maximizing his revenue, since it would make it easier for the billing office to submit invoices to insurance companies based on his template documentation of the history, physical exam, and treatment recommendations.