Internal medicine, American health care, and especially medical education

This week my team presented a patient who had puzzled them.  The patient complained of 3 weeks of facial swelling.  She had diabetes mellitus type II with severe gastroparesis.  She had both a feeding tube and a port (she used the port for saline boluses when she became volume contracted).

She had gone to several other hospitals and seen more than 5 physicians.  They had made a diagnosis of community acquired pneumonia and given antibiotics.

She came to us still complaining of a cough and chest pain, but mostly complaining of facial swelling and a hoarse voice.

As I listened to the story, I was confused (perhaps because the presenter seemed confused).  We looked at the CXR and suddenly I knew the answer.  My intuition took over.  

I then proceeded to read about my proposed diagnosis prior to going to the bedside.  

At that point I was not considering a differential diagnosis, because I did not feel that I needed system 2 thinking.

I hope you know the diagnosis by now.  If not I will provide some more clues.

At the bedside the patient had a diffusely swollen face and a hoarse voice.  Her neck was too swollen to evaluate her jugular veins.  Her hands and arms were also swollen.

I look at her feet and they were no swollen at all.

We confirmed the diagnosis that afternoon.

I never left system 1 thinking.  Like Klein explains, I just knew the answer.  I had not personally seen this entity in many years, but yet I knew the diagnosis.

Knowing the answer is not enough as Klein explains.  We must also think through the diagnosis and careful examine that diagnosis for potential flaws.  As I considered the diagnosis, I could not find flaws, but rather found increasing evidence to support the diagnosis.

This process of naturalistic decision making likely better explains most of our decision making in medicine.  

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When discussing cognition intuition does not refer to ESP, rather definition #3 in dictionary.com - a keen and quick insight. 

Physicians use this form of intuition often.  We learn patterns and use pattern recognition to make quick diagnoses and decisions.  Sometimes we call these patterns "illness scripts".

One can easily argue that experts develop more refined illness scripts over time.  Given these more refined scripts, experts can continue with system1 thinking unless the script is not totally satisfied.  Incomplete scripts or red flags lead experts to switch to system 2 thinking.

Currently I am expanding my understanding of these phenomenon focusing on the work of Gary Klein.  The link takes you to a long overview of his work in Naturalistic Decision Making.  He studies experts who have to make quick decisions, like fireman.  He describes his big break:

Then in 1984, a notice came out from the Army Research Institute asking for proposals about how people make life and death decisions under extreme time pressure and uncertainty.

What he describes runs counter to my previous understanding.  Decision makers under pressure (like physicians) intuitively pick one diagnosis, and then start mentally testing it against their illness script.  If the match raises questions, then they look for an alternate diagnosis.

Experts do not always generate a long list of potential diagnoses.  They only do this when the intuitive process tells them that this problem is too complex for an intuitive answer.

As I read more about this approach, the relevance to internal medicine and family medicine are becoming very clear.  We who teach need to learn to describe our illness scripts.  We need to make explicit the red flags or omissions that make us reject an intuitive diagnosis.  Only through an explicit understanding of a trainees illness script and that script's deficiencies can we help them develop a more advanced script.

I like how Klein describes the process:

That became part of our model — the question of how people with experience build up a repertoire of patterns so that they can immediately identify, classify, and categorize situations, and have a rapid impulse about what to do. Not just what to do, but they're framing the situation, and their frame is telling them what are the important cues. That's why they're always looking, or usually looking, in the right place. They know what to ignore, and what they have to watch carefully.

It's telling them what to expect, and so that's why performance of experts is smoother than the performance of novices, because they're not just doing the current job, they know what to expect next, so they're getting ready for that. It's telling them what are the relevant goals so that they can choose accordingly. 

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Time to share a frustration.  While some diseases and symtoms have clear causes, not all do.  If you smoke for 30 years, 2 packs a day, and develop COPD, or coronary artery disease, or lung cancer, then I know why.  If you drink 2 pints of vodka daily and develop cirrhosis, I likely know why.  

If you are promiscuous, or use IV drugs, and develop HIV, I can explain why.

But often I cannot explain why someone develops a disease.  As a physician I have learned that some problems remind me of the old Beach Boys' song – "God Only Knows".

Many patients cannot accept that explanation.  They KNOW that they have a disease because of something they ate (or did not eat).  They are mystified that suddenly they have an illness.  So here is my secret – often we too are mystified.

My advice to patients, if your physician does not have a clear explanation of your disease's origin, then perhaps the origin is not known in 2012.  Maybe in 2020 we can answer the question.

We know more than we did when I started my career.  We now know that most duodenal ulcers arise because of an infection with Helicobacterium pylori.  We now know that cervical cancer follow Human Papilloma Virus infection, that is spread through sexual contact.

Please be patient with us.  We do not have all the answers.  If we say we do not know, please do not ask us probing questions.  We hate saying that we do not know, but sometimes that is just the truth.

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