Wednesday, November 18, 2009

All Things Considered: "Story Specialists: Doctors Who Write"

NPR's All Things Considered had a story entitled "Story Specialists: Doctors Who Write." It features one of the internists here at Stanford, Abraham Verghese, who has been absolutely wonderful to work with when he does make the occasional foray into pre-clerkship curriculum (one of his priorities is the medicine clerkship). His first novel, My Own Country, dealt with his experiences practicing medicine in rural Tennessee as the AIDS crisis was emerging on the landscape. The story link has an excerpt from his most recent novel, Cutting For Stone.

Dr. Verghese discusses the link between stories and medicine:
"I think narrative is huge in medicine," Verghese says. He adds that if you listen carefully, you will hear clues needed to make a diagnosis: "It's very rare that some extra piece of knowledge in my brain solves the puzzle. Much more often it's the fact that the story I am hearing resonates with my collection of stories. Or there is an element in that story that reminds of something in my catalog of stories, and I go seek out the other element."

This "catalog of stories" is called "illness scripts", which are basically pattern recognition to figure out what is wrong with a patient based on their presentation. For example, say someone comes in with chest pain. A 60-year-old overweight male smoker who presents with chest pain is much more likely to get worked up for a MI than a 20-year-old female athlete who presents with chest pain. Is it possible that the 20-year-old female is having a heart attack? It's possible, but less likely than a bunch of other things (most common include musculoskeletal, psychogenic, or respiratory conditions). Illness scripts also allow you to ask more focused, specific questions to narrow down the options (you are "seek[ing] out the other element").

As the students gain more medical knowledge and expertise, they increase the number of illness scripts they have in their heads; otherwise, there's not really a good way to organize the staggering amount of information that they have to remember. We like to teach students to get the patient's story, but in the end they have to do something with it in order to help.

I forgot to mention that one of the downsides of illness scripts is that they are built by the physician's own clinical experience. When you are exposed to a wide variety of experiences, the illness scripts tend to be pretty solid. However, if you are exposed to unorthodox cases, the illness scripts tend not to be as general as they should be.

For example, if you are, say, working at a academic / research medical center, you may see rare cases of certain disorders. Take that 20-year-old female athlete with chest pain; let's say that she was sent home after observation but collapsed the next day from cardiac arrest, with the cause being hypertrophic cardiomyopathy (HOCM). If you are an experienced clinician with 25 years of medicine under your belt, you might be able to chalk that up to an anomaly. However, if you are a clerkship student, or even a resident, this may be such an impactful experience that for the next 10 years, any patient under 40 with chest pain you recommend an echocardiogram ($$) as part of their general workup. This is not an entirely bad decision, as it can prevent additional deaths from cardiac disorders; however, it is not a cost-efficient way to practice medicine, nor is it very fruitful in terms of outcomes, since HOCM is only present in 0.16 to 0.29% of the entire general population. And in cases where the diagnostic procedure from a faulty illness script is invasive, expensive, or difficult, the stakes are higher.

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