Every Patient Tells A Story Part 7

The patient's story of slowly worsening shortness of breath with any exertion combined with the clear evidence of this kind of overflow had the doctors at Necker convinced that the young farmer had heart failure. Laennec disagreed. He looked at the barrel chest of the farmer-and pictured the hyperinflated lungs he'd seen in cadavers with emphysema. He thumped the chest and heard it resonate-which suggested the lungs were filled with air-and yet noted that when he listened with his stethoscope, very little air could be heard moving in or out when the man breathed. Based on this, Laennec predicted that at autopsy the man would have a disease of the lungs, not of the heart.

They didn't have to wait long to find out. The farmer first came to Necker Hospital in May; he died just five months later-not of heart or lung disease but of smallpox. The autopsy showed, just as Laennec predicted, a normal heart. In the lungs, however, the delicate membra.n.a.l lacework of the air exchange tissue had been ripped away, leaving large empty holes through-out-the now cla.s.sic finding of emphysema.

One of the heart sounds first described and understood by Laennec was mitral stenosis-a pathological narrowing of one of the valves of the heart. He tells the story of a strapping young man, Louis Ponsard, sixteen years old, a gardener, who came to Laennec's hospital complaining of "oppression and palpitations." He was a short man, muscular, and according to Laennec, "having all the appearance of splendid health." Ponsard told the young doctor that two years earlier he "was occupied in carrying some soil on a wheelbarrow. He was forcibly stopped in the midst of his work by a violent beating of the heart, accompanied by oppression, spitting of blood and nasal hemorrhage, coming on without any preceding discomfort." The symptoms resolved later that day, Laennec writes, "but they reappeared each time the patient attempted to take the slightest bit of exercise."

When Laennec examined the patient, he noted a subtle vibration of the chest, what's called a thrill, between beats. This was accompanied by a murmur that Laennec describes as a "sound [like that] produced by a file rubbing on wood." Based on these signs and symptoms Laennec postulated that the young man suffered from "ossification of the mitral valve," what we now call mitral valve stenosis, or narrowing. When blood leaves the lungs, it pa.s.ses through the mitral valve to enter the left ventricle on its way out into the body. In this disease, that pa.s.sageway becomes narrowed and rigid. When there is a need for greater blood-during exertion-the normal valve is able to open wider to let the excess blood through. In this young man the valve was rigid, bonelike, and so couldn't expand to allow the greater quant.i.ty of blood through.

Understanding the problem this way allowed Laennec to treat the disease. If the problem was too much blood to make it through the narrowed valve, the available solution was to reduce the amount of blood. The young gardener was bled several times with a dramatic improvement in his symptoms.

This was probably one of the very few diseases for which the commonly applied treatment of bleeding may have been effective. Of course, the treatment is only temporary. The young gardener had to return to Necker several times over the next several years to be bled. And ultimately he had to change jobs. He became the servant of a priest, and with this reduced workload his symptoms became much more manageable. Laennec never heard from him again. Perhaps he lived happily ever after, but given what we know about mitral stenosis now, it's unlikely that he survived many years after his initial visits to Necker.

I learned about mitral stenosis the way I've learned so much of medicine-from my own mistakes. In fact, Laennec's discovery is what brought me to that makeshift cla.s.sroom at the American College of Physicians conference. Like the dozen or so other doctors, I was there because I suddenly understood that despite years of training and practice, I still didn't know how to perform an adequate examination of the heart. Just like the doctors in the studies I'd read, I couldn't recognize some of the most basic abnormalities of the heart. I owe that discovery to Susan Sukhoo.

Susan was a slender woman of Indian extraction who'd been born and raised in Guyana, then immigrated to Miami with her husband some twenty years ago. She became my patient when she moved to Connecticut to live near her sisters after finding out that her husband was supporting a mistress. She was fifty-eight, had a little hypertension that was well controlled on a single medication, and many of our early visits focused on the consequences of her grief and depression.

Then she developed asthma.

She came to my office one frigid December morning looking her usual self-dressed simply but with a quiet elegance in tidy jeans, colorful T-shirt, and blazer. A single strand of pearls hugged the contours of her clavicles, showing off a youthful neck. Her hair was swept up in a simple knot at the back of her head, its smooth darkness only beginning to show traces of white. She smiled shyly at me as I entered the room and greeted her. "I'm wheezeling," she told me in the lilting inflections of her Guyanese-Indian accent. I wasn't exactly sure what she meant. "When I walk, especially when it's cold out, I start wheezeling," she explained, and then, like a caller on the radio show Car Talk Car Talk, she began imitating the musical sound she heard when she breathed. She was wheezing.

The "wheezeling" sometimes woke her up at night and she would have to sit up. A couple of nights she ended up sleeping in a chair because she felt like she couldn't breathe lying down. She had no chest pain, but sometimes felt chest tightness when she took a deep breath. These episodes lasted only a few minutes. After they resolved, she told me, she felt fine. She had recently had an upper respiratory tract infection and with further questioning thought the wheeze might have started when she was sick.

On exam, her blood pressure was normal. The amount of oxygen in her blood was fine. But there were diffuse wheezes throughout both lung fields. The breath came in with the normal whoosh of air flowing through a tube. But when exhaling, her chest was filled with a variety of musical sounds. This cacophony of different pitches and durations sounded like an orchestra of plastic horns warming up before a performance. Otherwise her exam was unremarkable.

Wheezing is caused by a transient constriction of the airways. Asthma is the most common cause of wheezing but it would be unusual for a woman this age with no history of this disease to suddenly develop it. Some infections can cause the airways of the lungs to overreact to sudden changes in air temperature or flow and that can cause wheezing-especially when you go from the warmth of a well-heated room into the frigid winter air or take a sudden deep breath. I gave her an inhaler to dampen the overreacting airways and a.s.sured her that it probably wouldn't last long. Wheezing and cough are common symptoms after a cold and usually resolve after a month or so. She'd had her cold several weeks earlier so I figured she must be on the tail end of the thing.

When I saw her next, a couple of months later, I asked her about the wheezing. Oh yes, she told me, "the wheezeling was there every day." She took a deep breath and let it out slowly. I could hear the wheeze from across the room. The inhaler was helpful, she added, and she used it almost every day. I wasn't sure what to make of this. We learn in medical school that "all that wheezes isn't asthma," but what then? Was this emphysema? She had never smoked, but her husband had. Could this be a so-called cardiac wheeze, where a weak heart can't pump all the blood that comes into it and so fluid gets backed up into the lungs, causing the wheeze? She hadn't had any chest pain, and her only risk factor for a heart attack (which can give you a weak heart) was her high blood pressure, and that had always been well controlled. She was from an area where TB was common-could this be an unusual manifestation of tuberculosis?

I got an EKG, which was normal. Rea.s.sured that she hadn't had a hidden heart attack, I also tested her for tuberculosis. In addition, I ordered some tests to do over the next couple of weeks to try to identify the cause of the wheeze. Pulmonary function tests would help distinguish asthma from emphysema or heart disease. All the other possible causes seemed far too unlikely in this extremely healthy woman. I also gave her another inhaler, this one containing steroids to reduce the frequency of what I still a.s.sumed was an atypical asthma.

She returned to the office a month later. "Did anyone call to tell you I was in the hospital?" she asked. I'd heard nothing about it. It is a chronic problem in the community where I work. When a patient goes to the hospital-especially the other hospital in town-the doctor is often the last to know.

It happened in the middle of the night, she told me. She'd woken up drenched in sweat and gasping for air. A cough emerged from deep inside her chest. Her heart pounded so hard she felt the bed move with every beat. The chest tightness she'd felt when she'd first described her wheezing was back and much worse than it had ever been. She struggled to the phone-any exertion made her chest squeeze even tighter. She cried when she heard the siren, so grateful that help was close. In the ambulance and in the ER she'd been given albuterol, a medicine that relieves wheezing for patients with asthma. Normally it helped but that night it didn't seem to do anything.

An EKG showed she wasn't having a heart attack. A chest X-ray showed fluid in her lungs and they gave her a shot of something they told her was a medicine to help her pee out the extra fluid. Within an hour of getting that shot she started to feel better.

She stayed in the hospital for three days as her doctors tried to figure out why she had the fluid in her lungs. Dr. Eric Holmboe, an internist on the teaching faculty, had diagnosed her on examination. His residents had called to tell him about the fifty-eight-year-old woman with poorly controlled, newly diagnosed asthma, and even before he saw her he was creating a list of diseases that could cause an asthma-like presentation. Whatever it was, he told me, he would have laid out money that it wasn't asthma.

When he listened to her heart, he heard the murmur Laennec had described. It was a quiet sound and could easily have been overlooked in a noisy emergency room. He could really only hear it when the patient lay on her left side so that the mitral valve was closer to the surface of the chest. And yet when he heard it, he knew she had mitral stenosis.

An ultrasound of her heart confirmed his diagnosis. The blood that would normally travel through that opening, to fill up the left ventricle-the main pumping chamber of the heart-couldn't get through the now tiny orifice. The opening, normally the size of a half dollar, had shrunk down so that it was smaller than a dime. The circulating blood couldn't all get through and so it backed up, flooding the lungs with fluid. "The doctor in the hospital asked me if I had ever had rheumatic fever as a kid," Susan told me, "and I told him everybody in my family had it. But I hadn't thought about it for years and years."

Rheumatic fever is an inflammatory complication of strep infection-often strep throat. Most often joints are the target. Days to weeks after an untreated case of strep throat, the patient will develop hot, swollen, and painful joints. It can be a single joint, multiple joints, or most strangely of all the inflammation can travel from one joint to another. The same inflammatory process can attack the heart as well. It is frequently undetected because it doesn't cause any symptoms-not for years.

In Susan's case the damage done as a child had slowly eaten away at her valve and by the time she developed "asthma" the valve was nearly completely closed. She was scheduled to get a new mitral valve in a month, she told me that day.

Mitral stenosis-why hadn't I heard any evidence of this significant lesion during her heart exam? I placed my stethoscope on her chest, starting, as I had been taught, on the right, and worked my way to the left side of the sternum, then down to the middle of the rib cage, and then left again toward the edge. The lower left aspect of the chest is where this particular murmur is usually heard; it then travels to the far left side of the body. When I reached the lower left position I listened intently. I could barely hear-something. I had her lean forward, so that the heart would swing out, a little closer to the chest wall. There it was-a soft, low-pitched sound that came between heartbeats in diastole, rumbly and harsh and very, very quiet. I listened near the edge of the chest. I heard it there too. Now.

In my earlier exams I had completely missed this. I checked my previous notes-no mention of a murmur. It was a quiet sound and I hadn't done the kind of thorough exam I had been taught to do, so I hadn't heard it. I finished up my visit; I told her to let me know when she was to go into the hospital and I'd come visit her there.

Ultimately Susan's problem was resolved at the source. The tiny opening was widened. She had her scarred mitral valve removed and a metallic valve was inserted. Her heart was as good as new.

At home the night after I heard about Susan's diagnosis, and for many nights thereafter, I thought about this missed diagnosis. All those months of "wheezeling" and shortness of breath and I'd been treating her as if she had asthma. She was getting worse right in front of my eyes as the aperture of the mitral valve approached a critical stage. It distressed me to know I could have figured it out too, if only I had done a proper exam. How many other diagnoses have I missed because of an inadequate examination of the heart? And I'm not alone. How many diagnoses have we all missed, because most of us don't have a clue about an adequate heart exam?

Putting the Ear to the Test But what if it's not our fault? If so few doctors can make this kind of diagnosis, maybe it's not possible. Just how good is the heart exam at picking up these defects anyway? As practiced now, we know that it isn't very good at all. Few of the doctors in practice and in training are able to use the heart exam to make a correct diagnosis. We've come instead to depend on technology to make this diagnosis for us.

Echocardiography has been shown to be accurate in diagnosing many of the same diseases that the cardiac exam used to be good for. Small wonder then that the number of echocardiograms has increased so dramatically. The number of echos ordered almost doubled over a seven-year period-growing from 11 million a year in 1996 to 21 million a year in 2003. In one large multispecialty group in Boston the number of echos increased over 10 percent over one year alone, with 9 percent of all patients seen in the practice getting one. Is it simply that we no longer have any faith in our own ability to perform the exam, or is the exam fundamentally flawed and ready to be thrown over? Actually, studies show that the cardiac exam can be pretty darn good when done properly. In one study, five cardiologists were pitted against echocardiography in fifty-two patients with known valvular heart disease-one of the most difficult and important diagnoses we make when we examine the heart. The cardiologists had to correctly identify which of the four valves of the heart was affected and estimate the degree of damage. Each patient was also evaluated by echocardiography. How did the cardiologist do?

As in so many of these contests, the machine won. The echo was correct 95 to 100 percent of the time. Yet the doctors put up a good fight. Their diagnoses were right between 70 and 90 percent of the time. Other studies have shown similar results. That's certainly much better than the current crop of physicians if you believe Mangione's studies. The question is-is it good enough? Doctors and patients alike would probably say no. The ear and the stethoscope cannot replace the echo for locating the source of an abnormal heart sound when it's important.

But here's the thing: not all abnormal heart sounds are important. Up to 50 percent of people who have a heart murmur-the most common abnormal heart sound-have completely normal hearts. These patients don't need additional testing. What we really need are doctors who are able to reliably distinguish between those who need more testing and those for whom further testing is simply a waste of their time and money. How well do we do here, where it really counts? Can we distinguish between those murmurs that need further evaluation and those that are benign or innocent? Cardiologists can. In a study done by Christine Attenhofer of the University Hospital in Zurich, cardiologists correctly identified ninety-eight out of one hundred pathologic heart sounds. Can primary care docs match that? Somewhat surprisingly, there's very little research done addressing this important question. One study done of emergency room physicians suggests that they can-though not as well as the subspecialists. In this study, two hundred patients with heart murmurs were evaluated by an ER physician. The physician took a history, examined the patient, and got a chest X-ray and an EKG. He then doc.u.mented-in writing-whether the patient needed further evaluation or had an innocent murmur. After this evaluation all patients had echos. Of the two hundred patients, 65 percent had normal echocardiograms and thus innocent murmurs. These ER doctors were able to identify those who didn't need additional studies nine times out of ten, erring mostly in sending too many patients with a normal heart for further evaluation. But they missed fourteen of the patients who had abnormal hearts.

Can we get better? Several studies have been done evaluating programs designed to better teach the cardiac exam. Not surprisingly, all showed that if you teach these doctors-in-training, they will learn. One course used recorded sounds that partic.i.p.ants were required to listen to five hundred times. Their test scores increased fourfold-from the downright pathetic 20 percent correct to a respectable 85 percent correct. Other studies had students examine actual patients who had a variety of heart murmurs. These doctors doubled their test scores. So it is a skill that can be learned. We have the tools we need to bring back a reasonable, workable version of the heart exam. The question is, will we do it?

Carol Pfeiffer is a tall, slender brunette with a husky voice and a warm smile. She is sitting at the head of a table in a small conference room crammed with a half dozen second-year medical students dressed in their short white coats. A few of the students sit; the others move restlessly around the room. They chat nervously as they wait. Tension fills the air like a bad smell. The students are there to take their end-of-the-year final but there are no blue books, no number 2 pencils, no desks. This exam consists of a half dozen simulated patient encounters.

The patients these students will be seeing are actually actors who have been trained to depict one or more of the 320 medical conditions on which the students will be tested. Carol is the head of the Medical Skills a.s.sessment Program at the University of Connecticut. She explains the test to the anxious students, even though these guys are old hands at this-they took a similar test at the end of their first year and have learned from these patient-instructors throughout their first two years.

The test is set up to simulate an outpatient doctor's practice. The students will visit the six rooms in the order given on each one's schedule. Outside the door there is a little card listing the patient's chief complaint. When the bell rings the students will enter the rooms and begin collecting the essential information on each patient. They will get the patient's history, perform a physical exam, explain to the patient what they think is going on. Once they leave the room they will write a brief medical note on the patient.

The rooms are equipped with the usual doctor's office stuff-a small table with a couple of chairs, an exam table, a blood pressure cuff, and thermometer-plus some equipment not usually found in an office-a small camera and a microphone. The entire encounter will be videotaped and the students and their teacher will review it after the test. After reminding the students about how the test works, Carol asks for questions. When there are none she sends them to the corridor around the corner, to find the room with their first patient.

I follow Pfeiffer into what looks like the control room of a TV studio. It's dominated by a wall of small black-and-white monitors. I don a set of headphones and plug in to watch one of the encounters. Most of the scenarios require the student to recognize a common illness and recommend the appropriate study or treatment. In one room there's a young man complaining of shortness of breath-his history reveals that he has had an accidental exposure at work to toxic chemicals. Diagnosis: asthma due to occupational exposure. In another room a fifty-something-year-old man complains of chest pain with any exertion for the past day. Diagnosis: likely unstable angina. Some need a diagnosis and counseling: a worried mom brings in her daughter, who has a cold and ear pain. She wants antibiotics for her little girl. The student's job is to explain why antibiotics are not appropriate. A young woman complaining of trouble sleeping is found to have a pattern of binge drinking, putting her at risk for alcohol-related disease and disability. The student's job in this case is to counsel the woman about the risks from her behaviour.

After checking in on a few of the rooms, I settle in to watch a young man who is speaking with a heavyset patient with graying hair. The student introduces himself and washes his hands as he's been taught. He sits and asks the man what brought him in. It's his stomach, the man tells Chris, the young doctor-to-be. Every now and then he gets this pain that comes on an hour or so after he eats. It doesn't happen all the time but a couple of nights before it woke him up from sleep and he almost went to the emergency room but decided to come in to get it checked out instead. The pain was severe and constant, lasting several hours. That time he thought he had a fever as well. Sometimes he has diarrhea when he has the pain.

As the student asks questions, more details come out. He sometimes takes an antacid for the pain but it doesn't seem to do any good. The pain seems more common after a meal of fatty foods. The other night he'd had fried chicken. The pain seems to be mostly on his right side and doesn't worsen when he lies down; he's never noticed black or tarry stools, which would suggest a bleeding ulcer. The student gets the rest of the patient's history. He has high blood pressure and takes two medications for that; he's married, works in an office, doesn't drink or smoke. He's been on a health kick lately and lost twenty pounds over the past couple of months. The fried chicken was a little treat to celebrate his success.

Now it's time for the exam. The student, a beefy young man with light brown hair and an open pleasant face, asks the man to move to the exam table. The exam is perfectly normal until he gets to the abdomen. Chris presses gingerly on the right side, just below the rib cage. The man grunts in (mock) pain. He asks the patient to take a deep breath and as he's inhaling the student pushes briskly in the same area. The man grunts again. Chris tells the middle-aged man that he thinks maybe he has a gallstone and that the pain is caused when the stone blocks the duct leading out of the gallbladder. He'll need to get some tests before he can confirm that diagnosis, he concludes somewhat vaguely. The student shakes the man's hand again and steps out of the room.

I watch on the monitor as the "patient" opens a drawer and removes a form and a pen. He quickly moves through the yes/no answers by which he evaluates the student. Yes he introduced himself, and yes he washed his hands. No he didn't always use simple language. Yes he examined the abdomen. Yes he listened for the presence of bowel sounds and pressed on the right upper quadrant.

Suddenly there's another knock on the door and Chris walks back into the room. I forgot to do a rectal, he tells the surprised patient. Invasive exams such as this are not actually performed in these tests. Instead the student tells the patient he would like to do one and the patient gives him a card with the results of the exam written on it. But not this time. "It's too late for you to ask for that," the patient tells him. "You're out of here."

After Chris finishes up his note, he returns once more to the patient's room. The patient reviews how the student did in the encounter. He notes that Chris opened the encounter well but stumbled as he was asking questions about the pain. "Don't worry about making sure you ask every single question on the list," he tells the student. "You know this material. Let your instincts tell you where to go with your questions." And another point. "Be sensitive to the patient. Once you have figured out where the pain is, don't keep pressing on the spot."

After the test I sought out Chris as he was collecting his backpack from the conference room. The room was filled again but the difference was immediately apparent. The med students were laughing and talking about the mistakes they made. There was the giddiness of pressure relieved. "The hardest thing is that you can't write anything down while you're in with the patient," Chris tells me. "You have to hold it all in your head. You know I kind of dread these exams but we all know we need it." He's planning to go into surgery, but, he quickly adds, that doesn't mean he doesn't need to know how to do all this. "Surgeons see patients at the office too."

Certainly there is some pretty good evidence that these skills will come in handy no matter what area of patient care a doctor goes into. But these students will need to know the clinical exam well before they go into whatever specialty they have planned. At the end of their four years of medical school each of these students will be tested on these very same skills in the very same way.

Starting in 2004, all medical students have been required to pa.s.s an exam that tests their clinical skills: their ability to take a history, perform an appropriate physical exam, and collect the data needed to diagnose and treat a patient. The United States Medical Licensing Examination-known as the USMLE-is the test physicians must pa.s.s to get licensed in most states. When I took the exam it was made up of just two parts. The first, given at the end of my second year of med school, tested knowledge of the basic sciences of medicine-anatomy, physiology, pharmacology, genetics. The second part of the test was given after graduation and focused on the understanding of basic patient care concepts-could I interpret the patient data that was provided? Was I able to formulate an appropriate differential diagnosis? What studies should be ordered based on what was known? Which medicines would be appropriate in the given setting? Which would be dangerous and must be avoided? Students must still prove their mastery of the book knowledge of medicine, but now, in addition, they will have to demonstrate their skill with patients as well.

In adding this component to competency testing, the USMLE is hearkening back to an older model. As early as 1916 the licensing exam included an evaluation of a real patient, observed by an experienced physician-grader. After taking a history and performing a physical exam, the students were questioned about what they found. This component was dropped in 1964 because of the lack of standardization intrinsic to this kind of test.

But twenty years later the licensing board was asked to design a new test of these skills that would be reliable. The National Board of Medical Examiners, which oversees the USMLE, spent another twenty years trying to develop a system for testing these skills that was fair and reproducible. The medical school cla.s.s of 2005 was the first to have to jump through this additional hoop.

Medical schools didn't exactly embrace this new test with open arms. The American Medical a.s.sociation (AMA) was against it. So was their student branch as well as the student arm of the American Academy of Family Physicians. Opponents argued that most medical students already learn this stuff; and most inst.i.tutions already test it, so what's the point of repeating this testing? To the students it seemed like just one more expensive test-they have to pay to travel to one of a dozen centers across the country, and the test itself cost over $1,000. But ultimately everyone takes it because that's what you need to do to become a doctor.

Has it done any good? It's still too early to tell if the test has made any real difference in what doctors do, yet if my own inst.i.tution is any example, then I suspect it's having a tremendous impact on how doctors are trained-at least in medical school.

Eric Holmboe now heads the department that evaluates medical residents at the American Board of Internal Medicine (ABIM), the organization that accredits doctors specializing in internal medicine. Until 2004 he was a.s.sociate program director of the Primary Care Internal Medicine Residency Program at Yale. (That's when he saw my patient Susan Sukhoo.) At a recent meeting of directors of clinical teaching from medical schools in the Northeast, Holmboe described Yale's preparation for the clinical skills exam part of the USMLE. The faculty had arranged for all of the fourth-year medical students to go to the University of Connecticut in Farmington, where they could take the kind of test that Chris took as preparation for the real thing.

Before the test several of the Yale faculty traveled to northwest Connecticut to check out the facilities and the test. They chose seven clinical scenarios, giving them a few tweaks until everybody was comfortable with the setup. And students from Yale traveled up in groups of six to take the test over the course of several weeks.

When the scores came back, the faculty was shocked. Twenty percent of these fourth-year Yale medical students-seventeen out of eighty-five test takers-had flunked the test. Eric described the reaction when he presented the scores to the faculty. "It was G.o.d-awful-the grief reaction in spades," Eric told me. "Kubler-Ross was hovering over the room," referring to the anthropologist's famous stages of grief. "It was anger, denial, and bargaining all rolled up in one." There were concerns about the test-even though they had signed off on it before the students had gone up-and there was plenty of skepticism-this could not represent the real performance of fourth-year Yale medical students. But amid grumbling and skepticism, everyone agreed to view the tapes of the students who failed.

When they met again, four weeks later, att.i.tudes had changed. "The anger and denial had evolved into deep, deep depression," Eric reported. In one tape, a Yale medical student who was planning to go into neurology completely botched the cardiac exam. He was listening for heart sounds in all the wrong places. When he was given this feedback by the patient-instructor, the student's response was breathtaking in its arrogance and ignorance: he didn't need to know the heart exam-he was going into neurology. Stroke, the most common neurological disease, is often caused by problems originating in the heart. "When he said that," continued Eric, "it pretty much cinched the deal and suddenly it was Houston, we've got a problem."

In response, Yale revamped the way the physical exam was taught. When I was a student, the physical exam was taught at the end of the second year, just before we began our clinical clerkships that took us into the hospital wards. It was a twelve-week course with lectures a couple of times a week. During the lecture the physiology of the organ system was briefly reviewed and the exam technique was explained and sometimes (but not usually) demonstrated. Essentially I learned about the physical exam the way I learned about s.e.x and menstruation-I got a brief, very nonspecific chat and a book. And did I have any questions? No. Great. The end. All the real info I was left to gather on my own. I figured it out at p.u.b.erty and I figured it out again in medical school. Essentially I spent hours roaming the halls of the hospital looking for medical students already doing their clerkships to ask them to show me interesting physical exam findings. Like everyone I knew, I learned what I knew about the physical exam on my own, with a patient, a book, and the help and "wisdom" of a student just one or two years ahead of me.

Now Yale begins teaching their medical students from day one. In the very first year there are cla.s.ses on the techniques of interviewing and examination. Students meet in small groups weekly to review and practice these techniques for the first two years of school-first on each other, then on patients in offices and in the hospital. By the time medical students enter the hospital in their third year, they have the basics of these key data-collecting tools down. They are ready to build on a sound foundation. Unfortunately, there is frequently no one there to help them start construction.

I graduated from medical school with a set of physical exam skills that was spotty and idiosyncratic, and may have been considered unacceptable-had the doctors I then worked with ever observed me. I wasn't worried, though. I figured I'd learn the proper way to examine a patient when I was a resident. I was wrong. Studies show that by the end of residency training a physician's skill may be no better than the skills he had as a medical student.

Some of this is undoubtedly due to the time and access constraints already discussed. But some of this is due to an underlying att.i.tude that the physical exam is already history. I accompanied Holmboe to a meeting with several directors from medical school and residency programs to discuss a new initiative to sh.o.r.e up the clinical skills of doctors in training launched by the American Board of Internal Medicine (ABIM). At this meeting Dr. Raquel Buranosky from the University of Pittsburgh voiced a common complaint. "Med students in our program get hours and hours of training in the physical exam in their first and second years. They do great at our final exam. Then they go into their clinical clerkships and, poof, it's gone." There was general head nodding around the room and many of the directors told similar stories. Eric added one of his own. A colleague had worked with a medical student several times and been happy with his skills. Several weeks into the student's first clinical rotation-an internal medicine clerkship-the young student returned to have one last cla.s.s with his teacher. The teacher watched him evaluate a patient and was horrified to see the student do absolutely everything wrong. He interrupted the patient's story, he asked closed-ended questions, he examined patients through their clothes. He skipped much of the exam. The teacher couldn't believe it. He asked the student what had happened since they last met. Oh, replied the student, "my resident says we don't have time to do all that. I mean, what's the point?"

Anyone who's been through training won't doubt the accuracy of this young man's story. In residency, it often seems that no one cares if the patient is examined or not. Small wonder that many of the finer points of the exam simply slip away. And once they're gone, it practically takes a miracle to get them back. And yet with a patient like Patty Donnally, these skills can unravel a mystery.

A Kink in the System Patty Donnally is a youthful-appearing fifty-eight-year-old woman who has had high blood pressure since she was a teen. And no matter how many medications she's taken-and she has taken many-it's never been well controlled. Her internist tried for years to tame it. He put her on every combination of medications he could think of. Her blood pressure came down-but was never normal. Not even close. Occasionally he wondered if she was even taking her medicines. But she came to all her appointments, was aggressive in following up, even read up on her problem. That wasn't the behavior of someone who didn't take her meds. And when asked, she could recite her most current medication regimen no matter how many times it had changed. No. It was clear-this lady took her medicines. But her blood pressure remained high. After almost a decade her internist gave up and referred her to a specialist in hypertension. The specialist was baffled too and eventually he referred her to the hypertension clinic at Yale.

At Yale she was seen by Dr. Bill Asch, a young enthusiastic hypertension fellow whose cheerful disposition often made her forget the frustrations of her apparently untreatable disease. His wit made the schlep to New Haven almost worth it. So she was disappointed and a little annoyed when a new doctor walked through the door.

"Where's my regular doctor?" she asked the young woman who entered the tidy exam room. A trace of annoyance colored her voice, and the lines between her brows deepened in the top half of a frown. Dr. Shin Ru Lin sighed inwardly. She had finished her residency training a few weeks before, and had just started at Yale's hypertension subspecialty training program. She was getting to know the patients she inherited from Asch, who was doing research this year and not seeing patients. Serious and shy, she'd been a little hurt by the disappointment expressed by more than a few of his patients when they found that she was now going to be their doctor.

And she was more than a little intimidated by this case in particular. Ms. Donnally was on six potent hypertension drugs, and yet, according to the nursing note on the front of the chart, her blood pressure was still too high. The patient had seen many doctors, had had scores of tests. The chart was inches thick, and still no one understood what was going on. Lin had only just begun her graduate fellowship in hypertension-how was she supposed to figure this out? What could she possibly have to offer?

"When were you first diagnosed with hypertension?" the doctor asked tentatively.

"I've had it forever-you know, it's all in my records." Patty waved toward the thick chart. "My blood pressure is too high, I'm always tired, and my legs hurt when I walk. Nothing changes-except my doctors."

In a specialty clinic like this one for hypertension at YaleNew Haven Hospital, patients have already been to several doctors, and often they are as frustrated as the physician who referred them. Each specialist, each series of tests, eliminates more of the likely causes of the problem, and the diagnostic question seems increasingly difficult to answer. And in an academic medical center, patients are often seen by trainees, like Lin, who change every year.

Lin was overwhelmed. Waiting outside the exam room as the patient undressed for the physical exam, she opened the thick chart. She knew it would take her hours to go through it properly and she still had several more patients to see. Lin scolded herself for not reviewing it more thoroughly before meeting her for this first visit. She quickly paged through it. High blood pressure-okay. Also high cholesterol. She took a medicine for that. She didn't smoke or drink. She carefully kept track of her blood pressure at home. Before the doctor could get much further, it was time to go back in.

On exam, the patient's blood pressure was-as expected-very high. But there were unexpected findings as well. As Lin listened to the patient's neck over the carotid arteries, she heard a soft rhythmic whooshing noise over the normally silent vessels. This sound, known as a bruit, is caused by an unnatural turbulence in the flow of blood. It often indicates a narrowing of the arteries caused by atherosclerosis, commonly referred to as a hardening of the arteries.

She moved her stethoscope down to the chest. She heard more unexpected noises. In between the lub and dup of the normal heartbeat there was a brief, harsh murmur-like the snarl of an angry animal. Was this a new symptom? She would have to check the chart. It was audible everywhere she placed her stethoscope on the left side of the chest, though it seemed loudest at the top. Atherosclerosis could affect the valves of the heart as well as the arteries. This raspy murmur suggested that the disease may have narrowed the patient's aortic valve, one of the four valves of the heart. Could that be driving her blood pressure up? It seemed unlikely.

Then, in the abdomen, she found yet another noise: a soft shush-shush over the renal arteries. As she completed the exam, Lin remembered the patient's other complaint and examined her legs and feet. They looked fine-no lesions, redness, or rashes-but she couldn't find a pulse at either ankle. Was this more evidence of hardened arteries diminishing blood flow to her feet? That could explain the pain in her legs.

Finally, she asked herself the question all doctors must ask at the end of a visit: what could she do for this patient today? She added yet another medicine for the high blood pressure. And she would need to check the patient's cholesterol. Even though she was on one cholesterol medication, if all this noise and the leg pain were from narrowing of the arteries, it would be essential to bring her cholesterol down as low as possible.

What about the heart murmur? Although Lin couldn't imagine how a narrowed valve could drive the patient's blood pressure up, she thought it made sense to be thorough in a case this elusive. An echocardiogram would show whether the noise was coming from an abnormal cardiac valve.

That evening Lin sat down with the patient's chart. Before figuring out what she could do to solve this puzzle, she needed to know what had already been done. The most striking feature in this patient's case was a remarkably high level of renin, a chemical made by the kidney to increase blood pressure. When the kidneys receive too little blood, they release this enzyme, which increases blood flow to the kidneys by increasing the pressure in the arterial system-the way you might get water to a distant flower bed by increasing the pressure in a garden hose. This woman produced one hundred times the normal amount of renin. No wonder her blood pressure was abnormal.

So what in the world could cause the kidney to produce so much renin? Most commonly that occurs when atherosclerotic disease, the thickening and hardening of the vessels of the body, blocks the arteries supplying the kidney with blood. Perhaps that was the problem, she thought triumphantly. No, she realized moments later. An earlier angiogram had showed there was nothing blocking the arteries that carried the blood from the aorta to the kidneys.

Could she have a renin-producing tumor? There have been cases of these types of tumors in the kidney. No, an MRI of the kidney hadn't shown any tumors. Adrenaline makes your renin go up. Could she have an adrenaline-producing tumor? That had already been ruled out too. As Lin closed the chart and packed up to leave, she worried that she would have nothing new to offer the patient when she returned.

The following week, Lin ran into the attending doctor with whom she had seen the patient. "Hey, Shin, did you see the results of the echo?" he asked, referring to the echocardiogram and br.i.m.m.i.n.g with excitement. "Do you know what it showed?" He paused dramatically. "Aortic coarctation." Lin felt her eyes widen. She had found the cause of the hypertension-but that disease hadn't even crossed her mind. It was a diagnosis made by accident.

The aorta is the large, muscular vessel that takes blood from the heart and delivers it to all the parts of the body. A normal aorta is about three centimeters wide, about the size of a half dollar. In coarctation, the aorta develops abnormally, and instead of being a wide-open tube, it has a kink, narrowing the tube and limiting the flow of blood. The kidneys weren't getting enough blood, just as Lin and the other doctors had suspected. They had looked for such a blockage, but in the wrong places. Instead of being next to the kidneys, it turned out it was just inches from the heart.

Once Lin confirmed the diagnosis with an MRI, the patient was referred to Dr. John Fahey, a cardiologist with experience in the delicate process of repairing the aorta. The day after her surgery, Ms. Donnally told me, she needed only one medication to control her blood pressure. It was, she said, a miracle. And the pain in her legs diminished. Like her kidneys, the muscles in her legs must have been starved for blood.

The Old/New Science of the Physical Exam Why hadn't Lin, or any of the patient's previous doctors, considered coarctation of the aorta? If you look at a list of causes of hard-to-treat hypertension, it's always on that list. And yet it had been missed. Certainly it's an unusual cause of hypertension in an adult-mostly because it's ordinarily picked up in childhood. It's the number one cause of high blood pressure in children but far down the list of causes of adult hypertension. And yet doctors often think of diseases that are just as unusual. High on Dr. Lin's differential diagnosis was a renin-producing tumor. An exceptionally rare disease. This patient had already been tested for this and other diseases even less common than coarctation.

Moreover, Donnally had all the cla.s.sic signs and symptoms. She had the murmur that was heard throughout her chest, neck, and abdomen. She had no pulses at all in her lower extremities and pain in her legs when walking. And of course she had high blood pressure. Yet it was still missed, not by one doctor, but by many. I spoke at length with Dr. Lin and Dr. Asch about why this diagnosis was missed. Both confessed that they hadn't done the one physical exam test that would have most strongly suggested this diagnosis: comparing the blood pressure in the arms to the blood pressure in the legs. Normally the blood pressure in the legs is the same or higher than that in the arms. But because of the narrowing of the aorta, patients with coarctation provide less blood to the lower half of the body than normal. And because there's less blood, the blood pressure taken in the legs would be lower rather than higher.

When they finally checked, indeed the blood pressure in this patient's legs was much lower than that found in her arms. Both Asch and Lin say they now do that exam routinely on patients with resistant hypertension. But they didn't do it then. Of course since both doctors were in training, they were supervised in their care of this patient. Dr. John Hayslett, a well-known researcher and hypertension expert, carefully reviewed the care given to each patient at Yale's hypertension clinic. His work has appeared in the most prestigious journals in medicine and his clinic at Yale is considered one of the best in the country. He never asked about this particular physical exam test. Says Asch, he probably a.s.sumed it had been done in the course of doing a thorough physical exam-if not by these fellows then by any of the dozen or so doctors who had already seen this patient.

Hayslett couldn't know whether this particular exam had been done because he hadn't seen these postgraduate fellows do the exam. The a.s.sumption is that by the time you get to this level of training, a.s.sessment of the basics-like the physical exam-is simply not necessary.

This is a common a.s.sumption, says Dr. Eric Holmboe. "We send a resident or medical student into a room with a patient, telling them to take a history and perform a physical exam. They come out and we ask them what they found. That's like sending a music student into a soundproof room with a piano and a piece of sheet music and asking them when they came out, So, how'd you do? It's crazy. How would they even know? You'd fire the music teacher who taught that way." Maybe at some point in the past there was no need to evaluate the basic data gathering-though Holmboe is not sure there has ever been a time when teachers could a.s.sume these basic skills were done well. "There's a tendency to think that back in some previous golden era things were better. I call that Nostalgialitis imperfecta Nostalgialitis imperfecta," he continued with a smile. "But there's plenty of evidence that there were significant inadequacies in the way doctors took a history and performed a physical exam starting as early as the 1970s."

Eric wants to change all that. An energetic man in his forties with a rangy build, broad smile, and loping gait, he greeted me enthusiastically when I appeared at one of his workshops taking place in Boston. Eric is in charge of developing programs to sh.o.r.e up the physical exam training in medical residency programs for the American Board of Internal Medicine. One of the princ.i.p.al ways he does that is by teaching teachers how to teach. His focus is to convince teachers to actually watch residents as they examine their patients and then teach them how to fix what they find. "The way I was taught the physical exam was just crazy," he told me. "No one ever watched me. How could they help me get better? I could count on one hand the number of times I was observed performing the most basic parts of my job."

When Eric finished his training in internal medicine at Yale, he returned to Bethesda Naval Hospital to complete his military service. His job was to teach residents who were training at the hospital. Fresh out of his own residency, Eric recalled his frustrations with the system and began observing residents on the job, as they evaluated the patients who'd come to the hospital or the clinic. At first the residents were anxious about his presence. No one had ever done this before. Some were worried that they were being singled out. Had Eric heard something that made him question their abilities? Over time, Eric was able to convince his residents that this was an important and useful practice for everyone in training-not just those with problems.

"It didn't take long before the trainees in our program began to welcome these observed encounters. I wouldn't say they begged for them, but they were happy to have me there and I think they found the feedback extremely useful." And, he continued, they needed it.

"I couldn't believe what these residents were doing. Examining people fully clothed. Listening to the heart and lungs through layers of clothing, placing the stethoscope in the wrong places. Poking, prodding, and thumping in places where it just won't tell them anything." And he found residents almost universally grateful when he showed them a better way of doing it. "The physical exam just becomes a much more useful tool when you use it correctly."

In a paper first promulgating the use of direct observation as a tool in evaluating residents, Eric wrote: "Direct observation of trainees is necessary to evaluate the process of data acquisition and care. A trainee's ability to take a complete history; perform an accurate, thorough physical examination; communicate effectively; and demonstrate appropriate interpersonal and professional behavior can best be measured through the direct sampling of these clinical skills." It seems obvious and yet it's been a remarkably hard sell-not just to residents but to training programs as well. It's time-consuming and many physicians are not comfortable enough with their own physical exam skills to feel competent to supervise the skills in someone else. And it simply wasn't the way things were done-traditionally.

That tradition is summed up in one phrase that I heard frequently in my own training: see one, do one, teach one. It's how residents have been taught to do procedures for decades. It also describes how many were taught the physical exam. A study published recently shows how inadequate this style of teaching is. A group of residents in nine teaching hospitals in England were asked to describe how they were taught to perform seven relatively simple procedures-from giving a shot to taking an EKG. They were also asked about their confidence in their own ability to perform this procedure the first time they did it. The same questionnaire was given to a group of nurses who traditionally get highly structured training in the performance of procedures. Over a third of doctors said they received no training at all before performing the procedure and nearly half said they felt unqualified when they first performed them. Nearly half performed these procedures unsupervised when they did it the first time. Doctors are often sent out into the wards to perform on their patients-with inadequate training, and sometimes no training at all-procedures that carry some, usually small, risk to the patient if done incorrectly. And yet we continue to allow medical students and residents to perform these procedures without adequate training. The same is true of the noninvasive clinical stuff-the taking of a history or the performing of a physical exam that doctors do where there is no risk of directly doing harm, only of missing something important.

So Eric has spent the past several years as a one-man sales force, traveling from training program to training program selling the idea that direct observation of residents in training is the right thing to do. He has developed a four-day course to teach the teachers how to observe. One of the problems, says Holmboe, is that since many doctors themselves were not given any formal training in these skills, most doctors haven't developed formal criteria of how to talk to a patient and how to examine a patient. If doctors aren't certain that they are doing it right, how can they know if a student is doing it right? As a teaching tool, Eric scripted and videotaped three clinical encounters where a resident was shown taking a history, performing the physical exam, and counseling the patient. He taped three versions of each of three scenarios: one of poor quality, one of moderate quality, one of high quality. Then he asked teachers to grade each encounter. The grades were all over the map. The encounters that were poor were given grades as high as the high-quality encounters. No one had a clue. This cla.s.s helps teachers develop criteria for each component of the clinical exam and teaches them to apply them when they watch a trainee. Teachers are also coached in how to provide feedback in a constructive and useful way.

There are over eight thousand residency programs in the United States, and Eric hopes to reach them all. How well does the program work? Certainly physicians who complete Eric's program say that they feel much more comfortable watching residents and giving feedback. Whether better teaching translates into better doctoring is still unknown. But Holmboe is traveling to as many as he can in a one-man effort to resuscitate the physical exam. And yet Eric remains hopeful. His optimism engenders a little of my own. Maybe he can do it after all.

CHAPTER EIGHT.

Testing Troubles.

Carol Ann DeVries felt like she was falling apart. A compact woman with a cheerful, round face and deep-set brown eyes, she had been healthy all her life. Then, just a few weeks after her fifty-ninth birthday, everything changed. Out of nowhere she got a rampant case of hives. A short course of prednisone cleared them up, but neither Carol Ann nor her internist could figure out where they'd come from.

Then, one Sat.u.r.day morning, a few days later, she awoke feeling achy and hot, her throat was sandpaper, and she had an odd red rash near the base of her spine. Was this more hives? Carol Ann had a doctor's appointment scheduled for the next week, but she felt too awful to wait. She drove herself to the emergency room of her local hospital.

The ER doctor took her temperature, looked at the rash, and briskly told her she had Lyme disease. "An antibiotic will clear it up," he said, scribbling the prescription. "One pill twice a day for two weeks," he told her, and he headed out the door. "Wait a second," Carol Ann called after him. "Aren't you even going to get a test to see if I have Lyme?"