Doctors typically begin to diagnose patients the moment they meet them—even before they conduct an examination, they are interpreting a patient’s appearance, in search of clues.
On a spring afternoon several years ago, Evan McKinley was hiking in the woods near Halifax, Nova Scotia, when he felt a sharp pain in his chest. McKinley was a forest ranger in his early forties, trim and extremely fit. He had felt discomfort in his chest for several days, but this was more severe: it hurt each time he took a breath. McKinley slowly made his way through the woods to a shed that housed his office, where he sat and waited for the pain to pass.
Croskerry, who is sixty-four years old, began his career as an experimental psychologist, studying rats’ brains in the laboratory. In 1979, he decided to become a doctor, and, as a medical student, he was surprised at how little attention was paid to what he calls the “cognitive dimension” of clinical decision-making—the process by which doctors interpret their patients’ symptoms and weigh test results in order to arrive at a diagnosis and a plan of treatment.
Heuristics are indispensable in medicine; physicians, particularly in emergency rooms, must often make quick judgments about how to treat a patient, on the basis of a few, potentially serious symptoms. A doctor is trained to assume, for example, that a patient suffering from a high fever and sharp pain in the lower right side of the abdomen could be suffering from appendicitis; he immediately sends the patient for X-rays and contacts the surgeon on call.
A few minutes later, the internist approached Alter and took him aside. “That’s not a case of viral pneumonia,” the doctor said. “She has aspirin toxicity.” Representativeness and availability errors are intellectual mistakes, but the errors that doctors make because of their feelings for a patient can be just as significant. We all want to believe that our physician likes us and is moved by our plight. Doctors, in turn, are encouraged to develop positive feelings for their patients; caring is generally held to be the cornerstone of humanistic medicine.
Several years earlier, the surgical-oncology department at U.C.L.A. had devised an experimental treatment for this kind of sarcoma, involving a new chemotherapy drug called Adriamycin. Oncologists had nicknamed Adriamycin “the red death,” because of its cranberry color and its toxicity. Not only did it cause severe nausea, vomiting, mouth blisters, and reduced blood counts; repeated doses could injure cardiac muscle and lead to heart failure.
One morning, Brad developed a low-grade fever. During rounds, the residents told me that they had taken blood and urine cultures and that Brad’s physical examination was “nonfocal”—they had found no obvious reason for the fever. Patients often get low fevers during chemotherapy after their white-blood-cell count falls; if the fever has no identifiable cause, the doctor must decide whether and when to administer a course of antibiotics.He nodded.
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