Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis [Hardcover]

I've been reading a lot of non-fiction lately only because of what's become available from my library holds list. I enjoy the break from novels, though, and find that well-written books exploring the "real world" can be every bit as engaging. That's certainly the case with Lisa Sanders' first work. Dr. Sanders (Yale Med. Center) writes a fascinating monthly column for the New York Times magazine called "Diagnosis," in which she describes the process of diagnosing patients with strange, unpredictable and inexplicable symptoms. Every Patient Tells a Story details the role of the physical exam in medicine, describing how doctors are taught the process, how hi-tech tests are replacing looking, listening and touching and how many medical errors are made when doctors neglect to either perform an exam or run appropriate tests. The most interesting parts of the book are the specific case studies: everything from a patient who self-diagnoses her Rocky Mountain Spotted Fever to one who lives for two years thinking she has Chronic Lymes Disease only to finally be diagnosed with a rare form of arthritis. Ultimately, the book argues that medicine is an art. Doctors are human and, thus, fallible, which provides no great comfort but at least makes the reader more sensitive to the intricacies of diagnosis.

Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis
Lisa Sanders, M.D.
New York: Broadway Books, 2009, $29.95, 276 pgs.

Lisa Sanders' book is a riveting exploration of the most difficult and most
important thing that doctors do: diagnose the disease of a patient. As Sanders
explains through her book, diagnosis is not so much based on a scientific
formula as it is an art that takes many years to develop. Even experienced
physicians and specialists sometimes have a difficult time effectively and
accurately diagnosing patients. A patient's experience of being ill is also mired
with complexity and turbulence. And it is no wonder since the experience of
being ill is unique to each patient. The patient may have a really difficult time
to come to terms with his/her illness. When a patient becomes ill, life as (s)he
knew it is on hold. And this is really scary for most patients.

This is especially the case if patients become ill suddenly. Patients struggle
to come to terms with their illness. Doctors have a difficult time to sometimes
diagnose the disease effectively. Yet, never in the history of the medical
profession have doctors had the knowledge, and the skills that they have today
to effectively diagnose illness. And yet mistakes are made, diagnoses missed,
and symptoms or tests are sometimes misunderstood. In this high-tech world
of modern medicine, Sanders shows that knowledge, while essential, is not
sufficient to unravel the complexities of illness. She presents a look inside the
story that marks every illness. The diagnosis reveals the combination of
uncertainty and intrigue that doctors face when confronting patients who are
sick or dying.

In the process, Sanders shows with eloquent clarity the importance and
absolute necessity of getting the patient's story correctly, the challenges of the
physical exam, the pitfalls of doctor-to-doctor communication, the vagaries of
tests, and the near calamity of diagnostic errors. It is disturbing when a patient
suddenly dies right in front of a physician's eyes. Some doctors fear that they
missed a clue that could make a life or death difference. The diagnosis is
sometimes hidden and misunderstood. At the birth of medicine, the diagnosis
and the prognosis were the most effective tools a doctor brought to the patient's
bedside. The true cause of illness is often buried in the patient.

Effective therapy depends on an accurate diagnosis. The most complex and
important decision making will take place at the level of diagnosis. Often the
diagnosis is straightforward. But sometimes it isn't, and this is especially the
case when the symptoms are merely suggestive, the physical exam is
unrevealing, the tests are misleading, and the patients have complicated stories
or medical histories. Getting a patient's whole story is essential for diagnosis.
Yet it does take time. The mystery of a patient's illness is usually a wonderful
piece of detective work.

The physical examination is becoming a vanishing art with all the digital and
technological advances of medicine. It used to be a reliable tool for physicians
to understand and diagnose a patient. The patient's story and a careful
examination would often suggest a diagnosis. These days, doctors often skip the
physical exam altogether, shunting the patient directly to a diagnostic imaging
machine of some kind. Patients and physicians prefer the certainty of high-
technological testing devices to a low-tech, hands on examination by a
physician. The demise of the physical exam is a natural consequence of medical
progress. The sicker the patient is, the more likely it is for the physician to skip
the hands-on physical examination and opt for the highly technological imaging
machines. Yet over the years, there has been a growing sense that the physical
examination can make an important contribution to his/her ability to
understand the patient and disease.

The art of diagnosis can sometimes resemble the profiling of a patient's
physical symptoms of illness. At first glance, patients may think that the ideal
in diagnosis would be for a doctor to treat all of his/her patients identically,
regardless of gender, race, colour, age, and socioeconomic situation. But they
can't. Diseases do unfortunately discriminate on the basis of race, age, gender,
and status. Patients want doctors to be legitimately biassed in their thinking and
decision-making process when struggling to find a diagnosis. Doctors should
take into consideration any known associations that may help pin down an
illness. However, diagnoses can be missed when doctors apply false
generalizations or close off diagnostic possibilities just because they are less
likely in a certain group or population.

Sanders book shows that medical decision-making is a function of who the
patient is as much as what the patient has. Sanders' book will be important for
physicians, lay people, patients as well as for families of individuals who are
ill. I found Sanders book to be a penetrating and eye-opening book about
something that so many of us take for granted. Many non-medical factors
influence medical decisions and a patient's diagnosis. However, a diagnosis
does help to tell the final story in a life. Knowing how a patient died makes it
easier to remember how the patient lived. And this is usually a comfort to both
the patient, family, and physician when a patient is ill or dies.

Irene S. Roth