We can’t stress often enough that anecdotes are not reliable evidence; but on the other hand, patient stories can serve a valuable purpose in medical education. Hearing how a disease affected an individual patient is more powerful than reading a list of symptoms in a textbook and is far more likely to fix the disease in the student’s memory. When I think of Parkinson’s disease, the first thing that comes to mind is my first patient with Parkinson’s and how he responded to levodopa; and the first thing that may come to many people’s minds is Michael J. Fox. Of course, we must realize that they may not be typical examples; but putting a face to a diagnosis serves as a memory aid and a hook to hang the rest of our knowledge on.
In his new book, , Paul F. Griner, MD relates more than 50 stories that distill the wisdom he has developed over a 58-year career of practicing medicine and teaching young doctors. He describes them as “stories that provided a learning moment for me.” It’s interesting to see how much medicine has changed over his professional lifetime and yet how cases from the 50s and 60s are still highly relevant. Ethical dilemmas and lessons about medical practice come alive under his pen. Each story is followed by incisive questions and exercises that engage the reader and challenge him to think about the issues.
Is She a Virgin?
Instead of pontificating, Griner humbly questions his own judgment. Suspicious parents once demanded that he examine their 14-year-old daughter to see if she was still a virgin. He thought it was an invasion of the girl’s privacy, and he knew the physical exam was not a reliable guide to whether the girl was sexually active. He talked to the girl in private and chose not to examine her but instead to suggest ways to improve her communication with her parents. He then told the parents she was probably still a virgin. His anger may have clouded his judgment; he considers that maybe he should have examined the girl because she might have been pregnant, and he wonders how he might have handled the situation differently. Then he asks “what would you have done?”
When Griner was president of his hospital, he had an embarrassing experience. A dermatologist had him undress for a full skin exam and gave him a gown that was torn where the buttons met at the shoulder so it kept slipping off. The next day he called a meeting of his management team and entered the conference room wearing that gown and nothing else. His stunt impressed them and gave them vivid insight into the vulnerability patients feel. Changes were made. They still talk about it.
The Walking Dead
A patient who had had a heart attack was revived with an emergency chest incision and manual heart massage. He woke up, got off the table, and walked across the room with the doctor’s hand still inside his open chest. Then he collapsed and died. Why did they open his chest? Because defibrillators hadn’t been invented yet and closed chest massage for cardiac arrest wasn’t even described until 2 years later.
A Solution Worthy of MacGyver
It’s easy to forget that we have not always had portable EKG machines, monitors, and defibrillators. In the days before those were available, Griner was at a cardiac patient’s bedside when the patient became unresponsive. He diagnosed cardiac arrest due to ventricular fibrillation. He stripped the wires from the bedside radio, attached them to two long needles, plunged the needles into the patient’s chest, and had the nurse repeatedly insert the radio plug into the wall socket; the patient quickly revived. Always the skeptical scientist, he now wonders if the patient really was in ventricular fibrillation, since he had not been able to verify his diagnosis with an EKG, and since modern experts question whether a 120 volt shock could reverse v. fib. And he asks us to consider the ethical and legal implications of performing an unprecedented treatment like this on a patient without informed consent.
Looking Without Seeing
He asked a patient with fever and chills if his teeth chattered. The patient grinned and said, “Let’s look in the drawer and find out.” His false teeth were in the drawer of the bedside table! Griner stresses the importance of good bedside skills of listening, observing, and examining; and deplores the increasing tendency of young doctors to pay more attention to test results than to patients. The great majority of diagnoses can be made on the basis of the patient’s history alone, and most of the rest are made on the physical examination. Tests should be used to confirm diagnoses, not to make them.
Issues Worth Discussing
Griner talks about how today’s rapid improvements in technology may be outpacing our ability to apply it wisely. Doctors are losing their bedside diagnostic skills; it’s easier to order a battery of tests and hope something turns up. Excessive testing increases costs and can even harm patients.
New regulations allow medical residents to get more sleep. He relates being so exhausted during his training that once when he couldn’t get an IV started, he threw all the IV equipment on the floor and wished the patient would die just so he could get some sleep. New policies may reduce the risk of errors, but it can also be argued that they reduce the quality of education.
Are we upholding the ethical values of truthfulness, justice, dignity, and confidentiality? He discusses the ethics of hastening death in a patient suffering inexorably from terminal cancer, and admits he once killed such a patient with an overdose of morphine. He illustrates the problem of allocating scarce resources with his experience of having to decide which patients to treat with the pitifully few respirators available during an influenza epidemic. He asks what doctors should do when they think a colleague is incompetent, and illustrates it with an experience of his own with a superior in the military. (I could really relate to that one! You can read about my own experience in my book.)
Doctors today are pressed for time and tend to look more at their computers than at their patients. We all stand to lose when there is less time for human interactions. Griner wants to put a more human face back on medicine.
He describes several innovative teaching methods. One I found particularly intriguing was a program where 4th year medical students shadow a patient from admission to discharge and record every instance where care could be improved, everything from waiting times and housekeeping issues to medication errors and unprofessional behavior.
When one considers the amazing progress of science in its relation to medicine during the last thirty years, and the enormous mass of scientific material which must be made available to the modern physician, it is not surprising that the schools have tended to concern themselves more and more with this phase of the educational problem.
Griner might have said that, but he didn’t. Francis Peabody said it in 1927 regarding students at Harvard Medical School. Plus ça change, c’est la même chose.
In this entertaining gem of a book, Dr. Griner raises important questions that are well worth grappling with, and he teaches valuable lessons. I wish every medical student and health care professional could read this book. And anyone who likes to read true stories about medicine will find the book fascinating.