How Doctors Think Read Online Free Page B

knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physician's facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote. "The doctor is supposed to be emotionally neutral and evenhanded with everybody," Hall said, "and we know that's not true."
    Her research on rapport between doctors and patients bears on Anne Dodge's case. Hall discovered that the sickest patients are the least liked by doctors, and that very sick people sense this disaffection. Overall, doctors tend to like healthier people more. Why is this? "I am not a doctor-basher," Hall said. "Some doctors are averse to the very ill, and the reasons for this are quite forgivable." Many doctors have deep feelings of failure when dealing with diseases that resist even the best therapy; in such cases they become frustrated, because all their hard work seems in vain. So they stop trying. In fact, few physicians welcome patients like Anne Dodge warmly. Consider: fifteen years of anorexia nervosa and bulimia, a disorder with a social stigma, a malady that is often extremely difficult to remedy. Consider also how much time and attention Anne had been given over those fifteen years by so many caregivers, without a glimmer of improvement. And by December 2004, she was only getting worse.
    Roter and Hall also studied the effect a doctor's bedside manner has on successful diagnosis and treatment. "We tend to remember the extremes," Hall said, "the genius surgeon with an autistic bedside manner, or the kindly GP who is not terribly competent. But the good stuff goes together—good doctoring generally requires both. Good doctoring is a total package." This is because "most of what doctors do is talk," Hall concluded, "and the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient. Competency is not separable from communication skills. It's not a tradeoff."
    Falchuk conducts an inner monologue to guide his thinking. "She told me she was eating up to three thousand calories a day. Inside myself, I asked: Should I believe you? And if I do, then why aren't you gaining weight?" That simple possibility had to be carried to its logical end: that she was actually trying, that she really was putting the cereal, bread, and pasta in her mouth, chewing, swallowing, struggling not to vomit, and still wasting away, her blood counts still falling, her bones still decomposing, her immune system still failing. "I have to give her the benefit of a doubt," Falchuk told himself.
    Keeping an open mind was reflected in Falchuk's open-ended line of questioning. The more he observed Anne Dodge, and the more he listened, the more disquiet he felt. "It just seemed impossible to absolutely conclude it was all psychiatric," he said. "Everyone had written her off as some neurotic case. But my intuition told me that the picture didn't entirely fit. And once I felt that way, I began to wonder: What was missing?"
    Clinical intuition is a complex sense that becomes refined over years and years of practice, of listening to literally thousands of patients' stories, examining thousands of people, and most important, remembering when you were wrong. Falchuk had done research at the National Institutes of Health on patients with malabsorption, people who couldn't extract vital nutrients and calories from the food they ate. This background was key to recognizing that Anne Dodge might be suffering not only from anorexia nervosa or bulimia but also from some form of malabsorption. He told me that Anne reminded him that he had been fooled in the past by a patient who was also losing weight rapidly. That woman carried the diagnosis of malabsorption. She said she ate heartily and had terrible cramps and diarrhea, and her many doctors believed her. After more than