The setting: A boardroom. Many of us have sat in on meetings where a person of prominence, privilege, or prosperity floats up a program, a project, or a proposal that seems outrageous and outlandish. But because of the person's status, no one sitting around the table really challenges his or her proposal.
No one wants to raise their hand and criticize the presenter. No one wants to speak up and be called a wet blanket. No one wants to tell the Emperor he has no clothes on.
And, like a runaway locomotive, the project gets under way and then tanks.
The setting: a medical exam room. The patient is a middle-aged businessman with a complex cardiac situation. He had a heart attack in his thirties. He sees a local heart specialist who unravels the case and prescribes a well-established treatment regimen. But the patient does not do well.
No medical colleagues want to question the expertise of the cardiologist. But someone must.
The patient and the family then seek an opinion at a major medical center. The heart specialists there offer a different diagnosis and a different plan of management, which would have very little chance of benefit. This was the opinion of the advanced fellow in the department.
Another less-experienced cardiac trainee also comes on the scene and agrees with the first physician. The attending physician, the consultant, then weighs in and rather than taking his own personal history and rather than carefully examining the patient, the attending physician relies on the judgment of the two younger physicians.
With our computerized electronic health record, these notes are then pulled forward and are accepted as gospel by subsequent evaluators of the patient. This is an example of “group think,” where there is acceptance of the opinions without much forethought.
Ah, but bring on the experienced physician. The one with intuition and experience gained over years of treating similar patients.
The wise physician says, “Let’s start over.” My colleague Dr. Jerome Groopman has so wisely written about this approach in his many books. Set aside the medical records and address the patient directly.
The Art of Diagnosis
As I was coming up through the ranks in the medical realm, I had the privilege of working under some of the finest bedside clinicians in the world. This was in the era before the MR scan or the PET scan or other forms of sophisticated imaging. In most circumstances that physician deliberately met the patient, sat at the bedside, and took their own history and performed their own hands-on physical examination. This consultant was not swayed by the opinions of others or even the findings on the x-rays or lab reports.
I have seen circumstances where a complex patient was admitted to a hospital and the attending physician told the patient, “I have the records here. I have deliberately not reviewed them because I want to hear the story directly from you. I do not want to be prejudiced or biased by someone else's interpretation. So tell me why you are here.”
I have another patient who saw a cancer specialist who said, “I don’t trust the information in your medical record. Tell me about the reason you saw Dr. X. What was the outcome of the surgery you had in 2015? What medications are you actually taking? I want to hear your story.”
In the boardroom, failure means loss of confidence by the board of directors, a dip in stock price, a merger or bankruptcy.
In the medical exam room, the stakes are much higher. Failure means misdiagnosis, the wrong treatment, and a spiraling of the patient, even death.
There is no substitute for that face-to-face, knee-to-knee, hands-on examination of the patient without the group think opinion or the words in the medical records when there is a unique or difficult health issue.
There is no substitute for due diligence. Patients should not accept anything less.
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