The difference between good and bad thinking . . . involves overcoming the inertia that inclines one to accept suggestions at their face value . . . it involves willingness to endure a condition of mental unrest and disturbance. Reflective thinking, in short, means judgment suspended during further inquiry; and suspense is likely to be somewhat painful.
—John Dewey, How We Think (1910)
6:50 a.m. Saturday
I’m thinking maybe we got lucky.
Friday nights are cursed in big-city hospitals. No one knows why exactly but mortality rates go up on the weekend. (You’d think we would have figured this out by now, right? I mean, we’re talking about people’s lives here.) So, if my team didn’t get any new disasters last night—if we beat the Friday-night whammy—it’s cause for celebration. And from where I’m standing now, in the 10 Central corridor outside Mr. Warner’s room, I’m thinking we caught a break. I’ve seen my team’s other eighteen patients, including the first two of our three new overnight admissions from the ED, and they’re all looking pretty good. Mr. Warner is our last overnight admission, and from what I can see as I enter his room, he’s looking pretty good, too.
This is doctor-talk, of course. My patient’s “looking pretty good” is not anything you’d want to look like. Take Mr. Covinski, for example. When I saw him on 2 North a little while ago he was sleeping, thank God, because we had finally gotten his pain from his prostate cancer under control. His brother had flown him in here from Poland thirty-six hours ago and it had hurt just to watch this big, strapping, stoical guy grimace and groan and pace the room as we doubled, then redoubled, then doubled again the huge doses of morphine he needed to get any relief at all. When, at last, he murmured sleepily, Dah, dah, no boli, no boli, thank you, doctor, our work (and worry) had just begun. We don’t know if we can rein in his galloping cancer, which has begun to invade his spinal cord. Mr. Covinski’s just one bad break away from terminal paraplegia.
We worry even more about this because Mr. Rodriguez, another nice guy dealt a bad hand, lies paralyzed in the room next door to Mr. Covinski. Ten years ago, a drive-by shooting changed Mr. Rodriguez’s life forever. Somehow he remains upbeat despite the wheelchair and the colostomy bags and the gigantic gaping wound where his lower spine and buttocks used to be. (Last week, when the new med students joined our team, one of them fainted dead away on the floor when we rolled Mr. Rodriguez over to examine his rear end.) Lately, he spends more time in the hospital than at home, one resistant wound infection after another, and it’s probably just a matter of time before the bacteria finally win. Still, whenever we visit, he always asks us how we’re doing.
Doc Steinberg, our patient on 5 West, always asks how we’re doing, too, but he’s a retired psychiatrist, so we figure it’s just force of habit in his case. I’m the one who sounds like a shrink because I keep telling Doc Steinberg, It’s not your fault; it’s not your fault. He had a cold a few weeks ago, prescribed himself a broad-spectrum antibiotic that he didn’t need, and now he’s here, recovering from antibiotic-induced colitis that almost killed him. The bleeding in his colon has slowed but it caused his kidneys to stop working and now all four of his limbs look like tree trunks, so swollen with fluid he can’t even get out of bed. The next few days will tell whether he spends the rest of his life on a dialysis machine. Still, he always smiles and makes jokes about the head-to-toe costumes we all wear for infection control—You look like poltergeists, Doc Steinberg says—whenever we come into his isolation room. And, every day, as we exit his room, he intones his lesson for our interns and medical students: Remember, young doctors, the treatment can be worse than the disease.
We could probably use Doc Steinberg’s help with Ms. Jackson, our patient on 8 North who is homeless and crazy but refuses to speak with any social workers or Psychiatry. She’s been here for more than a month now—no nursing home or shelter will take her—roaming the hallways day and night, even at five this morning, trying to engage anyone who will listen to her manic rants about how her liver problem was caused by Halley’s Comet and why her breast cancer is actually good for her. Behind her psychosis, Ms. Jackson is a charming, intelligent woman, but her jaundice was caused by hepatitis C, not gamma rays, and we can’t always tell which hallucinations are caused by her worsening liver disease and which by her manic depression. As if that weren’t enough, her breast cancer has spread all through her body and we have no one to talk to about what to do when she starts to go downhill, as she soon will.
Looking “pretty good” in doctor-talk is all about compared to what?
On first glance, though, Mr. Warner really does look pretty good, even compared to you or me. Seen from the doorway to his room, he might be meditating or listening closely to music he cares about. In his cranked-up hospital bed, he sits erect, as if doing yoga, his eyes closed but his chin held high, intensely attentive to something. My first impression—how sick can he be if he’s so focused on something else?—would ring true to most casual observers, especially those not inured to the sensory assaults of a hospital ward. If, like Mr. Warner, I were held captive here—defenseless against the gurgle and flush of bedpans, the clatter of breakfast trays in the corridor, the caffeinated chatter at the nurses’ station—I would try to tune it all out, too, find some peaceful personal space just for myself.
I want this to be true: I want Mr. Warner not to be sick. I don’t want him to be like Mr. Atkins, the new patient I saw an hour ago who was helicoptered in last night with a belly full of cancer. (He doesn’t qualify as a Friday-night disaster. The disasters are the ones we can still save. This poor guy’s going to die and there’s nothing we can do about it except make his passing a little easier for him and his family.) No, I want Mr. Warner to be more like Mr. Tosca, the patient I just left downstairs in the emergency department. He was admitted to our team last night and is still waiting for a bed, but we can probably send him home this morning. That’s what I want for Mr. Warner, for his sake as well as mine.
Even if we get lucky this time, it won’t last. My team, like all the medical teams here, is on call for new admissions every day all day, 24/7. Our next disaster may be waiting for us right now in the emergency department, one STAT page away. Even so, there’s an ebb and flow to this business and you welcome the ebb as you brace for the flow.
But, of course, it doesn’t matter what I want. On second glance, Mr. Warner doesn’t look so good. His white-blond hair is damp, pasted down in random places, and I suspect, before I come closer to confirm it, that he’s wet with sweat. One blue-stockinged foot sticks out from under his sheets at an odd, supinated angle and there is something odd about those sheets, rumpled and untucked, like maybe the night wasn’t nearly as peaceful as he looks now.
These few odd facts, in the telling of them, sound simple enough, as if you just have to look to see them and know them to be so. But that’s not the way it is. In real time, these observations don’t register as discrete facts at all. I know them as I tell them now only upon reflection. In the moment, as I approach Mr. Warner’s bedside, all that I experience is an uneasy awareness of dissonance: Something here is not what it seems. Somewhere in my subconscious, a red flag is flapping.
Consciously, all I know is that Mr. Warner is a seventy-six-year-old HIV-positive man admitted through the emergency department a few hours ago for treatment of a urinary infection. When I read this in his emergency department chart, two things came immediately to mind. First, elderly people with HIV are rare, even today. Most of the lifesaving advances in HIV treatment are relatively new; almost everyone infected twenty or thirty years ago is dead. This means either that Mr. Warner acquired his infection late in life or that he is one of a few very lucky ones. Second, most patients admitted to the hospital from our emergency department for treatment of a urinary infection don’t have a urinary infection. (Or, if they do, that’s not the main reason they need to stay in the hospital.) This fact—that diagnoses made in our ED are often incomplete—is no criticism of our ED docs; it happens in every hospital. There’s only so much you can figure out in a busy emergency department during the few hours that sick, complicated patients stay there before being admitted to the hospital. In fact, the most important function of emergency departments today is identifying which patients are really sick (and must be hospitalized) and which ones are not (and can safely go home). The ED docs here at New York Presbyterian are very good at this: More than nine times out of ten, they’re right.
All told, then, I know four things before I meet Mr. Warner. First, he’s a rarity, an old man with HIV. Second, he’s here—admitted to the inpatient medical service from our emergency department—so he’s probably pretty sick. Third, whatever diagnostic testing has already been done in the ED, it’s likely that no one knows yet what’s really wrong with this guy. And, fourth, somewhere in my subconscious brain, that red flag is flapping. My gut is telling me: Be careful here.
Over the years I’ve learned to listen to my gut, but that doesn’t mean I can trust it. So I know what I have to do now—and there’s nothing subconscious about it. It’s like working in an auto repair shop. You listen to what the car owner says; you ask him some questions; you listen carefully to his answers; and then you look under the hood. People today think medicine is all about technology—DNA tests and MRI scans and robotic surgery. But it isn’t. There’s an age-old, tried-and-true method to clinical medicine, and there’s nothing mysterious or high-tech about it. It’s grunt work. And, as the grease monkeys in the auto shops say, if you shortcut the grunt work you’ll screw up the job.
• • •
I use my intuition—my gut—to make snap judgments every day. All doctors do. Occasionally, in a true emergency, there’s no alternative: We must decide in a flash. Much more often, though, we make snap decisions and we’re not even aware we’re doing it. Experienced doctors, in particular, develop this habit; reflexively, we “just know” what to do, probably because we’ve encountered a particular clinical situation so many times before.
These snap decisions can backfire. Instinctive judgments—the ones we make in the blink of an eye—are subject to bias, error, and bad luck. Knowing this, expert decision-makers take pains “to combine the best of conscious deliberation and instinctive judgment,” not an easy thing to do; indeed, learning how to do this, according to Malcolm Gladwell, author of Blink, is “one of the great challenges of our time.” Had I appreciated the enormity of this challenge years ago, before I began doing research about it, I might have hesitated before taking it on. But, as it turned out, when Gladwell wrote in Blink about efforts to improve doctors’ instinctive judgments, he was writing about me.
Together with a team of researchers in Chicago, I had published a series of studies in medical journals showing that use of a prediction rule—a guideline based on strong scientific evidence—improved doctors’ intuitive judgments when deciding how to treat patients who arrive in emergency departments with symptoms that could indicate a possible heart attack. This prediction rule relies on just four “bits” of clinical information, so to most doctors it seemed overly simplistic. How could such an important (life-or-death) clinical decision depend on so few things? But it does. We found that doctors’ intuitive decisions, unaided by the prediction rule, weren’t nearly as good as the decisions they made when using the rule. This finding interested Gladwell because it exemplifies a successful effort to “thin-slice” a complex, high-stakes decision, boiling it down to the few critical factors known to affect its outcome. The important point wasn’t that the prediction rule (an exemplar of “conscious deliberation”) performed better than doctors’ instinctive judgment. The point was that the combination of conscious deliberation and instinctive judgment is beneficial.
One might think doctors would welcome this kind of research, but most don’t. In fact, many doctors resent the idea that their clinical judgment can be improved by consulting simple, step-by-step algorithms. (Derisively, doctors call this idea “cookbook medicine.”) Expert clinical judgment, they protest, requires not only vast knowledge and long experience but also a finely tuned intuition that defies conscious, rational explanation.
The paradox here is obvious. We medical doctors acquire medical knowledge and validate it by the scientific method—by hyper-rational, deliberate, reproducible ways of knowing. And yet, many practicing doctors insist they know what to do for patients based on subconscious intuitions they can’t begin to explain. They may be right. I don’t know. Neither does Malcolm Gladwell or anyone else. But certainly Gladwell is right when he says we need to learn more about this. Because there’s a lot riding on these decisions.
• • •
When I speak to Mr. Warner, he opens his eyes. They are the color of a calm Caribbean. I introduce myself. He replies, How do you do?, his diction precise, its tone patrician. I tell him I’m the senior physician who will be caring for him in the hospital and he seems to look me over before saying, Oh, yes, how good of you to stop by, and now I’m beginning to question my flapping red flag—maybe I’m wrong, maybe he really is just meditating, tuning us out, not sick at all.
Then I notice that he seems to be looking not at me but over my shoulder somewhere. How are you feeling? I ask, watching to see if he focuses on me. I’m standing on his right but his eyes drift left and now I’m not sure if he sees me at all. I repeat my question and he says, Oh, yes, thanks very much, it’s kind of you to ask, as if he is addressing someone other than me.
And so he is.
According to Mr. Warner, he isn’t in the hospital at all (Oh, no, I never go to hospitals, how dreary they are), he’s visiting a friend for a week in the country (Today is Wednesday, of course, what a strange question) and it’s not January of 2010, it’s September of 1984 and Reagan is the president (He still looks awfully good, don’t you agree?) and he says, Now that you mention it, it is a bit stuffy in here, but no, he hasn’t had a fever or problems with urination or a headache or cough or anything else, and Oh, yes, I take my pills, yes, indeed, I never miss my pills—what, my pills? The names of my pills? Oh, yes, that’s a good one, ha ha ha, having names for pills . . .
So much, then, for the first part of the grunt work: the listening and asking questions and listening some more. This guy’s gonzo. I don’t know whether he’s always this confused—Alzheimer’s or AIDS or another kind of dementia—or whether he’s usually compos mentis but delirious now from acute illness. We’ll have to find out for sure from someone who knows him.
In the old days, Mr. Warner would have had one doctor. The doctor taking care of him in the hospital would have been the doctor who already knew him: his doctor. But I don’t know Mr. Warner and I can’t rely at all on what he tells me. This is a big problem because, for experienced doctors, the history (what the patient tells you) is 90 percent of diagnosis.
So I do what I must in this situation: I become a veterinarian. Unable to rely at all on verbal communication, I depend entirely on what I can see and smell, what I can feel with my hands and hear with my stethoscope, the nonverbal signs and sounds his body makes. Even master clinicians can learn only so much from the patient’s physical examination alone, but sometimes, like a mechanic looking under the hood, you can see right away what’s wrong.
As any mechanic will tell you, though, you can see only what you’re ready to see. For starters, your mind must be open, receptive to whatever sensory signals arrive, a sort of Zenlike “being there.” In busy hospitals, this is easier said than done. Here, in addition to the racket in the corridor, the damned televisions, and that infernal bleep-bleep-bleep from behind the curtain where Mr. Warner’s roommate lies, the distractions are olfactory and visual, too. That nauseating hospital smell—bodily effluvia mixed with medicinal vapors and bacterial decay. And what about these random personal items scattered around Mr. Warner’s bed? An expensive-looking leather travel clock. Three different pairs of eyeglasses. An apricot-colored ascot. With practice, doctors learn to ignore many of these sensory distractions and focus selectively, “attending” exclusively to the task at hand.
When looking under the hood, doctors must also know what’s normal and what’s not. For car mechanics, the trick is knowing all the different makes and models and years; for doctors, it’s knowing all the normal variants of the one make and model as it ages through the years. In the old days, many people had “routine” physical examinations performed by their doctors as part of an annual checkup. There are good (and bad) reasons why this practice has fallen out of favor today, but one unintended consequence is that recently trained doctors, when compared to dinosaurs like me, have examined relatively few normal people. The result is a less finely tuned diagnostic instrument, an examiner less able to know by looking at a spot on the skin, or feeling a lump in the breast, or hearing a murmur in the heart whether it’s abnormal (and potentially serious) or just a variant of normal (and nothing to worry about). Examining all the different parts of thousands of different people takes time, but, in the process, you get pretty good at knowing what’s within the normal human range and what isn’t.
Finally, if you want to “see smart” you must know what you’re looking for. In medicine, the symptoms and signs doctors look for are “context-specific,” contingent on the particular clinical situation. (This is why the patient’s history is so important: It tells the doctor what to look for.) In Mr. Warner’s case, the clinical context is unclear. I know that he’s HIV positive but I don’t know whether the virus has seriously damaged his immune system. Blood tests in the emergency department showed an elevated white blood cell count, often an indicator of infection, but because Mr. Warner is new to our hospital—he has no previous encounters recorded in our electronic medical records—we don’t know his CD4 lymphocyte count, the essential measure of HIV-infected patients’ immune function. How doctors think about HIV patients—what kinds of complications they may develop—depends critically on this key contextual fact: Is the patient seriously immune-compromised or not?
Just as important in Mr. Warner’s case, I don’t know whether his confusion is new or old. (Nor, if new, how new. Weeks? Hours?) A CT scan of his brain in the ED was reported as normal but the diagnostic significance of this result in Mr. Warner’s case depends critically on his history. Not knowing how long he’s been “not himself”—a simple thing his family or friends or personal doctor would know—means I can’t know yet how to process the information about his CT scan.
So, even though my mind is open as I begin to look under Mr. Warner’s hood—and even though I have lots of experience in distinguishing abnormal from normal findings—I am well aware that I may miss something important even if it’s right here in front of my nose. In this case, I don’t know exactly what I’m looking for—because I don’t know him.
He has a fever. I don’t take his temperature with a thermometer but he’s hot to the touch. This explains the beads of sweat on his forehead and the damp cling of his hospital gown. His pulse is strong and regular but it’s fast, 120 beats per minute. His breathing seems normal and unlabored but I take the fifteen seconds to actually count his breaths because tachypnea (rapid breathing, faster than twenty breaths per minute) is an important sign of how sick someone is. If you don’t take the trouble to count, you can miss this. Mr. Warner breathes six times in fifteen seconds. Twenty-four breaths per minute.
Almost certainly, then, he’s infected: the combination of fever, a fast pulse, rapid breathing, and a high white blood cell count defines SIRS, the medical acronym for Systemic Inflammatory Response Syndrome, the body’s typical physiological reaction to infection. Now the “context” for my looking is becoming clearer: Where is his infection? What’s causing it? How bad is it?
Top to bottom, I don’t find much. His scalp and eyes and ears are normal. His neck isn’t stiff. There’s no sign of thrush in his mouth—the sticky white plaques of fungus that often signify severely compromised immunity—and I feel no enlarged lymph glands in his neck, armpits, or groin. When I percuss with my fingers and listen with my stethoscope, his lungs sound healthy, not just in the back but in the front and sides, too. His belly is flat and nontender and all the organs there seem normal in size and shape. I had wondered about his left leg and foot when I first saw him from the doorway but he is able to move and bend them without difficulty, and I find no swelling or tenderness anywhere in his muscles or joints. His genitalia are normal and when I slide my gloved, lubricated finger into his rectum, he doesn’t flinch and there’s no sign of blood in his stool or swelling or tenderness of his prostate. The normal prostate exam and absence of any tenderness when I punch gently each of his kidneys make me doubt even more that he has a urinary infection, his preliminary diagnosis in the ED.
But I’m not finding an obvious alternative diagnosis, either. So far, I’ve found only two things that are not entirely normal. One is a small, bruised needle mark over his lower spine. This means he’s had a spinal tap, something that wasn’t mentioned in his ED chart. The second is his heart: The soft Shhh! I hear through my stethoscope when I lay it under his right collarbone tells me his aortic valve is a little stiff and the musical Whoot! I hear under his left nipple says his mitral valve leaks a little, too. But more than a few “normal” seventy-six-year-old hearts sing these same notes. So I don’t make much of them yet.
Finally, I perform a neurological examination. For some doctors, this would seem superfluous in a patient who had a normal CT scan of his brain just a few hours ago. In fact, many non-neurologists today don’t know how to do a competent neurological examination because they rely so heavily on CT and MRI scans to answer their neurological questions. But, in the old days, the neurological exam was all we had; CT scans and MRIs didn’t exist. After these wondrous technologies were introduced in the 1980s and 1990s, old-timers like me learned how often our bedside neurological exam missed important findings. But we also learned that CTs and MRIs can miss important things, too, some of which are detectable only by a thorough bedside neurological exam.
This neurological examination, which requires the patient’s cooperation, isn’t easily done with Mr. Warner. His verbal facility is intact (Yes, yes, I see it, that’s a wristwatch you’re wearing, rather a cheap one, actually . . . ), but his attention quickly wanders. He tends to drift off, not to sleep but somewhere else. He’s hyperalert but he’s listening to something or someone who isn’t me. Even so, he manages to cooperate well enough for me to establish that his cranial nerves (visual acuity and eye movement, hearing, facial movement and sensation, swallowing and tongue movement) function well. He moves his arms and legs with apparently normal strength and coordination. His reflexes (muscle twitches elicited by tapping his knees and elbows and other places) seem normal and symmetrical. When I formally test his mental status, he’s still completely out to lunch—disoriented to time and place, unaware of where he is or what he’s doing here. In fact, I’m finding exactly what I expected to find before I formally examined his nervous system—he’s confused and disoriented, with a waxing and waning attention span, but he has no “focal” abnormality of strength or perception or coordination. These are the findings one expects in an elderly patient delirious from infection. But none of this tells me what or where or how bad his infection is.
Except for one thing.
When I scratch the bottom of his foot with my thumbnail, dragging it slowly up the lateral side of his sole from his heel to the arch and then across the arch toward his big toe, his reaction is normal on the right foot but abnormal on the left. The normal response in this Babinski reflex is a curling down of all five toes, as most of us do when someone tickles our feet. But when I tickle Mr. Warner’s left foot, his big toe doesn’t curl down like his other toes. Instead, it stands up straight, archly erect, pointing back toward his face: Hey, hey, look at me!
I repeat this, several times, on both feet, to make sure. But every time the result is the same: unequivocally abnormal—and only on the left.
This is trouble. Big trouble.
It’s the Friday-night curse. In spades.
No one knows how this happens—how the mind of an expert diagnostician works—but in an instant, I think I know exactly what’s wrong with Mr. Warner. I can see his disease—it’s like I’m looking at it, a full-color picture in a pathology textbook, his heart and brain cut open on an autopsy table. If I’m right, Mr. Warner’s one priapic big toe means that even if we do everything we can to help him—and, in a great hospital like New York Presbyterian, we can do as much as anyone anywhere—the chance that he’ll ever leave the hospital alive is less than fifty-fifty.
• • •
Diagnosing disease has something to do with patterns. Like grandmasters in chess who can play (and win) twenty matches simultaneously, always knowing the best move to make from patterns of the pieces on the board, expert clinicians recognize patterns of patients’ symptoms and signs. Based on their prior experience with these patterns, expert doctors know what to do next. Research suggests that chess grandmasters store as many as fifty thousand different chessboard “patterns” in their working memory. It’s likely that expert doctors can recognize a similar number of clinical scenarios.
Unfortunately, most doctors are not experts. Like grandmasters in chess, master clinicians are rare. Remarkably, the medical profession doesn’t know much about its master clinicians.
How can this be? How can we not know more about medicine’s grandmasters? The main reason is that hospitals and medical schools don’t consider this a priority. Instead, hospitals focus on financial performance and meeting national accreditation standards; medical schools prioritize biomedical research and the training of competent (not expert) doctors. And, even if hospitals or universities considered it an important priority, how would they learn about master clinicians? Which “expert” doctors would they identify for study or emulation? Countless compendia list “best doctors” (in the United States, or New York, or wherever), but these rankings, much like the magazine ratings of “best” hospitals or “best” medical schools, are based as much on hype as on fact.
The truth is it’s not at all obvious who the best doctors are. Unlike chess, where the best players acquire grandmaster status by beating everyone else, there’s no objective way to identify the best players in medicine. This poses a real problem because the study of expertise in any field requires the study of its superstars. (K. Anders Ericsson, an expert on expertise, has noted: “Medicine has its legendary clinicians, but these are as rare as Olympic gold medalists and have not been systematically studied.”) Finally, even if we could corral these “legendary” clinicians, how would we study them? One of the most remarkable things about master clinicians, like experts in many other fields, is that most of them, when asked, can’t explain how they do what they do so well.
I suspect that the key to understanding this problem lies in learning more about how two different ways of human thinking complement each other. “System 1” thinking is fast, effortless, automatic, and nonconscious—the kind of thinking Malcolm Gladwell wrote about in Blink. Somewhat surprisingly, experts in many fields (including medicine) do much of their best work using System 1 thinking: They perform complex (cognitive and technical) operations effortlessly and fast, seeming not to think about them consciously at all. (This would explain why, when asked, experts can’t explain themselves.) But such expertise is achieved only after long experience and repeated practice of skills whose acquisition requires “System 2” thinking—the slow, assiduous, controlled process characteristic of conscious, deliberate learning. After many years (and only in some people), the need for (conscious) System 2 thinking when performing these complex tasks goes away—and then (subconscious) System 1 thinking “takes over.” How this happens is a mystery. But, just as grandmasters learn to recognize patterns of chess pieces and know instantly what to do, master clinicians learn to recognize patterns of symptoms and signs and know instantly what they mean.
One important difference between chess and medicine is that the grandmaster knows with certainty where all the pieces stand on the chessboard: The facts of each pattern are unambiguous. The grandmaster also knows that all relevant facts are there on the board to see, because the facts of chess are limited to thirty-two pieces on sixty-four squares. But in medicine, sometimes relevant clinical facts are missing and must be found. Even when all the facts are known, the pattern they make can be illusory because one or more of the “facts” may not be what it seems. Thus, unlike grandmasters in chess, master clinicians always “vet” the facts of the case—they make sure the pieces of information before them are factual and complete—before they allow themselves to “see” any pattern at all.
• • •
One upgoing toe. It seems such a trivial thing. But I can hang my hat—and maybe Mr. Warner’s life—on what it means.
Mr. Warner’s abnormal Babinski response on the left means that the motor pathways on the right side of his brain (which control muscle power on the left side of his body) are damaged. Just a moment ago, when I tested the muscle strength in his arms and legs, they had seemed normal to me, so I go back and test his strength again. Now, when he holds both of his arms up to shoulder height and I try to push them down against his resistance, maybe—but just maybe—his left is weaker than his right. And when I test his legs again, trying to push his knee down as he flexes it up hard toward his hip, I can talk myself into a left-right difference there, too. But it’s subtle, very subtle, and I’m not sure if it’s real.
I don’t want it to be real. I want to talk myself out of it. I want my Friday-night disaster just to go away.
And so I do a more sensitive test, which I hadn’t done before. I ask Mr. Warner to close his eyes and hold both of his arms up to shoulder height in front of him, palms up, and I watch to see what happens. He’s so out of it that he has difficulty following my instruction, but, even so, there can be no doubt: His right arm and hand remain elevated a rock-solid ninety-degree angle above his torso, his palm parallel to the ceiling; but, after just a few seconds, his left hand begins to pronate, its palm turning slowly toward his right, and then his whole left arm, slowly, very slowly, begins to drift down—an inch, then three. This “pronator drift” means that he does indeed have slight motor weakness of the left side of his body, so slight that it’s easy to miss.
Knowing this, now I put my face directly in front of his face and ask him to look me straight in the eyes. When he does this, I take my right hand and make a move as if to punch him hard on the left side of his face. I stop just short of hitting him but he doesn’t even blink. When I make the same threatening move with my left hand toward the right side of his face, he does the normal thing: He flinches, defensively pulling his head back to protect himself.
Now I know why Mr. Warner tends to turn his head to the left. It’s not that he sees something there that distracts him. In fact, it’s just the opposite: He can’t see anything in his left visual field. He is half blind and doesn’t know it. By turning his head to his left, he is subconsciously using his intact right visual field to see more of what’s in front of him.
Combined with his left-sided motor deficit, this visual field cut means one of two things: Either one lesion in Mr. Warner’s brain is responsible for both his weakness and his visual loss—in which case, it must be a very large lesion in his right cerebral hemisphere—or he has two separate lesions in his brain, one in the right frontal (motor) area and another in the right occipital (visual) area. In either case, what’s most important is that the CT scan of his brain just a few hours ago in the ED didn’t show anything abnormal: no signs of infection or hemorrhage or tumor.
Most likely, this means that Mr. Warner has had a big stroke (or two smaller strokes) at some time within the past twenty-four hours. When an artery that delivers oxygen and nutrients to a part of the brain is blocked by a blood clot (the cause of most strokes), that part of the brain suddenly can’t function, but the resulting brain damage may not be visible on a CT scan until twenty-four hours later. If diagnosed quickly, before the damage to oxygen-starved brain cells becomes permanent, strokes can be treated successfully with powerful clot-busting drugs, the same kind that are used to treat heart attacks. But clot-buster drugs help only if administered within three to six hours of the onset of the stroke, and because most stroke victims don’t get to the hospital in time, these drugs don’t help nearly as many people as they could.
Reflexively, I look at my watch. It’s 7:04. I’ve been with Mr. Warner for less than fifteen minutes but, including his time in the emergency department last night, he’s been here for more than ten hours. If Mr. Warner came to the ED with these neurological deficits, then it would be too late, our three-to-six-hour “therapeutic window” to use clot-buster drugs already closed. But if he didn’t—if, instead, he had his stroke after he arrived at the hospital, right here under our noses—then we would still have a chance to treat him and prevent potentially devastating brain damage. Not knowing which of these scenarios is true, ordinarily I would STAT page the hospital’s stroke team (on-site 24/7) to help me decide what to do, right now, no time to waste.
But I don’t page the stroke team. And I’m relieved that no one else did either.
Most patients having a stroke don’t have a fever and heart murmurs; they don’t have Mr. Warner’s kind of stroke. He probably has a blood clot in his brain, but if I’m right about what’s wrong with him, he has the one kind of blood clot—the one rare kind—for which we never use clot-busting drugs. Because, if we did, we’d kill him.
Mr. Warner’s kind of clot is called a vegetation. To the naked eye, it looks like a tiny piece of cauliflower. That’s what I’ve been seeing in my head—tiny bushes on a stalk—ever since that one big toe stood up and announced, Hey, hey, look at me! just a minute ago. In my mind’s eye I can see inside the cauliflower, too, as under a microscope, where bacteria, probably the virulent Staphylococcus species, are chewing—yes, literally chewing—on Mr. Warner’s once pristine, sterile heart valve. Surrounding the swarms of killer bacteria is an army of white blood cells, thousands of them, fighting desperately to contain and kill the Staph before the Staph kill Mr. Warner.
This vegetation is a battlefield. And if the right antibiotics don’t arrive in time to reinforce the army of white blood cells, the bacteria always win in cases like these. Always. There aren’t many things that are always true in medicine, but this is one of them, a 100 percent certainty. Right now, the bacteria clearly have the upper hand. Part of the vegetation has broken off from Mr. Warner’s heart valve, traveled through his circulation into his brain, and stuck there, closing off an artery.
That would be bad enough. A stroke is plenty bad enough.
But now those Staph bacteria are growing and multiplying—legions of them—not only in Mr. Warner’s heart but also inside that artery in his brain. And, they are eating. That’s what Staph bacteria do: They multiply and they eat. Unless Mr. Warner is a lucky man, unless we can kill all of the bacteria with huge doses of powerful intravenous antibiotics, those killer swarms will eat clear through the wall of that artery right into his brain.
Then the bleeding will start. The bleeding into his brain.
When that happens, there won’t be a damned thing we can do to save him. Clot-buster drugs would only make it worse. Much worse.
I hustle out to the nursing station. There, surrounded by computer terminals, several nurses are huddled together for their change-of-shift meeting, the nurses coming off last night’s eleven-to-seven shift “handing off” their patients to those starting the seven-to-three shift today. These hand-off meetings are crucially important to good patient care, the time when the nurses discuss what’s happened overnight to their patients, what needs to be done for each one this morning, what to watch out for today. As a rule, then, no one—and I mean no one—interrupts nurses during their change-of-shift meeting.
But there’s no time to waste. This can’t wait.
I steel myself for an icy reception, but after I quickly explain the situation, the head nurse, Ms. Croft, understands immediately. She’s a pro; she even thanks me. Whatever Mr. Warner’s diagnosis—we haven’t confirmed my own suspicions yet—he’s delirious and nurses know better than anyone how dangerous delirium can be. Confused, agitated, or hallucinating, some delirious patients climb out of their hospital bed and fall, breaking a hip. Others bleed after ripping out their IVs, urinary catheters, or surgical drains. I’ve even known one who died after jumping out her hospital room window.
Knowing these things, Ms. Croft assigns an aide—Now, Sylvia, do it now, please, she says urgently—to go into Mr. Warner’s room and sit “one-on-one” with him, right next to his bed, to make sure none of these bad things can happen to him. It takes a little longer for me to explain why we should not give anticoagulants (blood thinners) to Mr. Warner, not even the low doses given routinely to almost all hospitalized patients today to prevent life-threatening blood clots in their legs and lungs. But, after I lay it out, Ms. Croft tilts back her head, whistles ominously, and says, Got it. We’ll take care of it right away.
Urgently, I call down to the ED to speak with the staff who took care of Mr. Warner last night. I need to know more than what was scribbled in his chart. As I wait, holding on the phone, I’m wondering whether the ED guys know. Why did Mr. Warner come to the ED in the first place? Who brought him here? Who knows him? How long has he been sick? What do we know about his HIV disease—especially its impact on his immune system? Who is his doctor? Where is his doctor? What is his “baseline” mental status? Is his confusion new? Did anyone in the ED find the left-sided weakness and visual field deficit when they examined him? If not, why did they do the CT scan of his brain? All of these questions must be answered for me to fill in the blanks, help clarify whether I’m thinking straight.
But the ED guys can’t answer my questions.
None of them knows Mr. Warner.
Like the nurses here on 10 Central, the ED staff changes over at 7:00 a.m. The doctors and nurses in the ED work long, hard, busy twelve-hour shifts and the 7:00 p.m. to 7:00 a.m. night shift has signed off. They’ve left the building. The oncoming day-shift staff have received their “hand-offs” for the patients in the ED now. But they don’t know anything about Mr. Warner. He left the ED hours ago. He doesn’t belong to the ED docs anymore.
He belongs to me.
So, for all I know right now, Mr. Warner is like Ms. Jackson, our bipolar homeless lady who wanders the fifth floor, ranting. It’s like Mr. Warner has dropped down from another planet. We have no history, medical records, or friends to corroborate what he says. From the look of him, he isn’t a homeless psychotic, but, right now, he might as well be.
I log on to a computer at the nurses’ station. All tests done in the hospital, including those from the ED, are recorded there. According to the ED doc’s written note, Mr. Warner’s white blood count is high and there are red blood cells and white blood cells in his urine (an abnormal but nonspecific finding). But his other blood tests look good and the preliminary report of the CT scan, dictated at 1:12 a.m. by the radiology resident, is “normal for patient’s age.” I make a mental note of the uncertainty this raises. The “preliminary” report means that an attending radiologist, much more experienced than the radiology resident, hasn’t read the CT scan yet. The “normal for age” interpretation raises the possibility that the scan isn’t normal but that potentially important abnormalities have been attributed erroneously to “old age.”
I will need to review the CT images myself this morning with an attending radiologist. In Mr. Warner’s case, my working diagnosis—acute bacterial endocarditis with septic emboli to the brain—depends critically on the fact that his CT scan is normal. If it isn’t normal—if the resident’s preliminary interpretation is incorrect—then I’m back to square one.
Now I see in the computer that spinal fluid specimens were received in the laboratory at 2:57 a.m.; the results of the fluid analysis are still pending. Based on my own examination, I’d be surprised if the spinal fluid results will help us much, but at this point we’re missing so much critical information about Mr. Warner that every piece of objective data is welcome. We should have the preliminary spinal fluid results very soon.
Finally, I look at the orders entered into the computer for Mr. Warner by Dr. Tina Johansen, the resident on my team who has been in the hospital all night and who admitted Mr. Warner. As usual, Tina has done the orders meticulously well. She has started several different antibiotic drugs simultaneously. This means Tina isn’t sure what kind of infection Mr. Warner has—good for her, she’s thinking independently, not passively accepting the diagnosis made by other doctors in the ED—but I can see from her antibiotic choices that she may not be thinking the same way I am.
We need to get our heads together about this. Now. If I’m right, we have no time to lose.
I page Tina on her beeper. She answers right away.
Sorry to interrupt, I say into the phone, but we’d better start rounding now. I’m worried about Mr. Warner. So let’s see him first, up here on 10 Central, okay?
Tina’s voice is crisp and clear, all business. You’d never know she’d been working hard, continuously and sleepless, for twenty-four hours straight. And you’d never know that she’s not happy about my call. I’m interrupting her own rounds with the other members of our team, a process she (like all residents here) guards jealously, because this is the time when the residents see and talk about our patients without me, when they run the show themselves, sharing their opinions and teaching each other without feeling inhibited or intimidated by their attending physician. Resident rounds is an important part of their education—it won’t be long before they finish training and assume the responsibilities of an attending physician like me—and it’s a long-standing tradition here at Cornell. Knowing this, I interrupt residents’ rounds no less apologetically than I interrupt nurses’ change-of-shift meetings.
But medical care isn’t about the doctors or the nurses.
Tina doesn’t miss a beat.
We’ll be right there, she says.
Hospital medicine is all about teamwork. This has always been true to some extent, but the need for teamwork has grown dramatically in recent years because hospitalized patients are “sicker and quicker” than ever before. They are sicker because medical progress has allowed patients to live longer with chronic illnesses (such as heart failure, cancer, and AIDS). Because many diagnostic procedures and treatments that once required hospitalization are now done routinely outside the hospital, the average patient admitted to hospitals today is older, suffers from more comorbidities (multiple chronic conditions), and receives more sophisticated inpatient treatment than patients hospitalized in the past.
Remarkably, these sicker patients are also “quicker”—many of them remain in hospital, on average, only half as long as (less sick) patients did years ago. This acceleration of inpatient care has happened because hospitals no longer are reimbursed for every day the patient stays in hospital; instead, hospitals now receive one lump sum based on each patient’s principal diagnosis (regardless of how long the patient remains in hospital). So, hospitals try to minimize each patient’s “length of stay,” because shorter stays reduce the hospital’s per-patient costs. Today, hospitals’ profit margins are all about “patient throughput.”
These two trends—older, sicker patients and hospitals’ financial incentives to compress more care into less time—place a premium on efficient “24/7” inpatient care that is more intensive than ever before. Only teams of caregivers—working, of necessity, in shifts—can handle this around-the-clock responsibility well. (It is possible, but unproven, that this explains the “Friday-night curse”; even today, many hospitals are not staffed as well on weekends as on weekdays.)
In 2000, the Institute of Medicine reported that medical errors in hospitals caused almost as many annual deaths (98,000) in the United States as motor vehicle accidents (43,000), breast cancer (42,000), and AIDS (16,000) combined. Improved teamwork among doctors, nurses, and other hospital staff can mitigate many of these errors. Most important is clear communication of patient information and treatment goals among the many different caregivers who help “staff” patients around-the-clock throughout their hospital stay. This sounds easy but it’s deceptively hard to do well. Patient hand-offs, for example, are notorious occasions of error. This is why nurses guard their change-of-shift meetings—and focus their efforts so closely—when transferring care of patients from one shift of nurses to the next.
Most doctors don’t do hand-offs or work as a team nearly as well as nurses, because, until recently, we never had to learn how; unlike nurses, doctors didn’t do shift work. Now we have a lot of catching up to do.
Today, only two of my team’s regular seven members are in the hospital. The other five have the day off. The same will be true tomorrow, Sunday—but it will be a different two. Tina, by law, must leave the hospital no later than 10:00 a.m. today. (The legal maximum for residents is twenty-seven straight hours on duty.) Chris, not a regular member of our team, has been called in today to supervise Dan, an intern, because Brian, our team’s regular senior resident, has today off. Leah, a physician assistant, also has been brought in as a pinch hitter because our regular PA (and our two medical students) don’t work weekends. Leah will help to manage our team’s twenty patients today while Chris and Dan are busy admitting new patients. Tomorrow, Dan will leave the hospital in the morning after working all night tonight; Tina will have Sunday off. Brian and Ashley (our other intern), both off today, will take over the team tomorrow—but only after Dan and I catch them up early tomorrow morning on all our new patients and everything else that will have happened in the thirty-six hours since Brian and Ashley went off duty Friday evening.
If you find this hard to follow, so do we. It’s a challenge just keeping track of who will be here when—and who needs to “hand off” what to whom—to ensure that we take good care of our patients twenty-four hours a day.
Keeping track also of who’s teaching whom—and who’s learning what—is a whole other story. I pay attention to such things because, in addition to diagnosing and treating the patients in this teaching hospital, I’m expected to diagnose and treat the learners, too. This is especially challenging because my team consists of seven learners at six different levels of training—two residents, two interns, one physician assistant, and two medical students—each of whom deserves individual attention. Chris and Brian are senior (third-year) residents, both of whom will begin prestigious cardiology fellowships a few months from now. Their educational needs are different from those of Dan and Ashley, interns (first-year residents) who are new to clinical medicine, or Tina, a junior (second-year) resident who is somewhere in between. All of them are far more experienced clinically than my two medical students—one of whom is a third-year “clerk,” the other a fourth-year “subintern”—and different from Leah, a physician assistant who has a lot of clinical experience but never went to medical school.
For generations, U.S. medical learners have taught each other: Senior residents teach junior residents, who in turn teach interns, and so on down the line. This tradition endures today, but it has become much more difficult to sustain (and evaluate), because only rarely is the whole team on the playing field together. More than ever before, the team needs a coach.
• • •
Jeez, Tina says.
Doe-eyed and pretty, smart as a whip, Tina has answers to all of my questions without my even asking. Three nights ago Mr. Warner had dinner with his niece and was his usual bright, witty self. The next day, he had a slight fever and didn’t feel well. His niece called yesterday to inquire about him but no one answered the phone. Alarmed, she went to her uncle’s apartment, where she found him confused and unkempt and called an ambulance. Mr. Warner has been HIV positive since 1995. He had told his niece as recently as last week that his antiretroviral medications were a “miracle” that had kept him “healthy as ever.” We will need confirmation from his doctor, but this suggests that Mr. Warner’s immune function has not been severely compromised by his chronic HIV infection. Equally important, we now know that his baseline mental status is normal—his confusion is new—and he’s been ill for only a few days. Unfortunately for Mr. Warner, these facts support my own diagnostic suspicions.
Tina admits now she still isn’t sure what’s going on, which is why she took the time and trouble to do a spinal tap last night, even though she was busy with other patients and the ED docs didn’t think the tap was necessary. Tina was worried about bacterial meningitis or viral encephalitis as well as sepsis from a kidney infection. To cover all these possibilities, she started several different antibiotic regimens simultaneously, pending further test results from the lab. She did all the right things, given the information she had.
But now she has new information.
We’ve just finished examining Mr. Warner together.
Jeez, Tina says again, biting her lip.
When we first gathered at Mr. Warner’s bedside, he had resumed his peaceful, meditative pose. He remained this way—silent, motionless, eyes closed—even when Chris took down Mr. Warner’s damp gown, put a stethoscope to his bare chest, and listened carefully to his heart. Only after we roused Mr. Warner to attention—we needed his cooperation to test his strength and vision again—did he actually meet his team of doctors. Then, he opened his eyes wide, looked around at all of us, and blinked hard.
Well, good evening, good evening! How nice to see you all! My, my, there are quite a few of you, aren’t there? Was I expecting you? Oh, but that doesn’t matter, does it? Do come in, let me get you all something nice to drink. Come in, come in . . .
Dan and Leah suppressed giggles. But Chris lifted an eyebrow when that one upgoing toe went up. His other eyebrow rose when Mr. Warner’s left hand pronated, then drifted down, again. And when I threw my right cross at Mr. Warner’s face and he didn’t blink, Dan and Chris murmured Whoa! in unison.
This is all new to Tina. She hadn’t seen any of it last night. But it doesn’t take her long to put it together. She looks at me wide-eyed.
The neurological findings, she says, you think these are . . . ischemic? You think he’s had a stroke . . . or maybe multiple strokes?
That’s the most likely explanation, yes.
She considers this, then looks at Chris.
I wasn’t impressed by the heart murmur, she says. Were you?
Yeah, Chris says. Actually, it sounds to me like two different murmurs: aortic stenosis and mitral regurgitation—not severe, probably, but real.
Now Tina and Chris examine Mr. Warner’s hands and feet, inspecting his fingernails and the bottom of his toes. Then Tina looks at me again.
I don’t see any peripheral signs of endocarditis, she says. Do you?
No.
Even so, Tina muses aloud, fever . . . heart murmurs . . . strokes . . . And here I am treating him for everything except endocarditis!
The several antibiotics Tina had ordered didn’t cover the deadly staphylococcal infection that I was most worried about. Just as I hadn’t known everything Tina knew about Mr. Warner’s history, Tina hadn’t seen everything I’d seen on his physical examination. As a result, in her mind’s eye, Tina hadn’t seen those lethal vegetations growing in Mr. Warner’s heart—and now, maybe, in his brain.
But she’s seeing them now. And she’s kicking herself for not seeing them before.
Jeez, she says, shaking her head and looking sheepishly at me.
Don’t get ahead of yourself, Tina. We don’t know anything yet for sure.
We leave Mr. Warner with the nurse’s aide sitting by his side. I’m hoping his confusion will lessen after we get his fever down. Maybe then we can explain some of this to him, too.
As we walk out to the nursing station, Tina turns to Chris.
Occam’s Law, right? Tina says.
Could be, Chris answers.
Tina takes a seat in front of a computer terminal. She searches for incoming lab results. We can see now that there are forty white blood cells and twenty-five red blood cells in the fluid she removed during the spinal tap she performed last night. This is abnormal—normally, there aren’t any cells seen in spinal fluid—but it’s nonspecific, a finding compatible with Tina’s diagnostic hypotheses (early meningitis or encephalitis) as well as my own. We talk briefly about this. We agree we must wait for additional tests before we can draw any firm conclusions.
Tina types urgent new orders into the computer, her fingers a blur. She amends her previous antibiotic orders to cover the deadly staphylococcus. She asks the nurses to give the new antibiotics STAT. She places an order to transfer Mr. Warner to an intermediate cardiac care unit, where we can monitor his heart more closely. She arranges an urgent Cardiology consultation, an ultrasound examination of his heart, and an MRI of his brain.
I’m impressed, and it’s not Tina’s typing skills that catch my eye. It’s her honesty. Tina readily admitted that she must have missed Mr. Warner’s neurological findings when she examined him last night. Such confessions are not easy to make in the competitive environment of a top teaching hospital—even when her sin is easily forgiven, as in this case. Mr. Warner’s findings are subtle; I could easily have missed them myself. Equally impressive, Tina not only understood the implications of her mistake immediately, she also exhibited the single most difficult cognitive skill in medicine: the ability to change one’s mind—to reconsider, or reject outright, one’s previous conclusions when new facts render those conclusions less tenable. This sounds easy but it isn’t. Some doctors learn it, then lose it. Many never learn it at all.
Tina finishes typing in her new orders. Staring at the monitor now, she wonders aloud why the nurses have held her order for heparin, the blood-thinner I asked the nurses not to give a short while ago.
I look at Chris. He’s not sure. I explain.
Patients who have endocarditis-related stroke are much more likely to bleed into the brain than patients who have other kinds of stroke. If this is what’s happening to Mr. Warner, we must do everything we can to minimize his risk.
If this is what’s happening . . . Tina says.
Right. We don’t know yet. The other possibilities you mentioned—sepsis, early meningitis, encephalitis—are definitely still in the game.
Chris gives Tina a thumbs-up.
Whew! Tina says. I’m glad I did something right!
You did fine. Mr. Warner’s a tough one.
I look at my watch. It’s 7:42. We’ve got a long way to go. We hustle down the corridor toward the elevators.
What’s Occam’s Law? she asks.
William of Occam was a monk, or something like that, like hundreds of years ago, Tina says. He claimed that when you’re trying to find the cause of a complex set of phenomena, the simplest explanation is usually the correct one.
Simplest? Leah asks.
Yeah, Tina says, not simplest like . . . easiest or . . . dumbest, but like . . . if one cause can explain all of the phenomena in question, then that one cause is more probable than multiple different causes operating at the same time.
O-kay, Leah says, unconvinced.
Like in this case, Tina continues. We’re saying that one diagnosis—bacterial endocarditis—can explain everything we’ve found in Mr. Warner: his fever, heart murmurs, the neurological findings, the cells in his urine and spinal fluid, the CT scan. Occam’s Law says it’s more likely that Mr. Warner has this one diagnosis that can explain everything than that he has multiple diagnoses—a kidney infection and a stroke and heart murmurs—all unrelated but present simultaneously.
The elevator arrives, empty. We get on board, push the button for the fourteenth floor.
Leah looks at Tina.
So . . . this Occam’s Law thing . . . it’s always right?
Tina hesitates, then turns to me.
No, I say. Actually, in medicine it’s often wrong. It tends to be right in young, previously healthy patients. In them, an illness characterized by many complex phenomena usually does follow Occam’s Law. But elderly people who already have lots of different things wrong with them? Or people who have underlying conditions like AIDS that predispose them to many other diseases, too? Often those cases don’t follow Occam’s Law.
So . . . ? Leah says as we get off the elevator. In this case . . . ? I mean Mr. Warner is old. And, he’s got HIV . . .
Yeah.
Hickam’s Dictum, Chris says.
Leah rolls her eyes. Dickam’s what? she says.
Hickam’s Dictum, Chris repeats. Hickam was a doc at Duke ages ago, like in the sixties or seventies maybe . . . Uh, no offense, Dr. Reilly.
Everyone laughs.
Anyway, Chris continues, Hickam wasn’t an Occam fan. So he came up with his own saying. It’s . . . kind of . . . the flip side of Occam.
How’s it go? Tina asks.
Chris makes rabbit ears with his fingers and intones, “The patient can have as many diseases . . .”
He pauses for the punch line, smiling.
“. . . as he damn well pleases.”
Tina guffaws, a big belly laugh.
Leah looks at me.
So . . . ? she asks.
We’ll see, Leah. We’ll see.