Saturday, 17 July 2010

Diagnosis – Lisa Sanders ****

In the class system of popular science books, Diagnosis has all the marks of good breeding. It is authored by an experienced medical professional, is based on a popular New York Times column, is backed by a hugely successful TV series (House, M. D.), and bears a cover endorsement from a household name in the UK and US (Hugh Laurie). With such a background, what could possibly go wrong? The answer, not surprisingly, is “not much.” Lisa Sanders — the technical adviser to House – gives a frank and engaging tour of the modern diagnostic process, packed with real-life case studies.
The brevity and variety of the case studies means it is hard to get bored with this book; even if one loses track of the argument, there is always another medical mystery to latch on to. Some of these mysteries are bizarre, from the patient who has turned highlighter yellow to the computer programmer who suddenly loses his memory. Others are less colourful but no less difficult or telling: the patient with a tell-tale rash that has been overlooked among his more dramatic symptoms; the enlarged prostate gland, incapacitating an old man’s kidneys, that is discovered by chance in the rush to get him to surgery. All cases are chosen to make a point about medical diagnoses.
Saunder’s main points are: doctors should listen to everything the patient tells them, not just the bare facts; doctors should translate medical diagnoses into a language patients can understand; high-tech testing procedures are no substitute for a sensitive physical exam using at least three of the doctor’s five senses; an uncertain diagnosis is better than a false one; and doctors are not immune to cognitive errors.
In and around these key ideas, Sanders weaves a narrative about modern medical education, drawing from research studies and her own experience. In this regard it is especially interesting to read about the informality of the learning process, with interns thrust unsupervised into physical exams, medical lore passed from doctor to doctor in the corridors, and senior doctors drawing regularly on more experienced staff for help on tough cases. Sanders brings to life the awkwardness of her first physical exam, conducted on a topless patient-trainer; the embarrassment of making basic errors in a field where mishaps can be fatal; the eeriness of her first autopsy and various other medical rites of passage. Another recurring theme is the reasoning process that is involved in making a diagnosis. In this respect, a highlight is Sander’s fond portrayal of a “stump the professor” meeting in which student medics challenge a guest professor with a difficult case, the point being less to get the right answer than to learn from the professor’s approach to the problem. There is also a too-brief section on the cognitive science of medical decision-making, where Sanders does little more than distinguish between intuitive and analytical thought processes.
Occasionally the broader argument of the book gets lost in the details of the case studies. Or rather, it is not clear what the overall argument is meant to be. Over half of the book is devoted to aspects of the physical exam – seeing, hearing, and touching the patient to make a diagnosis – and Sanders clearly wishes to argue for a reversal of the trend towards hands-off medical training and practice. But if that is her argument it is not stated in the introduction or in the non-existent conclusion. And other parts of the book, though interesting in themselves, do not obviously fit into the back-to-basics theme. These include sections on attempts to automate diagnosis with computers, the use of Google as a diagnostic tool, and the curious and unsettling case of the phantom illness “chronic Lyme disease.” This ambiguity of aim is not helped by the book’s odd structure: it is divided into three parts of wildly different lengths.
Diagnosis could have been more carefully planned, but it holds the reader’s attention all the way through and gives colour to some pressing issues in modern medicine.
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Review by Michael Bycroft

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