Every Patient Tells a Story (24 page)
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 documented—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 participants 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 Assessment 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.
