Wednesday, February 25, 2015

What Doctors Can Learn from Sherlock Holmes

I remember reading Sir Arthur Conan Doyle’s Sherlock Holmes detective stories as a child. I tore through each page of each book, relishing Holmes’s crime-fighting abilities and dreaming that I could replicate them. I even would have settled for the opportunity to work alongside Holmes like his loyal ally Dr. Watson, sharing in adventures and assisting the great investigator. Today, when I return to stories like The Sign of the Four, I am just as enthralled and entertained as I was then.

Sherlock Holmes sculpture by John Doubleday,
at Meiringen, Switzerland, near the Reichenbach waterfalls,
where Holmes faces his nemesis Professor Moriarty
in “The Final Problem.”
Image via Shutterstock

Holmes’s power of observation is his most impressive trait. He observes his surroundings more carefully than any of the professionals at Scotland Yard. He notices the way a man dresses, the way someone walks, different types of ash from pipes, and unique types of handwriting. Holmes succeeds as a detective using this unmatched faculty. As a budding physician, I am beginning to realize how relevant this ability is to the practice of medicine.

Indeed, Conan Doyle based Holmes off of his teacher in medical school: Dr. Joseph Bell, a professor of medicine at the University of Edinburgh. The author wrote to Dr. Bell in 1892: “It is most certainly to you that I owe Sherlock Holmes.” Though Conan Doyle never pursued medicine as a career, he assimilated much from his mentor. He describes his encounter with Dr. Bell in the book Memories and Adventures (1924):

For some reason which I have never understood he singled me out from the drove of students who frequented his wards and made me his outpatient clerk, which meant that I had to array his outpatients, make simple notes of their cases, and then show them in, one by one, to the large room in which Bell sat in state surrounded by his dressers and students. Then I had ample chance of studying his methods and of noticing that he often learned more of the patient by a few quick glances than I had done by my questions.

From Dr. Bell’s perspective, teaching students to use their eyes as well as their textbook knowledge was of paramount importance. Deflecting his former student’s praise, Dr. Bell explained in the Strand Magazine

Dr. Conan Doyle has, by his imaginative genius, made a great deal out of very little, and his warm remembrance of one of his old teachers has coloured the picture. In teaching the treatment of disease and accident, all careful teachers have first to show the student how to recognize accurately the case. The recognition depends in great measure on the accurate and rapid appreciation of small points in which the diseased differs from the healthy state. In fact, the student must be taught to observe. To interest him in this kind of work we teachers find it useful to show the student how much a trained use of the observation can discover in ordinary matters such as the previous history, nationality, and occupation of a patient.

An example of Bell’s acumen tells us much about his prowess as a physician. Conan Doyle recounts the following conversation between Bell and a patient:

“Well, my man, you’ve served in the army.”
“Aye, sir.”
“Not long discharged?”
“No, sir.”
“A Highland regiment?”
“Aye, sir.”
“A non-com. officer?”
“Aye, sir.”
“Stationed at Barbados?”
“Aye, sir.”
“You see, gentlemen,” he would explain, “the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilian ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British.” To his audience of Watsons it all seemed very miraculous until it was explained, and then it became simple enough. It is no wonder that after the study of such a character I used and amplified his methods when in later life I tried to build up a scientific detective who solved cases on his own merits and not through the folly of the criminal.

Dr. Bell further explained his methods in the Strand Magazine:

And the whole trick is much easier than it appears at first. For instance, physiognomy helps you to nationality, accent to district, and, to an educated ear, almost to county. Nearly every handicraft writes its sign manual on the hands. The scars of the miner differ from those of the quarryman. The carpenter’s callosities are not those of the mason. The shoemaker and the tailor are quite different.

It is tempting to think of Dr. Bell’s and Sherlock Holmes’s skill as the stuff of history. How many of us handcraft shoes these days? Also, these methods seem useless in the age of labs and imaging. We can track liver enzymes, look at cells from biopsies, get blood counts, and perform full body scans showing us much of what we need to see. Nevertheless, to rely on labs and imaging and other recent techniques to dismiss Dr. Bell’s method would be a mistake.
* * *
During an outpatient clinic week, one woman came in complaining of a “racing heartbeat.” The resident and I interviewed her together and asked a series of questions that most physicians ask a patient during a visit: When did this start? What does it feel like? Do you have any shortness of breath with it? Does it happen while you’re active or at rest? Does anything make it better or worse? Is there any pain associated with it? Is it constant or does it wax and wane? Do you have any other symptoms with it? Have you had any sick contacts recently?

From what we gathered, she, her two children, and her husband all had pertussis, or whooping cough (That a whole family has a disease for which we have a vaccine is distressing — see my post on vaccines here.) She had been coughing hard for months and was taking Robitussin to mitigate her symptoms. But at random times during the day, she felt like her heart was racing. She denied an association between the cough and any activity and claimed that she wasn’t taking any medicine other than Robitussin. None of us could figure out why she was having these symptoms. We ordered an Electrocardiogram (EKG), which demonstrated a fast heart rate but no abnormal rhythms.

As we walked out of the room we noticed an inhaler of albuterol hanging out of the patient’s purse. An inhaler is used by asthmatics to control wheezing. It is one of the first-line treatments for asthma and it allows patients to breathe in medication, thus making sure the medicine gets into the lungs. We asked if she was using it. She admitted to taking it seven to eight times per day. Her son had asthma and she used his inhaler to help with her cough.

Albuterol acts on beta-2 receptors in the lungs. These receptors, when stimulated, cause relaxation of the muscles that control the airways. In asthmatics, the airways clamp down and cause shortness of breath and wheezing. Albuterol reverses this effect. Unfortunately, there is minor cross-reactivity between beta-2 receptors and beta-1 receptors. Beta-1 receptors can increase the heart rate and cause cardiac arrhythmias. This particular patient was using the inhaler so often that she was getting a lot of cross-reactivity and consequently felt like her heart was going to jump out of her chest.

We explained this to her and told her to stop using the inhaler. She left without any prescriptions — an unusual outcome for a clinic visit. In this case, even though we had taken a thorough history by asking the patient careful questions and getting an EKG, we were flummoxed. Only by observing not just the patient but her belongings were we able to figure out what was going on.

A doctor’s success depends both on the ability to elicit information from the patient and to watch carefully for signs of unusual behavior or circumstances. Observation is and remains, as it was for Dr. Joseph Bell, integral to the accurate recognition of a patient’s illness. It requires levels of attentiveness that only the expert observer could describe as “much easier than it appears at first”; while being foundational, it is by no means elementary.

Thursday, February 12, 2015

Finding Humor in Medicine

Dmitrijs Bindemanis via Shutterstock

One morning, I checked in on an 82-year-old female who was admitted overnight after falling in her home. She looked like any other elderly woman: gray hair, thin legs and arms, and wrinkled skin. Yet she lacked the frailty and exhaustion that sick older people often exhibit and wore a faint smirk — the angles of her lips curved upwards just enough to discern an optimistic disposition. As I knocked and entered she startled and pulled the covers up to her chin.

I asked the woman how she felt, if there was anything she needed and, in turn, she answered and asked me how I was doing. She seemed, in other words, to be skillfully participating in the sort of anodyne introductory conversation that people have when they first meet in such settings. But when I asked her if she knew where she was, she replied “no.” It turns out she had dementia, a slow and progressive deterioration of mental function, and could tell me almost nothing about life at home. In response to more detailed questions I only received a nod or a barely audible “yes.” Even when I kneeled close and raised my voice, assuming she was hard of hearing, I received similar responses. Disease had mangled her memory and her ability to socialize appropriately.

When we rounded, I presented her to the medical team and entered the room to examine and speak with her. Our attending physician asked the patient how she was feeling. Frustrated by her inability to answer my questions, the patient replied “sad” and exclaimed “I could really use a joke to lift my spirits!” It’s a request that we so rarely hear in a hospital; everyone wants food, or drink, or medicine, but few people request a joke. The attending asked me to tell the patient a good joke after rounds.

I’m not skilled at the art of joke-telling — it requires the appropriate joke at the appropriate time with the appropriate delivery. And this particular situation did not lend itself to a complex yarn with a long backstory. It needed to be simple. So I thought a knock-knock joke would do the trick; after all, everyone knows how knock-knock jokes work. Here’s the one I planned to use:

Knock, knock
Who’s there?
Rufus, who?
Rufus the highest part of the house.

Granted, it is corny, but I was sure it would elicit a chuckle from an old lady with dementia. Then I told her the joke:

Me: Knock, knock
Her: Knock, knock
Me (jokingly): Who’s there?
Her: Who’s there?
Me (attempting to start over again): Knock, knock
Her: Knock, knock

She wasn’t doing this playfully; she did it because she could not understand or remember how knock-knock jokes work. When we all got back to the physician workroom, I told the medical team about this encounter and we had a good laugh. Indeed, dementia is the theme of many jokes in medicine. Have you heard the one about the doctor and the Alzheimer’s patient?

"I'm sorry to tell you this but you have cancer," the doctor told her patient.
"I do?"
"Yes, but that's not all... you also have Alzheimer’s disease," said the doctor.
"I do?"
"Yes,” nodded the physician.
The patient beamed and said: "Oh well, at least I don't have cancer."

Or, maybe you’ve heard this other good joke about dementia:

The doctor tells his patient: "Well I have good news and bad news..."
The patient says, "Lay it on me Doc. What's the bad news?"
"You have Alzheimer's disease."
"Good heavens! What's the good news?"
"You can go home and forget about it!"

But what is so funny about these jokes? Aren't we laughing about a debilitating disease that tears apart lives? In that room I entered was a woman who could not participate in a joke that even the youngest and simplest child could understand. Why is some part of this funny?

*   *   *
In another medical unit, we took care of an 80-year-old with metastatic cancer nearing the end of his life. He needed a breathing machine to pump air into his lungs and was being fed through a tube which connected his stomach to a container of liquid nutrients. He lay in bed without moving, occasionally blinking his eyes. Because he lay in bed all day he developed pressure ulcers. The pressure from an immobile person’s weight on the bed causes skin breakdown. This leads to serious and life-threatening infections as well as terrible pain. In order to slow the breakdown process, nurses constantly change the position of the immobile patient, rolling him or her every few hours and putting creams and ointments on the sores.

During rounds, I helped the nurses and the attending physician to examine the patient's pressure sores. When we turned the patient, his hospital gown opened exposing his bare derrière. I bent down to look closely at his sacrum, an anatomical spot above his anal opening, which contained multiple ulcers. As I got close, the patient let out a huge fart. I almost burst out laughing but abruptly held myself back when I saw the attending physician, staid and focused on the ulcer. Why did I nearly laugh at flatulence from a patient who was so close to death that he could not control his bowels? Should I laugh at that?

Irreverent, dark, depressing, and, yes, immature humor pervades the medical profession. We all tell each other funny stories like these when we get together. I remember one resident telling me a knee-slapper about a demented patient throwing feces at her. It’s funny, in an upsetting way.

Multiple days a week, physicians witness some of the darkest moments that human beings experience in their lives: cancer diagnoses, deathalcoholismdrug overdoseschild abuse, neglect and abandonment, depression, horrific trauma, progressive physical and mental disease, stillbirths, strokes, and more. Humor is one of the ways physicians deal with this barrage of depressing encounters.

But why? Perhaps to understand this response in the relatively mild context of the hospital, we can examine the most extreme example of humor in the face of suffering — the Jewish experience before and during the Holocaust.

Ruth Wisse, the Martin Peretz Professor of Yiddish Literature and Professor of Comparative Literature at Harvard University, wrestles with the idea of tragic humor in No Joke, her wonderful 2013 book on Jewish humor. Professor Wisse notes that during tumultuous times, Jewish humor flourished because of “an increased need for entertainment that would distract or temporarily release the tension, and offer consolation.” One Jewish comedian in particular, Shimon Dzigan, exemplified this concept during the early twentieth century in Eastern Europe, playing characters on stage in sketches which poked fun at local Polish political figures and even German leaders. In explaining why he sought humor in dark times, Dzigan explained, “I have no answer. I can only say that perhaps because we subconsciously felt that our verdict was sealed and our fate unavoidable, we consciously wished to shout it down and drown it out. With effervescent joy we wanted to drive off the gnawing sadness, the dread and fear that nested deep inside us.” Indeed, there is a gaping chasm between how those who joke about serious matters actually feel and what they laugh about. The laughing isn’t merely a cover for their feelings but a way of making those feelings less unpleasant and less controlling. Wisse eloquently observes: “If cognitive dissonance is caused by a divergence between convictions and actuality, and if humor attempts to exploit that discomfort, no one was ever so perfectly placed to joke as were Jews under Hitler and Stalin.” Wisse also provides an entertaining example of a joke during the Holocaust:

Two acquaintances meet on the street. “It’s good to see you back,” says the first.

“I hear that conditions in the concentration camp are horrible.” “Not at all,” replies the second. “They wake us at 7:30. Breakfast with choice of coffee or cocoa is followed by sports or free time for reading. Then a plentiful lunch, rest period, games, a stroll, and conversation until dinner, the main meal of the day. This is followed by entertainment, usually a movie…”

The first man is incredulous. “Really! The lies they spread about the place! I recently ran into Klein, who told me horror stories.”

“That’s why he’s back there,” nods the second.

Doctors, to be sure, are not in a position that even closely resembles the position of Jews during the dark days of the twentieth century. But the humor that physicians use to deal with the things that they see is similar. There is a pit of Weltschmerz in medicine as well; a divergence between convictions and actuality. Most doctors enter medicine with a desire to help and to heal. But medicine necessarily deals with death and failure and all the emotions that come with them. To exploit and, at the same time, cloak that discomfort we resort to laughing at the actions of demented patients or inappropriately commenting about a patient’s impending death. Whether right or wrong, laughter transiently drives out the gnawing sadness, the dread, and the fear that, perhaps, one day we will be that patient.