“I think he’s just anxious about it,” the medical student told me a few sentences into the presentation. His patient had had a spontaneous pneumothorax, a leak of air between the lung and chest wall, a few years ago, and now he had some uncomfortable feeling and was worried about a recurrence. I hadn’t heard the full story yet, the presentation where the student tells me more about the symptoms, what makes them better, what makes them worse, what other medical problems the patient has, what medications he takes, what his physical exam is, what other studies have been done and reviewed. But the student seemed so sure “just anxious” was the diagnosis and the patient had had a chest X-ray to evaluate for pneumothorax prior to seeing us.
“Did you look at the X-ray?” I asked. He hadn’t. He hadn’t even read the radiology report. Yet the student had deemed that the patient, who likely knew more about pneumothorax from having had one before than the student did, was “anxious.” This student isn’t just a “bad apple.” I see this repeatedly. It’s not just that the students don’t know much about pulmonary medicine – they don’t, but that is what they’re here to learn. It’s the alarming display of hubris that leads to their dismissal of the patients’ complaints. Is dismissing the patient as “anxious” a way of making up for a deficit in history taking and presentation? Within two sentences of the presentation, they state to me that they think the patient is “just anxious” because the complaints don’t make sense. The complaints don’t make sense to the students, because they don’t know enough medicine – nothing makes sense to them yet! Even the whole of modern medicine is far from understanding everything about the human body, and the most expert among us have learned that the more we learn, the more we learn how little we know. Such confidence and certainty, it seems, must be the purview of the inexperienced.
And yet, hubris is not limited to medical students. Many doctors suffer from it, perhaps we are selected for it. We are all, often, wrong. In fact, we so frequently misdiagnose our patients, that many diseases are characterized by delay of diagnosis for years. When we can’t make sense of our patients’ complaints, we have a tendency to blame the patient. At our expert level, if we can’t figure it out, it must not be “true,” and the fault must lie with the patient. The patient is anxious, obese, or deconditioned, or just plain crazy. Some collections of symptoms we fail to understand but have seen often enough that we have named chronic fatigue syndrome and reflex sympathetic dystrophy to name a couple. Even official sounding diseases like idiopathic juvenile arthritis just mean inflammation of the joints of young people of unknown cause, or idiopathic pulmonary fibrosis: scarring of the lungs of unknown cause. We have no idea what causes these diseases, sometimes we know that a medication helps because we’ve tried it with others before. People suffer and come to us in hope of better understanding, and the least we can do is take them seriously and really consider their complaints.
The month before I had seen a woman with a pneumothorax after surgery. She was obese, like so many other Americans, but she had been a college athlete, and after her procedure found herself short of breath simply walking up a flight of stairs. She kept calling her doctor and he and his staff kept telling her she was short of breath because she “wasn’t walking around enough after surgery,” or because she was obese. Finally they did a chest X-ray and diagnosed her pneumothorax as the cause of her shortness of breath. “They were very apologetic,” she told me, once they had made the diagnosis, not scolding as they had been before.
I’m also struck that often I get a full report of the patient’s ethnicity, race, and national origins, even as little is relayed about the patient’s complaints. Here, even more, I wonder whether the biases, conscious and subconscious, come to the fore as patients as dismissed, and I will continue to argue that we should leave race out of it. Unless I’m about to hear about suspicion for tuberculosis, it seems to me the details of the ethnicity of a minority Christian Armenian from Syria can stay out the first lines of the presentation. Indeed, telling me that “he’s from Syria, but says he’s actually Armenian,” conveys to me that the patient felt that the doctor was putting him into a box, and he felt the need to clarify that not all Syrians are the same. Indeed, the countries of the world have a significant cultural, ethnic, and religious diversity that is simply beyond the understanding of most medical providers.
How do we teach humility? Is it that the high-achieving students we select for during the admission process ensures that they believe they have never been wrong before? I don’t know. At the very least, we should expose medical students to patients who can describe meandering through years of misdiagnosis and dismissal until they were finally diagnosed. These patient stories should be presented as unknowns and students should be asked to come up with an assessment or a differential diagnosis. The story of how these patients went from provider to provider being dismissed as deconditioned, obese, or just plain crazy should be relayed.
“There but for the grace of god go I,” the students should think hearing about the other doctor’s misdiagnosis. I remember seeing a patient with Cushing’s disease, a disease of overproduction of cortisol, in endocrine clinic. He was a slightly overweight man, no one I would’ve picked out of a crowd in modern American society. “How did they figure it out?” I asked. He was diagnosed with diabetes and hypertension, he said. “They kept telling me to lose weight and exercise more,” he said. But his blood pressure and diabetes were still out of control. They, and his obesity, were driven by his excess cortisol, not his lifestyle. Finally, someone listened and sent a simple blood test.
Perhaps listening to these patients’ stories the students will begin to see what it’s like to be a patient. Perhaps next time they will think of the hubris of doctors adding insult to injury, until, finally, someone listened and made the diagnosis.