Thursday, March 24, 2011

EPTAS after ch. 1 and 2

After reading Chapter 1, what are some surprises or comments you have on how doctors really diagnose patients? Did you find the reading interesting? Scary? Reassuring? Please share your thoughts.

After reading Chapter 2, how did Dr. Fitzgerald go about determining her diagnosis? What mistake did she make? Why do you think happened? Was this a realistic scenario?

Alternative chapter 2 prompt:

At the end of chapter 2, we hear about a new program for Yale's students on their first day, and Dr. Angoff mentions a bridge of education. Please reflect on these questions:
  1. How is your College Prep education changing you? What bridge are you crossing now?
  2. How do you expect your university experience will change you? How is that bridge similar and different to the one you are crossing now? Which is more significant?
  3. What important aspects of you do you want to hold onto?
  4. As you think about potential careers, are there others (besides medicine) that cause a similar division between the practitioners and those they serve?
  5. What are the costs & benefits of these divisions?


  1. After reading about the questioning/diagnostic process in the first chapter, I actually wasn’t that surprised. It does make sense to have a few basic questions that cover wide ground, for efficiency’s sake, and as alarming as the perfunctory nature of this process is, it also makes sense that some people limit the element of human interaction as much as possible. This section was not very promising or heartening, but on a personal level, it simply made me more aware of how important it is to give the doctor the full story and not allow oneself to become a list of basic symptoms and yes or no questions.
    What really struck me about this chapter was the first patient (Maria Rogers) and her total denial of her condition. The author portrayed this as being the doctor’s fault for not “creating a story” (as the second doctor did) and relating to the patient’s life, but I thought that was unfair. Sometimes, no matter how understanding or compassionate the doctor is, there will probably be an impossible, inconvincible patient, and blaming the person delivering the news to that patient is pointless.
    After reading the section about “stump the professor” and Dr. Fitzgerald, I was a little surprised about the glowing tone with which the author seemed to portray her. Her process of taking and categorizing evidence and then trying to fit it into the bigger picture of the patient’s life was certainly interesting and probably helpful to medical students, but I thought she was being rather casual about the simulation. She made the mistake of writing off the CT scan because it probably wouldn’t bring back any unexpected results, and then when she really was stumped, she basically laughed off the fact that she’d failed. It obviously wasn’t a realistic situation because no one’s life was really riding on the line, but it could have been setting an irresponsible standard for the students. Shouldn’t she have tried her hardest to solve each case? That would be encouraging the students to keep their focus not on themselves but on the life and health of the patient, which is after all why they should even be in medical school.

  2. I wasn't very surprised by the first chapter's description of how doctors diagnose patients. It makes sense that doctors would try to gather as much data as possible to be sure of their diagnosis, and to be as efficient as possible, even if it makes the patient slightly uncomfortable. The doctors, after all, have to worry about everyone their caring for, not just the individual patient. overall, the first chapter was encouraging, because it seemed to indicate that doctors fail to treat an ailment when their patients hold back critical information, not when doctors make mistakes.
    In the "stump the professor" section, i was also surprised that the author described Dr. Fitzgerald in such a good light. it seemed like the good doctor's method for diagnosing the patient was at odds with the point the book was trying to make. the author seems to be encouraging doctors to use every possible source of information that they have, while Dr. Fitzgerald seemed to be trying to use as little information as possible, best exemplified by her rejection of the CT scan data, despite the fact that the information was very pertinent to the situation. However, i don't think she was taking the game to lightly, because it was just that: a game.

  3. The diagnostic process described in the first chapter was similar to what I had expected--a doctor attempts to group together all the objective facts, leaving out anything that could be perceived as extraneous, and goes with the first diagnosis that seems logical. It is extremely important for a doctor to gather all the facts in order to form a diagnosis, and in a system that is motivated by a certain degree of efficiency, doctors cannot be blamed for omitting or skipping over facts they deem (initially) irrelevant. For the same reason, it isn't surprising that a doctor will embrace the first diagnosis that seems to fit, for if they have no reason to suspect a flawed diagnosis, they will consider the case solved, and move on. The only part of this chapter that surprised me was how the patient was in complete denial of her condition, even after being presented with a clear link between her marijuana use and her persistent vomiting. In this case, I think that the patient was in a sense filtering out information; she thought that the marijuana use was irrelevant, and therefore she never stopped to consider it a viable cause.

    In the second chapter, Dr. Fitzgerald is (in my opinion, unjustly) likened to TV's Dr. House for her supposed diagnostic talents. She is given the bare minimum in terms of medical data, and then after a few tests, somehow comes to the diagnosis. In this particular case, she shrugs off a CT scan because she believed that the results wouldn't tell her anything new, when that very scan was the key to solving the case. She seems to have acquired a certain sort of arrogance when it comes to diagnosing patients, to the extent that she believes that solutions can only be found in unlikely places, therefore surveying all the regular suspects is a waste of time. I think that this is an extremely unrealistic scenario, because if anything, in most hospitals, doctors would begin with ordering the standard tests and then move on to more obscure methods, rather than skipping the standard procedure completely. If anything, despite Dr. Fitzgerald's diagnostic skills, a novice doctor might've been more likely to solve this particular case because the novice would've first gone to the usual suspects, while Dr. Fitzgerald's jaded outlook caused her to skip the obvious.

  4. Reading the first chapter was often more disheartening than surprising to me. Although it seems reasonable that doctors try to fit their patients into a framework by asking a few basic questions, there is no excuse for not taking adequate time with a patient. Though I realize that doctors are pressed for time, it is still inexcusable for them to make mistakes simply because they failed to listen to a patient. I was shocked by the examples of how different doctors and patients recall a meeting, and how the two can recall completely different stories and symptoms for the same ailment. It is the doctor's job to listen to the patient. How else can they discover what is wrong?
    I was surprised to learn that Dr. Hsia discovered her diagnosis simply through a google search. Had none of Maria's doctors thought to do that before? Had it not occured to the patient herself? The description made the diagnostic process seem very mundane in contrast to the high-drama mystery that is seen in other places in the novel. On one hand I appreciated the honesty and direct approach, but on the other, I was somehow expecting a process slightly more involved.
    To me Dr. Fitzgerald's approach in the second chapter seemed completely against the point the author was trying to make in the end of the chapter. Though Sanders was discussing the necessity of humanizing patients and remembering their significance beyond a diagnosis, Fitzerald removed all human qualities from her diagnostic process, leaving behind only an empty body. She made her critical mistake when she decided against ordering a CT scan, because she was expecting it to turn out normal and so many scans were ordered and "wasted." If this scenario were real however, I would think (hope!) that a doctor would order the scan even if it was unlikely to show results, simply because the patient's needs should come before any sort of agenda on the doctors part. I was surprised by both the audience's appreciation for Fitzgerald and the authors' seemingly appreciative recollection; Fitzgerald seemed arrogant and overly casual to me, not what I'd hope to see.

  5. After reading chapter one, I felt more inclined to tell doctors everything when going in for a diagnosis. The explanations of the process highlighted the importance of the role of the patient but also explained the role of the doctor and the sources of their unsuccessful cases. It was interesting to learn how collaborative the process is. The process not only depends on the patient to be honest and not shy about their stories but also emphasizes the role of doctors in being caring and setting up a relationship in which the patient can feel comfortable to release information. I was really surprised when Maria disagreed with the diagnosis that Dr. Hsia gave her. I thought that she would be happy to be diagnosed and look forward to the path of recovery but she was instantly in denial and shut herself away from the possibility that that diagnosis could prove to be true. In the “stump the professor section “Dr. Fitzgerald makes diagnosis’s by being given little information and with little medical data comes to a diagnosis. I was surprised that people cared little for her mistake but cared more for the thought process but then I realized that that makes sense. At first it was disturbing because it seemed that that process would cost a few lives because of the doctor’s rushing and being too excited to find a diagnosis. This is exemplified in the catscan situation. But in reality the process is what allows successful diagnoses to be made and the standard tests and taking one’s time aren’t skipped.

  6. After reading the first chapter, I wasn’t too surprised that doctors need to obtain sufficient amount of data to come up with their diagnosis in a reasonable amount of time. In addition, It is understandable why doctors must act efficiently because they have to care for more than one patient, but at same this is the reason some critical information are missed. I felt that cases such as the patient with the marijuana is actually very common in that sometimes patients just don’t listen to the doctors despite evidence presented. It is very difficult to accept facts that one’s illness and it is very difficult to deal with. As a result, people like this patient tend to deny the truth to make them feel better. However, at the same time, her illness does get better.
    In the second story, Dr Fitzgerald ,an experienced doctor, is presented with a patient with confusion. She takes a very detailed history from which she draws all the important details to see if there is a match between the presentation and the illnesses in her database. Every doctor has his/her own database collected through years of formal education and real-life experience. In Dr Fitzgerald’s database, the chance of CT scan in finding a tumor is low in a patient without weakness or seizure. That is how she misses the diagnosis in this case. Clinical pearls help doctors make diagnosis and sort like problems but they should not be used as absolute standard. Patients may not present exactly like the textbooks describe (Human body is a very complicated machine). Doctors should keep an open mind and look at all possibilities before arriving at the conclusion. By the way, I agree with the author’s comment at the end of the chapter that patient should be treated like a person rather than a medical record number or a diagnosis.

  7. Maria Rogers’ case seemed to be handled in an appropriate fashion. There was nothing quite surprising about the way Dr. Hsia diagnosed her patient. Doctors cannot be expected to know every single disease that exists, and if Google is at her immediate disposal, why shouldn’t she use it? What was surprising, though, was that the patient vehemently rejected Dr. Hsia’s proposed diagnosis. For these reasons, I found the reading to be insightful, but the story’s conclusion to be disappointing. Too often patients feel as though they have more knowledge of medicine than do their doctors. Based on Maria’s reaction, it appears as though she simply does not want to give up smoking. It sounds as if her inability to smoke would bring about greater suffering than that caused by cannabinoid hyperemesis. In this chapter, Lisa Sanders shows us that the path leading up to a diagnosis may not be as straightforward as we think. Pinpointing the correct diagnosis isn’t the end of the story. A doctor’s duty is to “treat pain and relieve suffering.” Therefore, if the patient refuses to accept a diagnosis, the doctor must still persist in doing all that she can to convince the patient so.

    Pertaining to reaching the diagnosis and, more importantly, reaching out to the patient, two main ideas are called into question:

    Firstly, the information needed to piece together a diagnosis may, as the chapter title suggests, lie beyond the facts: “far too often neither the doctor nor the patient seems to appreciate the importance of what the patient has to say in the making of a diagnosis.” For a patient’s story to be of most use, both the patient and the doctor need to be cooperative and attentive in telling and listening to the story. Patients may conceal essential information that they’ve personally deemed to be unessential. At the same time, doctors may incessantly interrupt a patient’s story, thereby potentially losing key facts. In Maria Rogers’ case, the vital piece of information wasn’t even that she was a casual smoker. It was that her symptoms (primarily nausea) improved when she took hot showers. This simple idea seemed to have been overlooked not only by Dr. Hsia, but also perhaps by Maria herself. Neither put much emphasis on such a crucial fact, and consequently it was dismissed to be trivial.

    Secondly, a strong relationship must be developed between the doctor and the patient. The patient has to trust the doctor’s judgment and diagnosis. Likewise, the doctor must understand the patient and be able give the patient’s story back in a way that he or she can understand. Again, neither Dr. Hsia nor Maria Rogers could fulfill these roles. Dr. Hsia was exposed for her tremendous lack of resilience. Taken aback by Maria’s rejection, Dr. Hsia let her patient escape from the hospital untreated.

  8. (Part 2. Sorry, my response to the second chapter wouldn't fit.)

    In the second chapter, Dr. Faith Fitzgerald tackles a string of challenging cases. Nasir describes to her a patient’s case, including the patient’s history, story, test data, and so on. Fitzgerald discovers that the patient has progressing dementia, but no signs of physical abnormality or infection. She then proceeds to rattle off a list of potential causes, like Alzheimer’s or HIV. Interestingly, she chooses to forgo a CT scan of the patient’s brain. The reason why she fails is that this case is not set in a realistic environment. In fact, this reproduced scenario is not realistic in the slightest. The whole point of the talk was to see how Fitzgerald thought – how she attached symptoms and conditions to various illnesses and narrowed them down. She is expected to make a diagnosis in a couple of hours in what I assume to be mostly in her head. What’s most unrealistic about this scenario is that there is no interaction with the patient. Reaching a diagnosis is a collaborative process, and interacting with the patient gives the doctor a better sense of what the patient is going through. In a real situation, (I hope) Fitzgerald wouldn’t just give up and ask for the answer. Fitzgerald is simply given a pile of information in one instant, and is forced to make a decision only a few moments later.

    This chapter in a sense makes a case against the “impersonal language of medicine.” But, given the high-pressure environment in which many doctors work, there doesn’t seem to be any alternative to using this type of language. First and foremost, doctors want the essential pieces of information. However useful, a personal account is not what doctors want to hear first. By analyzing symptoms, they hope to draw a quick conclusion. They might get lucky if the patient’s symptoms all correspond to the five Fs of gallbladder disease. But, if all else fails, then some deeper digging is obviously necessary and encouraged.

  9. I don't find it surprising at all that there are a few questions for a diagnosis that cover a wide range of areas. I think that it is very important to get a diagnosis right and if google or other normal sear engines help a doctor do this, that is obviously very useful. I also think it is very important for a doctor to treat their patient like a human rather than a data set. I think this is important morally, but it will also help the doctor get an accurate diagnosis. I think that medicine in general is really scary and that is a doctor misdiagnosis you, it can lead to terrible things like death... I think that it is natural for humans to make mistakes, but I think that it is important for doctors to take every precaution and use all of the resources that they have at their disposal.

    In chapter two, Doctor Fitzgerald was not able to diagnose the patient with a CT scan which is understandable, but also adds to the fear.

  10. Ch 1
    I was definitely surprised about some the diagnosing process exhibited in this chapter. So much of it is guess and check and they can only use the information that they have obviously but it in the examples given I don't think it put the doctors in a very good light. The way the diagnosis was finally found was a Google search on the only symptom and the only thing that made it better. This isn't exactly information that the doctor worked hard to pull out of the chart, it is the fundamental components of the patient's problem. And then, the doctor found very quickly an answer online, asked the patient if she smoke Marijuana and even though the patient didn't accept the treatment, the diagnosis was made. I didn't really understand how if all it took was a simple google search to diagnose the patient that no one else of the 5 doctors she saw found anything.

    Ch 2
    I think in this chapter that the doctors biggest mistake was starting a little too specific and not doing a couple general/preliminary tests first. Yes extraneous tests are not good either but it seems like a person who is clearly exhibiting neurological problems should receive a CT scan as one of the first things. I am not a doctor by any stretch yet people I have known who have had brain tumors all exhibited very similar symptoms to this patient so my personal guess is that her symptoms were not uncommon to a brain tumor. I was a little confused about how this diagnosis was overlooked and not the first thing they looked for.

  11. In chapter 1, the fact that doctors ask general questions is understandable considering the amount of information they have to gather every time a patient visits. Considering doctors have to check the patient's heartbeat, blood pressure, ears, etc. why not ask them the same questions every time they visit. Also, doctor's questions can help push the patient to remember certain symptoms that they didnt seem important enough to tell the doctor. If, for example, the doctor asks, "Do you catch the cold often?", it might lead to the doctor making the diagnosis that the patient has a weak immune system or something.

    Dr. Fitzgerald's presentation was not the most realistic because she was expecting the most obscure diagnosis to be presented to her, hence not ordering the basic CT scan. I dont think a doctor ever makes such drastic decisions such as not ordering a CT scan in regular hospital situations.

  12. The diagnostic process wasn’t really surprising – its understandable that a doctor will gather a lot of information, leave out factors that seem irrelevant, and come to a conclusion based on the variety of factors that seem to be the most important. Considering this process, it makes sense that the first diagnosis that makes complete sense is usually the one that is accepted, closing the case – there is no reason to believe there is a flaw in the process after a logical conclusion has been reached. In Maria’s case, I thought that her ignorance was a little ridiculous – that she chose to completely ignore that her marijuana use was the root of her issues when it was so clearly affecting her. But at the same time, this attitude makes sense (though it seems so insensible) – we always think we are the exception to the rule and that consequences don’t apply to us; that we are special. Despite the signs that it was the marijuana affecting her, Maria CHOSE to ignore it because she didn’t want it to be true.
    In the second chapter, we see that Dr. Fitzgerald was too sure of her abilities/expertise, and so she ignored the obvious CT scan because she needed to go through more obscure procedures… Yet, it was this CT scan, seemingly so arbitrary and overly obvious, that would have solved the case. I think that it is crucial for doctors to go through the classic procedures even if they seem like they wouldn’t prove anything – even if its unlikely to show a result and seems unnecessary, as with Dr. Fitzgerald’s case, it may be the key to understanding the situation at hand. Fitzgerald’s arrogance led her to skip this crucial scan, her critical mistake. The CT scan was the “obvious” choice for a reason – its never a good decision to decide against something just because it is overused… it doesn’t seem very realistic that a doctor would skip something like this just because it might not show any new results.

  13. I was completely surprised by Maria Rogers’ denial of her condition. Dr. Hsia was clearly a trained physician, and had done enough research to conclude that Maria had cannabinoid hyperemesis. It puzzled me why Maria could still repudiate Dr. Hsia when confronted with substantial evidence. I especially enjoyed how throughout the chapter, Sanders makes clear the difference between the doctor’s interpretation and the patient’s interpretation of a diagnosis. Clearly, Dr. Hsia was most likely correct in her diagnosis, but without convincing the patient of her condition, Hsia’s diagnosis was useless. I found this quite scary. For example, if one were given a doctor who could not adequately present a well-substantiated diagnosis, one might not believe the doctor, and may continue to live with one’s condition. I believe we have to train our doctors to understanding and careful with the presentation of their diagnosis to their patient, otherwise there will be no helpful progress with the condition. Also, I appreciated Sander’s little addition of another patient with Hodgkin’s lymphoma, and how the doctor appropriately handled the confrontation between patient and doctor. Dr. Wein was able to convey and convince Randy to deal with his condition, and be determined to become healthy. I know from personal experience that a doctor cannot help someone who needs help just by diagnosing them. It is ultimately the patients that have to heal themselves. I feel like the doctor is just a mechanism for which one heals oneself, and I appreciate that Sander’s has highlighted this difference for me.

    First of all, Dr. Fitzgerald is not in any way like Dr. House.

    The scenarios between the two of them are completely different. As such, I believe that Dr. Fitzgerald was not put in a realistic scenario. Dr. Fitzgerald is pacing around in front of hundreds of doctors literally showing off her diagnostic ability to memorize rare diseases. She makes the mistake of not ordering a common CT scan for her elderly patient, and realizes that it was the key to solving the entire case. Why? Because she knows a simple case would not be presented to her, so it shouldn’t have simple answer. Therefore, she skips one of the most basic procedures. What bothers me about this entire scenario is WHY Dr. Fitzgerald denies the CT scan. Dr. Fitzgerald assumes that the CT scan will be normal because she will most likely be presented with some difficult condition no one’s ever heard of. Therefore, she skips a very basic and very important scan BECAUSE it “probably” will not help her. Doctors in real life don’t know in advance that they will be dealing with an easy or a hard case. Also, real doctors can’t just blow off a mistake and say, “oh well.” Real doctors have the lives of patients on their hands, with time pressure and a medical license riding on the line as well. Dr. Fitzgerald was not only not exposed to any of these very important qualities for making a realistic scenario, but also had a cocky attitude because she went out and memorized a ridiculous number of rare diseases.

    Anyone could do that. Anyone could go out and memorize a ton of rare diseases and become Dr. Fitzgerald. What makes a doctor a doctor is the training to work with people and make difficult decisions and realizations under pressure. That takes years of training. Without a realistic scenario, Dr. Fitzgerald’s detective skills are nothing but memorization, something that I can respect, but cannot praise.

  14. I was less surprised by the manner in which the doctor went about diagnosing the patient than I was at the complete rejection of the diagnosis that the patient displayed. She wanted to be cured of her unrelenting nausea and vomiting, but she was unwilling to accept the most probable of all of the diagnoses. I like the fact that Dr. Hsia used all possible resources, because as the author, Lisa Sanders, pointed out earlier, it is common that doctors will miss key information that could potentially lead them to the correct diagnosis. Dr. Hsia did not want to miss any of those key facts, and she managed to find a diagnosis that fit perfectly, so I think that despite her potentially unorthodox methods of reaching the conclusion that the marijuana was the source of the illness, the fact that she used all possible outlets of information was most important.

    In chapter 2, the mistake that Dr. Fitzgerald made was that she stopped being careful and decided to skip the CT scan, even though she said that it was usually mandatory for all patients. However, I do not think that all doctors are required to have answers for every problem, and so I do not think that her deciding not to do a CT scan is the worst of mistakes.

  15. I found it a little scary knowing that there is so much possible error in the diagnostic system. Especially as a kid, it is drilled into you that doctors can make you better. Unfortunately, doctors are only human: they do not know everything, and can make mistakes. I thought it made total sense for Lisa Sanders, the author, to emphasize how important it is to obtain a full patient history. One missed detail could potentially hold the answer to a tricky diagnosis.
    I think Dr. Hsia’s process of looking for missed clues, consulting other doctors, and finally using the Internet was logical and intelligent. I was surprised when Maria didn't accept her diagnosis after the doctors went through such a process, and spent so much time and energy to figure it out, coming up with the obviously correct illness. I found it hard to understand the criticism that Dr. Hsia did not create a story that “the patient could accept.” Her process seemed logical, and her explanation for the illness was clear, and I don't really understand how she could have told a different version of the diagnosis, one that “ would make sense in the larger context of her life.”

    In the “stump the professor” presentation, Dr. Fitzgerald, an experienced diagnostic expert, is given the bare details of a patient’s condition and asked to find the illness. I think that the mistake she made was in being too confident in her ability to reason out the diagnosis. Her mistake was in jumping to conclusions based on her thoughts and predictions, rather than collecting all the data. It is important to obtain the bare bones, the raw information (such as the CT scan) before attempting to piece together a story that can lead to a diagnosis. I think, or hope, that for difficult and tricky cases in hospitals the doctors are less likely to jump to conclusions, as Dr. Fitzgerald did, and more likely to get many test results, in hopes of eliminating human errors and finding the clue to the illness.

  16. Although the diagnostic process described in chapter one was not too surprising, I found a lot of what Sanders said about the extensive progression of steps in making a diagnosis interesting. The chapter emphasizes the point that the patient’s story is the best place to gather information for a diagnosis. Sanders uses an example of Sherlock Holmes to say that although “you may be able to say with precision what the average man will do, ‘you can never foretell what any one man will do’” (7). Because of this, the sole usage of medical facts of a case is not always the best way to diagnose a person. I found Osler’s statement interesting. He said to his trainees, “It is much more important to know what kind of patient has the disease than what sort of disease the person has” (7). This also enforces the importance of knowing the patient, and not just his/her symptoms. As later stated in the chapter, it is very important to translate the doctor’s scientific world into the patient’s reality. Just as it is important for the doctor to know the patient, it is also important for the doctor to relay that information back to the patient in a comprehendible manner. Chapter 1 made me realize the importance of telling the full story to the doctor, not just what I presume they need to hear. Also, the reading made me more aware of the importance of making a timely diagnosis. Maria’s story put into perspective the sometimes dire importance of a single fact in a patient’s medical history. Randy’s story was frightening because it illustrated the importance of making a timely diagnosis, as it could determine whether a patient lives or dies.

    As some people have already said, I believe that Dr. Fitzgerald’s method of diagnosing the patient’s presented was contradictory to the point that knowing the patient (and not only his/her technical symptoms) is very important in solving his/her medical case. The “Stump the Professor” talk proved the point that knowing all of the details of a case is essential in making an accurate diagnosis. Fitzgerald’s quick and seemingly insignificant decision to not get a head CT scan of the patient would directly cause the patient’s fate. This proves that missing a single step in the diagnosis process could end up determining whether the doctor can solve the case or not.

  17. I wasn't that surprised to find out how doctors diagnose patients. It makes sense that doctors wouldn't really want to spend time listening to what their patients have to say. After all, while the story of your illness might seem important to you as a patient, to a doctor it's just one of thousands that they hear and have to find a solution to. Although listening to everything that a patient has to say might lead to a more rapid and correct diagnosis in some cases, often it's probably just an annoyance that could be avoided by asking targeted questions to make a diagnosis. Anyway, it can be difficult for patients to communicate effectively with doctors even when they are trying to. How are you supposed to know what's important and what's a waste of time? What if you're exaggerating or leaving things out or distorting the truth without intending to? I guess this side of the equation, that is, how patients can best communicate with their doctors, is difficult to deal with.

    Dr. Fitzgerald tried to determine the diagnosis by listening to the initial reported symptoms, then listing a variety of possible diagnoses, ordering tests, and trying to figure out what was plausible. Her mistake was failing to order a CT scan because she thought a physical abnormality in the brain was unlikely. The scenario in which she was working was very unrealistic though. Because it was a conversation between doctors, who are all highly trained at communicating in the language of medicine, it eliminated the complication of an actual patient whose words and attitudes would not fall into the patterns of medical jargon. Also, the lack of an actual patient during the diagnosis session removed an essential component of medical practice: the basic human relationship between the doctor and the patient. Maybe if the old woman and her husband, both of whom were suffering as a result of the woman's mental deterioration, were in the room, Dr. Fitzgerald would have been less ready to reject the prospect of a CT scan that could have shed light on a potential treatment.

  18. The fact that this process of diagnosis described in Chapter 1 isn’t something we find alarming is in itself a scary situation that we might want to reconsider in the near future. It does make sense that most doctors try to get only the raw facts and make diagnoses off these, since the facts are what they can analyze more easily because they have more background knowledge to sort out these facts. Yet we do have to take into consideration that we are dealing with people’s lives, and one left-out detail in the story could potentially lead to a patient’s death.

    Although I do think that doctors must be able to convey the patient’s condition in an easy to comprehend, somewhat pleasant manner, I slightly disagree with the statement that doctors must create a story that is uplifting to the patient. People didn’t become doctors because they wanted to use their imagination to invent a story that isn’t entirely true. In my opinion, it is less of “telling a story” than it is relaying the factual information in a positive and caring manner. Doctors aren’t trained to be storytellers, and even though I found it almost heroic that Wein was able to “heal” his mind, I don’t think doctors should be obligated to resort to such measures. Also, I thought that the author was simply highlighting two extremes of the story—Maria Rogers versus Randy—rather than allowing us to look at a more realistic range of cases.

    After reading Chapter 2, I think that Dr. Fitzgerald did make the mistake of passing on a critical physical test (CT scan). However, I am not entirely sure that she would have made the same decision if it were a real-life scenario. What she is doing in this chapter is simply for others’ entertainment, so her decision wasn’t affected by the normal pressures of a personal patient-doctor encounter. Furthermore, Dr. Fitzgerald wasn’t receiving first-hand information, so the data given to her could have been limited or slightly skewed. On the other hand, Dr. Fitzgerald could likely have made the same decision in real life—and reaped much greater consequences. Whether this were a realistic scenario or not, it reminds us that we should never be quick to a conclusion until we know for sure through several tests that our diagnosis is right.

  19. In chapter 1, I wasn’t particularly surprised by the true nature of doctors’ diagnosis. From my experience its seems that doctors want to hear only about the basics of the disease, and probably have already come up with an idea that they are confident about before the patient has even finished their story. This “facts only” approach is effective the majority of the time, but I understand how this method would fail when faced with rare manifestations of diseases. When going too see the doctor, I actually have come to expect the doctor to interrupt my story. I have realized that when I am discussing my symptoms, I leave each symptom as a question, waiting for the doctor to confirm or deny if that symptom is really what I am experiencing. In this was the doctor’s “facts only” approach has permanently transformed the patient-doctor relationship. In the case of Maria Rogers, the transformed and inhibited patient-doctor interaction prevented the doctor from being able to articulate the type of disease to Maria. I think it is interesting that in order to address this problem, courses in patient-doctor conversations have been incorporated into medical school curriculum. In chapter 2, Dr. Fitzgerald determines a diagnosis by first hearing the bare bones of the patient’s story, then ordering tests. Dr. Fitzgerald then considered multiple potential areas of medicine, approaching the disease from different angles. However, Fitzgerald made her crucial mistake by failing to order a head CT. Fitzgerald made the assumption that almost all patients with a deteriorating mental conditions get CTs and yet the CTs never provide any helpful information. Instead of dealing with this particular patient’s disease, Fitzgerald made her decision off of her knowledge of general types of dementia. I don’t think that this is a realistic scenario because getting a head CT for a patient with dementia is a pretty standard ER practice. Fitzgerald didn’t go through these seemingly futile steps because she was just displaying her thought process, not dealing with an actual patient in which she probably would have taken the necessary precautions.

  20. - From DANIEL COHEN Period 4

    Chapter 1: I thought it was surprising how doctors chose to diagnose this patient. A lot of people think either doctors are omniscient and know everything or they are totally devoted to the science of a case and not the patient. This case shows how difficult being a doctor can be. This reading was frightening and reassuring at the same time. It was frightening because the guy was forgetting everything every five minutes and the doctors did not know what to do about it at all. They had no clue that it was cancer at the beginning. It was reassuring to me because the doctors were able to succeed by the end even though the problem was very complex and linked to something that you would not think caused memory loss.

    Chapter 2: Dr. Fizgerald went about diagnosing her patient through general information about the patient, their physical appearance, condition and then medical history. She then used a sort of disease catalog in her head to try and figure out a test, diagnosis and treatment that would fit this patient's medical story. She then found a way to "hang" her knowledge of the subject's problems with possible tests to try and prove hunches correct. She made a mistake when she turned down a student's recommendation of a CT scan of the patient's head. I think this happened partly because she was a little caught up in the entire "diagnosis as entertainment" idea and may have begun to think a little too much of herself onstage. After all, there is a reason diagnosis is not widely considered to be "entertaining".

  21. I found the story of Maria Rogers interesting, but somewhat disheartening. The fact that Dr. Hsia found her diagnosis of cannabinoid hyperemesis was impressive, but I was pretty surprised that she was the only person to have thought to "just Google it." That she did not act the arrogant doctor was good, but I wasn't inspired by her diagnostic skills. Furthermore, the fact that she was not able to present the diagnosis in a way that the patient could understand or recognize was disappointing. I wanted to stop the doctor and tell her that this patient would not want to accept that it was her cannabis use at the root of her vomiting, seeing as the cannabis use itself was part of the patient's normal lifestyle and sense of well-being.
    I thought the story of Randy Whittier was more uplifting. The patient was lucky to be able to recognize his memory problems fairly quickly, and to have his fiancé urge him strongly enough to see a doctor. But mainly it was thanks to Dr. Abend's thoroughness in doing tests, obviously the CT in particular, that Randy was diagnosed with Hodgkin's lymphoma/paraneoplastic syndrome in time to save his body and memory. He got a happy ending, unlike Maria, so that was nice to read.
    On the other hand, Dr. Fitzgerald in chapter 2 was certainly not thorough in her approach and seemed pretty full of herself. She did not even make a final diagnosis, she just gave up. True, this was just a simulation, but her nonchalance discredited the whole premise. Clearly this was not a realistic scenario. If she had simply ordered the head CT she would have saved the patient and gained more respect from the readers of this book.
    The section about the Yale medical students was much more pleasant, because it made me hopeful that these future doctors would retain their passion for humanity as they progressed further in their medical education. Yet it felt heavy-handed, in that the author was further underscoring her thesis that a patient's personal story is just as important as their medical story, after her point was already very clear. Nevertheless it did make me consider how I don't want to lose my own curiosity and interest as my studies become more intense. As we create a bridge from adolescence to adulthood, I think it's very important that we hold on to our childhood curiosity about the world, because otherwise what we learn lacks true context and meaning.

  22. Chapter 1 surprised me in many ways. the most surprising of all was to find that there are diseases that our doctors may have no knowledge about. that while we think that we may be having unrelated symptoms there may actually be a desase behind them all. and that our doctor may never know of this disease until they type the symptoms into google. while this is surprising it is also a bit scary. it is a bit disconcerting to know that we may be diagnosed through a blog on google rather than years of medical eduction and the knowledge of our own doctor. it is also scary to know that there are these eccentric diseases that may explain years of speculation as to what might be behind our odd symptoms. it is overwhelming because it makes me think that all oddities should be reported to the doctor because they may actually lead to a possible diagnosis.

    In the “stump the professor” section Dr. Fitzgerald is given the initial specific symptoms and the general information on the patients condition and subsequently searching for what she thought was the most plausible diagnosis and finally ordering tests and figuring out what the patients diagnosis might be. However, this sequence of events is flawed. Fitzgerald was too confident and she jumped to conclusions rather than reaching a conclusion based solely on evidence and data. She inappropriately reversed the normal coarse of action and she begun to diagnose before she had found the path to that diagnosis. This shows the necessary humble, unassuming and self-doubting character that a doctor must achieve in order to successfully do their job in the most thorough fashion.

  23. After reading the first chapter, I was truly startled by the way that the author *claimed* doctors diagnose patients. Regardless of whatever data she presented, I cannot believe that doctors have little to no knowledge of certain diseases. This possibly could be coming from my prior knowledge of my dad's medical practices. He and his associates most certainly *do not* diagnose patients with the aide of search engines. The years of college education and medical school that aide doctors in deductive thought that save lives cannot be replicated with the use of the internet. Therefore, it is clear that Dr. Hsia was extremely lucky to located this 'cannabinoid' disease via an online search engine. Whatever disagreement I had with the first chapter, I nonetheless was rooting for Dr. Hsia and Maria, and pleased when her disease was diagnosed.
    In the second chapter, Dr. Fitzgerald (to say the least) is praised by the author for the way she was able to "categorize" the patients symptoms and organize them to lead her to a diagnosis. While this method may be effective in medical school, I personally believe Dr. Fitzgerald gives a poor name to doctors and medical professors who deductively reason and use thier medical knowledge to diagnose patients. By skipping the "normal" tests and skipping to the smaller possibilities, Fitzgerald missed the big picture.

  24. In chapter 1, the description of how doctors come up with diagnoses was something I hadn't thought of before, although I guess it makes sense because they are only human. However, that fact is also a little worrying. It means that mistakes are almost inevitable, and the best they can do about those mistakes is hope that the disease they guessed wrong about wasn't fatal, or that they have enough time to go back and fix it, give the patient the correct diagnosis, and start treating them. The stories that this book tells are fascinating, but many of them are about very close calls. I knew that things like that could happen in the emergency room, or during a surgery, but I don't usually think about diagnoses as life-or-death situations, except maybe when watching House. Even then, I guess it didn't occur to me that doctors actually go through that kind of situation almost regularly.
    In chapter 2, Dr. Fitzgerald tried to find a diagnosis by learning all the symptoms of the patient and matching them to diseases that she knew that sounded similar. The mistake she made, however, was not getting a head CT scan because she assumed that if the problem was that visible, as a brain tumor would be, then it would have shown itself more clearly through other tests and symptoms. Even though it was a logical enough guess, it wouldn't have hurt to look at the results of the scan. It was definitely not a realistic situation because it was stressed that in the class, the point is the thought process that leads to a diagnosis, not the diagnosis itself. In real life, however, the point of that thought process is to get a diagnosis and help the patient. There is much more on the line. I also think it would have been interesting if the book included the other two stories presented to Dr. Fitzgerald, for which she made the right diagnosis.

  25. Although it can be a little scary, the diagnostic process wasn't too alarming. It makes sense for a doctor to take an objective point of view, and gather as much data as needed. Although it did show that there was room for error, it was pretty much what I expected.

    In the second chapter the doctor's mistake was that she chose to focus on what she knew and not get a CT scan. Based of her knowledge, she expected that a CT scan would be unnecessary because the symptoms didn't seem to point to that. This scenario didn't seem realistic, because doctor's would normally get all th information necessary to get the correct diagnosis.

  26. I think that it is important that all doctors use what is necessary for a diagnosis, if this is google search, ok, but what we should be asking is why this was necessary. Doctors should be aware of what causes certain symptoms and should be able to diagnose based on that knowledge.
    Also, in the case where that one patient didn't tell her entire story, it is nearly impossible for a doctor to diagnose. If a patient wants to be healed, the she or she must be honest in both symptoms and story. The patient must also accept the diagnosis. On the other hand, if the patient isn't truthful and doesn't accept the diagnosis , then the patient is his or her own responsibility, not that of the doctor.