WWWWF: A Look at Wichita Falls on the Web

Snail's-pace narrative and meticulous details make for rough reading

Up until this point, "How Doctors Think" has been a fairly enjoyable, interesting read with a lot of cool insights and tips for patients and physicians alike.

Things seem to have ground to a halt by Chapter 8.

The detailed description of medical community life is there, as Groopman plunges into the world of radiology and the pitfalls of gestalt reasoning.

And the scary insights and sobering stats are also present.

One film of the sixty was of a patient who was missing his left clavicle. Presenting such a chest x-ray was meant to assess performance in noticing what was not on the film rather than merely searching for a positive finding -- an exercise that points out our natural preference for focusing on positive data and ignoring the negative, as James Lock emphasized. Remarkably, 60 percent of the radiologists failed to identify the missing clavicle.

But the narrative seems to have flown by the wayside. As he delves deeper and deeper into medical terminology and pschoanalysis behind the mistakes being made, the chapter just loses steam. You can only read about CT scans, anterior cruciate ligaments and "interobserer variability" so many times before you start to shut stuff out.

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Spurs Nation is rocking and rolling

Enjoy

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My attention is still somewhat distracted

Hopefully the distraction will be removed Thursday.

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Advice for patients and doctors

For patients, be an inquiring mind

Patients can help the doctor think by asking questions. If he mentions a possible complication from surgery, they can ask how often it happens. If he talks about pain and lingering discomfort from a procedure, they can ask how the pain compares with having a tooth pulled under Novocain, or some other unpleasant event. If he recommends a procedure, patients can ask why, what might be found, with what probability, and, importantly, how much difference it will make to find it. Some physicians will be uneasy, some even angry, when queried this way, because they may not have all the answers. Others will take the time and clearly respond to these simple, direct, reasonable questions. The kind of response illuminates how much the doctor really knows about your case, and how much still needs to be discovered.

For doctors, there's also a plethora of insights. For one, bedside manner counts.

Paradoxically, such confidence is bolstered, Light said, when a physician opens his mind to a patient and explains what he knows and what he doesn't know, what is firm about his findings and what is still unclear, which symptoms he can account for and which still demand explanation.

And

This was another message that Dr. Light believes surgeons should communicate to their patients, especially in advance of an operation. "The perfect is the enemy of the good," Light said. "Nothing that you do in surgery is perfect. Everything is a compromise." ...While you cannot predict a specific outcome for any particular patient, Light emphasized, you need to be candid and not paint too rosy a scenario.

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Surgery insights just one scary notion after another

Chapter 7 relates Dr. Groopman's problems in finding a hand surgeon to diagnose his problems after his hand began to ache and swell. After a while I just realized how often I wrote "Yeesh!" from being dumbfounded by the revelations. From the start, his ordeal seems ridiculous

Over the course of three years, the patient had consulted six hand surgeons and got four different opinions about what was wrong and what to do about it. I was that patient.

But the hits keep coming. For instance, with the makeup of our bodies

"Often we don't know what accounts for symptoms of pain in the hand, given that almost everyone has a hole in a bone if you look hard enough."

Or the necessity of operations.

Dr. B studied in detail every unusual shadow and shape on my x-rays and MRI scan. In addition to the cysts in the scaphoid and lunate bones, he noted a tiny cyst in the another bone, on the pinkie side of the wrist. The tendon that runs toward the pinkie also seemed to have slipped slightly out of position. Dr. B thought there was a hairline fracture in the scaphoid bone, not simply a cyst. He said that I needed three surgeries. ...

Dr. Terry Light said, of course, that to comment properly on Dr. B's opinion, he would hae had to examine me and view the MRI; but the idea of three surgeries to address every finding on the scan -- this gave Light pause. "That's the problem with MRI. It can show us way too much."

My favorite is the guy who just makes something up.

At each follow-up visit, I pressed Dr. A for answers. He would just shrug. Then, a year after I first consulted him, he said, "I think you have developed a hyperactive synovium." The synovium, the lining of the joints around the wrist and hand, Dr. A explained, had become too sensitive to endure even minor stresses. It overreacted by becoming inflamed. He suggested a surgical procedure to strip away all of it. ...

I am not a specialist in diseases of the ones and joints, and I'd never heard of a "hyperactive synovium." Niether had Dr. Light: he said that the diagnosis "didn't register. It doesn't really mean anything to me.

Dr. A had come to the end of his thinking. But instead of returning to the honesty of "I really don't know," he invented something to respond to my plaintive questioning and suggested an operation that could be damaging.

The remedy is to get someone else in the room to bounce ideas off of. Groopman took his wife.

Pam had been quiet, communicating through glances with me. As I read the paper, she began to question the resident, politely but pointedly. She wanted to know how long the procedure took, what the likelihood of each complication was -- not just a list of possible complications -- and how long it took to recover.

All of it made me come up with a new company idea: Medical Buddies. Get a group of retired nurses, nurses assistants, etc., and hire them on a contract basis to just accompany folks on visits to the doctor when they think something serious is in the offing. That way, a lot of the questions a medical professional might have can be used to benefit a patient.

The alternative -- i.e., the here and now -- is just frightening to contemplate.

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Just because the doc's a specialist doesn't mean immunity from bias

Chapter 6 shines the spotlight on how specialists can also run into problems. The chapter has some good stuff but also runs into issues of complex writing.

For instance, Groopman is once again does a good job of delving into medical behind-the-scenes to stop you cold.

"Most of what we do in pediatric cardiology, we make up. In fact, a fraction of what is routinely done today in my specialty, I made up," Lock said with a grin. That is because children often have such unique problems with their hearts that there is little precedent. But, Lock continued, "you simply have to do something. The big problem is that most people assume that once it's made up, it's actually real. Especially the people who make it up themselves. Then they think it came straight from God."

And this little tidbit

One of the most common congenital abnormalities of the heart is a hole between the two upper chambers, between the right atrium and the left atrium. Since the pressure in the left side of the heart is higher than in the right, blood will flow from the left atrium through the hole into the right atrium.This aberrant blood flow is called a shunt and can overload the right side of the heart, leading to heart failure and other complications. Lock told me that doctors send children for surgery to close these holes if there is a two-to-one shunt, meaning that twice as much blood flows through the right side of the heart than the left.

"Do you know where that two-to-one number came from?" Lock asked. I imagined it was from careful clinical studies of children with the hole. "You would think so. But you'd be wrong. At a medical meeting in the 1960s, a pediatrician presented the question 'When should the hole be closed?' to a group of cardiologists. There was a heated debate about how much shunting required a surgical fix. So the meeting organizers, out of desperation, took a vote. Some voted for a lower number, some for a higher number. The median ended up being two-to-one. ... Children can have two-to-one shunt and still have a good chance of being healthy and never needing any specific treatment. Many children with two-to-one shunts undergo surgery and probably don't need the operation."

But sometimes things just get to cluttered with clinical terms and too-technical explainations

Lock took a blank sheet of paper and began to rapidly sketch the outlines of the heart, its chambers and valves. There was a disorder called "common AV canal," he said, where the wall between the left and right sides of the heart does not fully form. This most often occurs in children with Down yndrome. "The central part of the heart is missing, and this can include the lower wall between the atria, part of the mitral valve and part of the tricuspid valve, and the upper wall between the ventricles -- all don't form." Some of these children also have aortic stenosis, Lock explained, meaning partial closure of the aortic valve, or co-arctation of the aorta, meaning that the large vessel is narrowed "When this happens, the left ventricle can be very small."

What it boils down to is making sure you consult as many specialists as possible to overcome their tendencies to overvalue their treatments while dismissing others. Not a bad idea, just one that gets hard to see through some of the writing.

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Wow

Taking a little time getting my blog up.

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Good advice for physicians

About seeing the big picture

Physicians should caution themselves to be not so ready to match a patient's symptoms and clinical findings against their mental templates or clinical prototypes. This is no easy. In medical school, and later during residency training, the emphasis is on learning the typical picture of a certain disorder, whether it is a peptic ulcer or a migraine or a kidney stone. Seemingly unusual or atypical presentations often get short shrift ... Another echoing maxim on rounds: "When you hear hoofbeats, think about horses, not zebras."

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Tidbits from the tome

About adoption

Moreover, since most birth mothers are themselves unmarried, they reject the idea of another single woman receiving their baby. Only two countries readily allow assignment of infants to middle-aged single women: Vietnam and Guatemala.

About breathing

Normally, the air we breathe is 20 percent oxygn and the remainder largely nitrogen with a small amount of carbon dioxide. Our lungs are built like a honeycomb, and the sacs in this honeycomb are called alveoli. The oxygen we inhale passes through the thin wall of these alveoli into the bloodstream. When bacteria and mucus fill the lungs, as in pneumonia, it is difficult for oxygen to pass through the clogged sacs and into the blood.

About eating

The most common form of malnutrition and immune deficiency in poor countries is due to the lack of adequate protein, as in severe starvation.

About nutrition

Furthermore, aside from relatively common dietary deficiencies -- lack of vitamin B12 causing pernicious anemia, or insufficient vitamin C giving rise to scurvy -- little is known about the effects of nutrition on many bodily functions.

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...To make sure doctors aren't dismissing factors and to make it through the chapter

Chapter 5, "A New Mother's Challenge," had some good stuff in it, providing one woman's story as insight into how "diagnosis momentum" can run amok. Basically it happens "Once a particular diagnosis becomes fixed in a physician's mind, despite incomplete evidence ... the first doctor passes on his diagnosis to his peers or subordiantes. ... Diagnosis momentum, like a boulder rolling down a mountain, gains enough force to crush anything in its way."

A child starts having severe pneumonia and when all the doctors determined it was SCID, animmunodeficiency disorder, the mom refuses to discount the counter-evidence. She ends up helping doctors discover the true cause, a nutrional deficit.

The best thing about the chapter is depth about medical techniques and technology, giving a real sense of the action.

"There is one last resort," the ICU doctor told Rachel. "ECMO."

Rachel's thoughts moved slowly. "What is ECMO?" she asked in a whisper.

ECMO, he explained, stands for extracorporeal membrane oxygenation. It is a process whereby Shira's blood would be freshened with oxygen outside her body -- thus "extracorporeal" -- via a specialized machine. First an incision would be made in her neck and a large catheter inserted to drain the blood out of her veins into the machine. Inside the apparatus, the blood is percolated over a broad porous membrane. Then oxygen is pumped up through the membrane into the blood. At the exit, a pump returns the oxygen-enriched blood to the body. In essence, ECMO acts like an artificial lung and heart.

But Groopman also gets into some problems with his narrative, particularly as he tries to build sympathy for the mother. Groopman puts in so much work -- a lot of it to get across the woman's religious convictions that just seems forced -- that sometimes the message gets lost. Take this, after the child is helped but the mother learns of 9/11.

Rachel stood frozen in the room and felt as if her heart, so full of joy, were being torn. At the moment she celebrated Shira's restored life, thousands were likely dead in the attack on the World Trade Center. How can I rejoice when God's creatures are dying?

Laying it on a bit too thick for me.

Well, by the end of the story, Groopman's gotten to his point: "Rachel Stein was not an expert in cognitive psychology and did not study errors in medical decision-making. She was a desperate and frightened mother. But she found the strength to educate herself about her child's plight. And when she found inconsistencies in the many doctors' reasoning, she politely but persistently refused to e deterred. She diverted the boulder."

It was just a little difficult to see the forest from the trees thanks to all the paper filled with the winding tale.

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I'm still reading, but I keep forgetting to bring the book back from home...

I've been a little preoccupied of late.

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