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Every patient has a story. Physicians already know that. The longer we practice, the more it is true. So why do we need to read this book? Because we forget. Because our brains are frail. Because we’re in a hurry. Because we often fail to take the time to listen. There are many more reasons, as many reasons as we have patients. 

Lisa Sanders, MD, is a particularly fine story teller who is willing to take the time to tell us a few stories about her patients. An internist on the faculty of the Yale University School of Medicine, she is also an astute clinician who shares a few of the lessons from the practice of medicine she has learned along the way. Her column “Diagnosis” appears monthly in the New York Times Magazine, and she is the inspiration and medical advisor for the runaway television series “House.” Are you listening yet?

Sanders begins with the story of a young woman lying in the ICU for a week while dying of progressive, inscrutable liver failure. She is in a large university hospital at an academic center, where her diagnosis has eluded multiple specialists, until an aging internist called in on the case notices, buried in her chart, overlooked results that suggest mild hemolysis. This combination—liver failure and isolated red blood cell destruction—is an unusual manifestation of an unusual inherited illness that the internist recognizes. He goes to the bedside with his ophthalmoscope and confirms his diagnosis of Wilson’s disease. The patient receives an organ transplant the following week and survives.

How was the internist able to make a diagnosis after so many had failed? “I was lucky,” he explains. “No one can know everything in medicine. I happened to know this. A bell went off and a connection was made.” 

“This book,” writes Sanders, “is about that bell. How doctors know what they know is a messy process, filled with red herrings, false leads and dead ends. An important clue can be overlooked in the patient’s history or physical exam. An unfamiliar lab finding may obscure rather than reveal.” Or the doctor may be too busy or too tired to think through the case. “Even the great William Osler,” writes Sanders, “must have had his bad days.”

Sanders weaves a handful of medical mysteries throughout her book, dividing it into four parts. Part One is the title track: “Every Patient Tells a Story.” Part Two, “High Touch,” chronicles the “vanishing art of history-taking and physical diagnosis.” In Part Three, “High Tech,” Sanders details the enormous power and limitations of our rapidly advancing diagnostic technology. She concludes in Part Four with “The Limits of the Medical Mind.”

In each part, Sanders raises questions about our art and science, and challenges many of the practices we accept routinely. Has technology replaced the physical exam? Daily I see evaluation of abdominal pain start with contrast CT of the abdomen. I wrote recently in this magazine about a 14-year-old gymnast with a painful knee who had X-rays, CT and MRI of his joint before actually being examined. During that exam, he was found to have Osgood-Schlatter’s disease, a diagnosis that could have been made at the outset with the clinician’s thumb on the tibial tuberosity. 

Notwithstanding this example, many of our traditional examination techniques have been found by statistical analysis to have little diagnostic value. These include the puddle sign in the diagnosis of ascites and, believe it or not, lung auscultation in the diagnosis of pneumonia.

Sanders quotes from Steve McGee, MD, a noted clinician and author who has devoted the better part of his career to teaching evidence-based physical diagnosis. “Parts of our traditional exam are surprisingly worthless,” he admits. “But much of it remains very reliable if performed well. The problem is students don’t develop much confidence in their skills, and tend to further devalue it.” 

No matter how much we preach the value of physical diagnosis, our “hidden curriculum” (what we actually believe and practice under the time pressures of current medicine and observant eyes of our students) often undermines our message to those we teach. After all, how much weight is given to the resident’s description of a heart murmur compared with the echocardiogram? How many times have I heard an attending ask, not “What did you hear?” but “What did the ECHO report say?”

Historically, the discipline of physical diagnosis evolved over centuries of trying to infer indirectly from perceptions outside the body what was going on inside. Modern imaging takes us virtually inside the body and gives us vivid 3D pictures of the state of internal anatomy and physiology we’ve only been guessing at since Hippocrates. Can you imagine what Hippocrates or William Osler would have done with MRI or ultrasound? 

I grew up with Alexander Cope’s “Early Diagnosis of the Acute Abdomen” and Aubrey Leatham’s classic four-part “Auscultation of the Heart“ published in Lancet. Both physicians were brilliant British physical diagnosticians, whose works we quoted as if sacred clinical scripture. Neither are given much attention in today’s medicine, and probably with good reason. Though there is still much to be gained from their study, the hours of current medical education simply do not allow the time.

Consider how much the discipline of our neurologic exam was built on answering the central question “Where is the lesion?” And how often is a true neurologic exam now short-circuited by a brain CT to answer this question? As one acerbic house officer recently retorted to me when I questioned him about the patient’s plantar responses, “One CT picture is worth a thousand Babinski’s.”

I do not decry technology, nor does Sanders. I believe medical students should be given hand-held ultrasound units in their first year of medical school and taught to use them throughout their training and careers. But our emphasis on technology comes at a cost, both monetarily and clinically. Sixty-two million CT scans were ordered in the United States last year. Recently, two hospitals in Southern California were found to have miscalibrated their CT scanners, exposing patients to undue amounts of radiation. 

What I do decry is the replacement of important history taking and physical examination skills by an overdependence on technology, with all its costly and unintended consequences. Sander’s book is a compelling plea for doctors to keep listening. One of the physician’s most powerful tools remains his or her ability to give a patient’s story back to the patient, in a way that provides understanding and meaning to the patient’s illness. Our technology powerfully extends our senses, allowing us to “see” into human illness in ways that were unimaginable only a couple of decades ago. I applaud that power. But without our eyes and ears and capacity to touch, I believe we are diminished both as diagnosticians and healers.

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