EP. 18: THE DOCTOR AS DETECTIVE

WITH LISA SANDERS

Jul 5

WITH LISA SANDERS, MD

A physician and New York Times columnist shares her passion for approaching medical mysteries as detective work.

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Episode Summary

As the real-life inspiration for and medical consultant to the popular TV show House, M.D., journalist-turned-physician Dr. Lisa Sanders has played quite the role in elevating the prestige and drama of medical diagnosis. For the past 20 years, Dr. Sanders has written a column in the New York Times titled Diagnosis, in which she discusses bizarre and fascinating medical cases. In 2019, this column was turned into a Netflix documentary series of the same name. She has garnered much acclaim for presenting the process of diagnosis as a detective story, rather than the rote recall of a set of facts and figures. Dr. Sanders joins us in this episode to speak about her remarkable career path, her work, and how storytelling contributes to patient healing.

Dr. Lisa Sanders, Associate Professor of Medicine at Yale Medical School, is the writer of the popular Diagnosis column in the New York Times Magazine and the Think Like a Doctor column featured in the New York Times blog, Well. Her column was the inspiration for the Fox program House, M.D. (2004-2012) and she served as a consultant to the show. In 2010, she published a book titled Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis. In 2019, she collaborated with the New York Times on an eight-hour documentary series on the process of diagnosis for Netflix. Her most recent book is a collection of her columns and is titled, Diagnosis: Solving the Most Baffling Medical Mysteries.
Dr. Sanders graduated from the College of William and Mary, where she majored in English, and thereafter worked as a TV journalist for ABC at Good Morning America. Less than 10 years later, while working for CBS News, she won an Emmy Award for Outstanding Coverage of a Breaking News Story for coverage of Hurricane Hugo as it slammed into her hometown of Charleston, S.C. After two years at Columbia University’s Post-Baccalaureate Premedical Program, Sanders matriculated and graduated from the Yale School of Medicine.
In addition to her time in the hospital, Sanders is currently researching clinical decision making and the way diagnostic decisions and errors are made. She has also published two books on weight loss and food choice — The Perfect Fit Diet: Combine What Science Knows About Weight Loss With What You Know About Yourself in 2004 and The Perfect Fit Diet: How to Lose Weight, Keep it Off and Still Eat the Foods You Love in 2005.
In this episode, you will hear about:
• Dr. Sanders’ career prior to medicine as a TV journalist and how it influenced her path as a physician - 1:59
• Dr. Sanders’ revelation about diagnosis as detective work and how she developed her passion for it - 4:59
• Being part of the handful of “weirdos” that Yale Medical School admits every year, and combating imposter syndrome - 7:14
• Dr. Sanders’ reflections on the how money-making impacts physician burnout and how the burden of choice in medical career paths may lead to a sense of disconnect - 12:39
• Medical diagnosis itself as a kind of healing, allowing patients to contextualize their circumstances within their personal narratives - 18:05
• Dr. Sanders’ best-practices on communicating with patients - 29:03
• The methodology of solving and describing medical mysteries - 32:10
• Challenges and opportunities in eliciting and listening to patient stories - 42:16
• Dr. Sanders’ hope that the human dimension of medicine does not get displaced by the technical dimension, and why storytelling is integral to patient healing - 46:41
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:03] From 2004 to 2012, "House, M.D.", was one of the most popular shows on television around the world. The show, which followed the arrogant and witty Dr. Gregory House as he went about cracking seemingly unsolvable medical cases, was based in large part on the writings of our guest today, Dr. Lisa Sanders, who also served as a medical consultant on the show during its entire run. For the past 20 years, Dr. Sanders has written a column for the New York Times on Medical Mysteries, which was adapted in 2019 as a Netflix miniseries titled "Diagnosis." She's also the author of multiple bestselling books on the process of medical diagnoses. In this episode, Dr. Sanders joins us in conversation about her unorthodox path to medicine and the role of storytelling in healing patients. Dr. Sanders, thank you so much for taking the time to speak with us today.

Lisa Sanders: [00:01:57] Thanks for inviting me. Please call me Lisa.

Henry Bair: [00:01:59] So, Lisa, you have had such a colorful career in medicine, not only as a clinician, but also as a medical educator and writer and journalist. I think it's safe to say that you are a celebrity in your own right. Famous for your writings about medical diagnosis. But I understand that even before medicine, you had led a successful prior career as a television journalist. Can you tell us more about that and why you decided to become a doctor?

Lisa Sanders: [00:02:31] When I first got out of college, my first real job was in television news, and it was fun. I have to say. It was really fun. My first job was at Good Morning America with two hosts that you've never heard of because it was so long ago and I had a great time. I did a lot of different kinds of stories. Eventually, I moved to CBS News and did a lot of medical stories once I got there. And so after I'd been doing television for a decade or so. I started looking around for what's next. And it seemed to me that medicine could be what's next? I mean, I didn't know that I could get into medical school because I hadn't. Even though I loved science and math when I was in high school. By the time I got through college, I thought, oh, my God, science, math. They seemed so daunting. And people who I knew who were doing it were doing it to go to medical school. And it just seemed like such a slog. But I thought, okay, I can try that. So I took on the slog. Did all the math and science that I had so cleverly skipped when I was in college and applied to medical school. And I thought, if I get in, that's great. That means that maybe I can be a doctor. And if I don't get in, maybe I should look for something else to do.

Lisa Sanders: [00:04:02] I could always stay in television. I did get in. I got into Yale Medical School, which was fantastic. I loved it, and I've just been going ever since. When I left television, I thought, I'm done with this. I'm not interested in journalism. I'm really I'm really interested in having a different kind of relationship with the people around me. You know, in television, you reach millions of people. But you don't really touch any. And I thought in medicine my reach would be much smaller. But I would actually be able to touch other people in more than just the physical way that I would have an important impact on other people, something that I didn't really feel that I had in television. And I think that's true. I think that's right. I think that was a good bet on my part.

Lisa Sanders: [00:04:59] The other thing that happened while I was in medical school is that I discovered diagnosis. As I said, I covered medicine while I was in television, and I thought I still understood how medicine works. You know, I interviewed people who had published big studies in the New England Journal. You know, we did all of that stuff. I had no idea about diagnosis. I mean, I thought really the diagnosis was like the multiplication tables. Four times six is 24, it is always 24. And so a fever and a rash is going to be. What? It could be one of these 15 different things.

Lisa Sanders: [00:05:44] And trying to figure out the diagnosis, I realized, was not the multiplication tables a matter of memorization, although there was that. But it was a detective story. It was putting together the suspects and figuring out who had an alibi and then finally figuring out who done it. And I thought, this is amazing. I had no idea. I had no idea. And I thought, well, if I didn't have any idea, then, then there's a very good chance that other people don't have this idea either. They just don't know this about medicine. And I think that and you can tell me, you know, but I think that doctors have been uncomfortable with the amount of uncertainty there is in medicine, especially in diagnosis. I mean, the reason it's not four times six is 24 is because there's a lot of uncertainty around all this stuff. You know, our bodies have these very limited ways to express distress and there are lots of things that can hurt us. So trying to match those together, that's one of the things. But the real reason that there's so much uncertainty is because there's so much we don't know. So I think that that kind of uncertainty and diagnosis made doctors a little uncomfortable. And that's why that's why I didn't know about it, is that doctors just didn't talk about it. I don't know. What do you think?

Tyler Johnson: [00:07:14] Lisa, I'd like to go to two things from what you just said. I want to follow up certainly on what you're just talking about with making diagnoses. But I wanted to back up a little bit before we get to that which we want to talk about for a good while. Now, you can dispel this. Maybe this is just an Internet rumor, but I read that when you got into medical school, I think you were in your thirties and had come from already having had a very different career, as you said that I think you said somewhere that you got in because there was a spot reserved for, quote, "weirdos", unquote, and that they gave that spot to you or something to that effect. A lot of our listeners, I think, are preparing for medical school or just getting into medical school. I have learned over the years that almost everybody is feeling some version of imposter syndrome and feels like they don't fit in and they're not really smart enough and everybody else is better than them and whatever. And you would think maybe intuitively that as somebody who was coming in a little bit older and already having this career underneath you and everything else, that you would be sort of on top of the world and the master of the realm. But I'm curious if you ever had those feelings of feeling like you didn't fit in, or maybe that you didn't even measure up and how you work through those things or what that was like for you.

Lisa Sanders: [00:08:27] Let me answer your first question first and then go on to your second question about imposter syndrome. So Yale has sort of a tradition of saving 1/10 of its sort of admission classes. For weirdos, you know. So I was one of ten weirdos. You know, my best friend had come from Salomon Brothers, where I was a stockbroker. My other best friend has a PhD in physical chemistry, and she had worked as a chemist in industry for many years. Another one was an architect. Another one was a professional baseball player from the Minnesota Twins. And so we found each other when we got to medical school. And I was extremely grateful not to be the I mean, I already was the oldest student there at 36. I was, you know, ancient.

Tyler Johnson: [00:09:25] I'm sure they didn't do this. But I have this picture in my mind that you show up for your white coat ceremony before the first day, and they've embroidered weirdo on all of those people's white coats. That would be really impressive. They probably don't do that. But I'm just saying.

Lisa Sanders: [00:09:39] They don't have to because we look different. I mean, first of all, we're a decade older than all these children. You know, I say this, you know, some of those children turned out to be my best friends and are still my very close friends. But so I was 36 when I was started. Most of these children were 21 or 22. They just graduated from college. We didn't need signs. We were wearing them at the corners of our eyes, all those little teeny weeny lines. No, we didn't. We didn't need to advertise our weirdness. Every time we opened our mouths, our weirdness showed up. And, you know, I was so grateful to hear that everyone else had imposter syndrome, too, you know? I mean, you know, you can't come from outside and get in on the weirdo slot and not worry that you're just not up to this. I remember I went to a. See the dean of students during my second or third year, I guess during my third year, when I was thinking about what I was going to do next and getting a little pushback about being interested in primary care. And I went to Dean Gifford, who is this wonderful, wonderful guy. And I said, you know, I'm a little worried because you say that Yale graduates leaders in medicine, but I'm not actually interested in leading anybody anywhere.

Lisa Sanders: [00:11:16] I'm interested in taking care of patients. And he was like, Don't worry, Lisa, you're going to be just fine. But I did worry that that everybody else knew more than I did. I mean, I got through all the prerequisites with I asked the I went to Columbia to get my pre-med post back stuff done. And I said to my counselor, What do I have to get to get into medical school? They said, wait, you can't get anything less than a B-plus. That would totally this was a different era. Obviously. Now, I couldn't get him with a B-plus, I'm sure. But you can't get in with anything less than a B-plus. And your MCATs have to be stellar, like a challenge accepted. So, you know, I got through with A's and A minuses and B pluses and even one B minus. I still got it. But I did worry, you know, I mean, a B-minus in a doctor. You know what people say about doctors when they're when they disapprove of the doctor, they go, you know, you know what they call the doctor who graduated at the bottom of their medical class? Doctor!

Tyler Johnson: [00:12:39] Don't worry, Lisa, we won't tell The New York Times about your B-minus. Will be our little secret. So I wanted to follow up on one other thing and then I promise we're going to get to the diagnostic stuff, which is maybe the most interesting. But one of the motivation, I guess, behind this podcast is the idea that so we all know there's an epidemic of burnout. We know that a lot of the reasons for the epidemic of burnout have to do with systemic factors that are beyond the reach of any individual doctor, which are also important. And we've also talked about those to some degree, and those also need to be worked on. At the same time, we feel like part of the reason for the epidemic of burnout is because doctors have just lost touch with the the deeper meaning that brought them into medicine in the first place. And one thing that we hear from all quarters is this idea that you talked about, the difference between your how when you were in television, you had an enormous reach but didn't touch anybody. And then you went into medicine and now your reach was severely limited compared to being a TV personality. But you but you were able to actually touch people. I know that a lot of doctors feel like that ability to actually physically touch patients or to form a more holistic, emotional bond, whatever you want to call it, is being sort of drown in this rising tide of bureaucracy and electronic medical records and billing requirements and all the rest of it. And so I guess I'm just curious, as you have gone through your medical career, what do you do to try to keep touch with that core principle of making sure that medicine still is about being able to individually touch a patient?

Lisa Sanders: [00:14:35] Well, I will tell you, but I assure you that if you take any of my advice, it will cost you money.

Tyler Johnson: [00:14:45] Noted.

Lisa Sanders: [00:14:47] Because if you want to make the kind of money many people feel that doctors are owed, then you're going to have to throw your patient off to the side. To make big money. You can go into neurosurgery, you'll make big money. You don't have to throw your patient over. But in primary care, if you want to make the kind of money you thought you were going to make, you're going to have to do more. You know, this is a widgets business. And if you want to make a lot of money, you have to process a lot of widgets. I've never been interested in processing a lot of widgets. You know, I've noticed that there aren't very many doctors who have to get second jobs. There aren't any doctors, very many doctors getting food stamps. Doctors, even the worst paid doctors do extremely well. You just have to have faith that there are things that are more important than money. I think that there are things that are more important than money. And if you want to buck the system, you can only do it, I think, by not getting everything you're owed. That's terrible, isn't it? But I think but I think there's actually something else is going into the burnout. I have this theory about people who want to go into medicine. People want to go into medicine, have spent their entire lives doing what's expected of them, what they need to do.

Lisa Sanders: [00:16:30] Everyone knows the way, knows what you've got to do to get into medical school, then knows what you've got to do to get the residency you want. Then at the end of residency or even during residency. You have to think, what do I want? You know what? That's the thought that many of these kids have never had before. It's it's I would call it an opportunity, but it's not it's kind of a burden because they really have no experience making choices based on their own desires and interests. You know, one of the things about coming to medicine as a second career is that I knew what I wanted. If I wanted to make a lot of money, I would have just stayed in television. I mean, it's not like I wanted to be poor and I'm not. But, you know, I wouldn't be in academic medicine, I wouldn't be in primary care. I wouldn't be doing the things that I really love. If I let money play as big a role as somehow is expected of us. Maybe smarter people to go back to this imposter syndrome. Maybe smarter people can figure out how to do what they want to do, get paid the way they want to get paid, and still have a great life. I certainly hope they write a book because I would certainly buy it.

Henry Bair: [00:18:05] Moving on to a diagnosis which you have talked a lot about being your. One of the things that brings you the most joy in in your medical work. You know, as I was reading a lot of your writings about diagnosis, about specific cases, I realize these are stories. Each of these diagnoses, each of these medical mysteries have there's a protagonist, there's an antagonist. There is a rising action, there's a climax, and there's a resolution. It's a story. And in your book, every patient tells a story, which I have right here. There is a passage in here, a paragraph that I think really wonderfully summarizes what I see as the thesis behind why you share these stories. And I'm just going to read this paragraph here. So you write.

Henry Bair: [00:18:51] "One of the most important and powerful tools a doctor has lies in her ability to give a patient's story back to the patient in a form that will allow him to understand what his illness is and what it means. Done successfully, this gift helps the patient incorporate that knowledge into the larger story of his life; through understanding the patient can regain some control over his affliction. If he cannot control the disease, he can at least have some control over his response to the disease. A story that can help a patient make sense of even a devastating illness is a story that can heal."

Henry Bair: [00:19:26] I think that's that's an incredible thought right there. And I was hoping you could tell us more about this idea. How did you develop it? And is there an instance, a patient you can tell us about for whom giving them their story was a way of helping them heal?

Lisa Sanders: [00:19:41] Well, when you think about how a diagnosis is made, it starts with the patient's story. And I teach medical students, the students, residents, about how to talk to patients, how to get their story. And really, you have to you have to let a patient entrust you with their story. And then once you have their story, it's your obligation to doctor-ize it. You get information that they didn't think to offer or couldn't offer. You get tests, you try to use this bigger story or this medical story to answer the patient's basic question of. "What's wrong with me?" But in some ways that's the easy job, it's certainly the fun job. The patient has the responsibility, the obligation, the burden of living that story. And so it's your job as a doctor to take what you now understand about that patient and help the patient understand it and accept it and move forward. I think that that's at least as important as figuring out what they have is figuring out how to communicate that. There are so many times when you read in a chart what a patient's diagnosis is, but the patient doesn't either get it or recognize it as a diagnosis or can't connect their experience to what's been told to them.

Lisa Sanders: [00:21:27] That means that this diagnosis, as successful as it might be from the doctor's perspective, is not successful from the patient's perspective. I did a series of documentaries on patients for Netflix. And one of these patients had got some sort of GI bug. And after that GI bug, he developed this strange, super strange regurgitation thing. And it was very hard for her to hold any food down. He wasn't vomiting. She would eat something and then would come right back up. And there's a word for that called rumination syndrome, because whatever unfeeling jerk of a doctor first noticed it, thought it was like how cows regurgitate their food in order to digest it. I mean, what a terrible and so rumination, you know, like ruminants. What a terrible, terrible name for what is, you know, not something that's in control. You and I could not make food come out this way. I mean, it's clearly something that's very abnormal and very strange and very hard to deal with. So this poor patient was diagnosed with rumination syndrome. And the doctor not only didn't apologize for the name, but then said, Oh, that means it's just all in your head. That meant that this woman, this young woman, was never going to be able to deal with that diagnosis.

Lisa Sanders: [00:23:02] Right. He had just poisoned it for her. I spent a lot of time trying to help her and her mother. She was 18 when I met her. But and so her mother had been driving her search for a diagnosis, and they just could not accept that this was something that wasn't caused by something outside of her. We don't talk about this a lot. But, you know, in some studies, up to 25% of people who have some sort of viral GI thing, you know, the last 24 hours where you have just the worst 24 hours of your life and then it's over. But like for 25% of people who go through an experience like that, they end up having some change to their GI system. Might not be permanent, but it's not brief. And I think she might have been one of them who knows what causes this kind of thing. But, you know, to fix it is hard. But she was never going to be able to fix it because it had been told to her badly. So how you give the story back is at least as important as what we value as doctors that figuring it out.

Tyler Johnson: [00:24:19] So, Lisa, I want to acknowledge and complicate that idea a little bit in the following way. So first of all, I completely agree with you that there are a few things as frustrating to patients as feeling like they're in a situation where the doctor can't give them the story back in a meaningful way. Right. Where if the doctor is. I mean, many we've all seen patients who have seen a long series of doctors and nobody can give them an answer. And that feels enormously frustrating and unsatisfying for patients and I think causes its own burden. And I think in some cases may even add symptoms on top of the symptoms that were already there. As an oncologist, though, I also want to focus what about those times when, yes, you're giving the patient's story back to them and yes, you have a very definitive diagnosis, but it's terrible. Right. So the person who comes in because they're winded and then you figure out that they're anemic and then you get a colonoscopy and lo and behold, that's colon cancer. And the way that you have to give them the story back is to say, well, you were feeling a little rundown and it turns out it's actually because it's cancer. Or the person who discovers that they have a new defect in their heart muscle that's making it so that their heart can't pump normally or whatever the thing is. What does that moment look like for you when you are giving it back and you do have an answer, but the answer is really hard. Both What does it look like for you and how do you try to approach that with a measure of grace, even in spite of how hard that is?

Lisa Sanders: [00:25:50] I think that I'm not an oncologist, so I don't know how it works for you, but I think that many people express gratitude when the uncertainty is over, at least then they have a target that they can go for that there's something that they are up against and they have identified it or you've identified it, but they know what it is. And now they have to move from looking for an answer to dealing with that answer. And I think that for many patients. That is something that they're grateful for, even if they're not grateful for the specific diagnosis that they got. But I'll tell you, a lot of times patients know if it's something serious. A lot of times patients feel that it's something serious when it's not. That's also a problem. But I think that often when you tell somebody that they have something bad, they're like, I knew it. I knew it certainly when I was a resident. Might have been an intern when I had to tell my first patient is really, really bad news. And it was a terrible, terrible situation. If this happens to one of our interns, I would have said, why didn't you tell me that this was going on and we could have supported you in some way? But I just thought, this is what happened. So there was a patient who I had never met who had gone to the emergency room and had a CAT scan, and his CAT scan showed up before the answer came back, left against medical advice and came to this appointment to get the report from what happened in his CAT scan.

Lisa Sanders: [00:27:33] He had a huge pancreatic mass. So I had never met him before. And I came in and we all get the training like. So tell me what you know about your disease so far, so that you can start where the patient is. Because I'm going to die, right? You're going to. You're telling me that it's some sort of terrible cancer? That's why nobody would tell me over the phone and come in because I knew it. And there's nothing you can do for me. I'm out of here. And he left. I'm, like, walking behind him. Excuse me, sir. It was just terrible. I felt I was I felt like I was such a failure. So it's not always going to go well. Giving this story back. Sometimes it can be a nightmare, but most of the time that's never happened to me. Then. Maybe because I'm better. Maybe because I have patients who are different. But it hasn't happened since then. I mean, it's not always easy. We're in this business where, you know, nobody gets out of this place alive. I'm not talking about the hospital. I'm talking about this place. And we're in that business. So we have to be prepared to help our patients through whatever lies before them. That's our job. That's why we're here.

Henry Bair: [00:29:03] The question that I have in my mind is that I have had to have those conversations before, and I know my medical school peers have also had to be present in those circumstances, whether or not they were the ones who were actually giving the the bad news. And I guess I was wondering, you mentioned that it's not always going to be easy. What are some things that you do or what are some things that you train residents and medical students to do to help make sure that before you approach giving bad news, you set the stage well, you lay the groundwork so that this turns out as good as it can possibly be despite the bad news.

Lisa Sanders: [00:29:46] Well, I'm not an expert in this, of course, because most of my patients do fine, you know, because most patients I'm not an oncologist. I'm not somebody who's who specializes in heart failure. So I mean, I know what other people know that you have to be with a patient in that moment to try to tune in to where they are and try to express. What's going on in language that you think that they can understand so it doesn't do you any good. You tell somebody that they have a stage or NGO sarcoma, you know, I mean, that doesn't really tell them very much. So you have to figure out without speaking down to a patient, but just speaking to a patient, you have to figure out. What they know. That's why you ask them. Tell me what you know about what's gone on so far. And that way you can get a very good sense about what they've been told. You sort of know what they've been told by their guard, but how they understood. What they've been told. And that gives you, I think, a very good grasp of what you need to do to communicate. I mean, people are not all like us. We're all very, very different. People come to us with different backgrounds.

Tyler Johnson: [00:31:20] To that point, I remember one time when I was in training, listening to a very senior, wonderful oncologist go through this whole long explanation to a patient who had just been newly diagnosed with a cancer and say, you know what the cancer was and what stage it was, and the studies looking at the chemotherapy and what the drugs were going to be. And anyway, I went through this whole thing and then left the room to go see another patient. And I was in the room with the patient sort of tidying things up at the end. And the patient looked at me and with sort of plaintive pleading in her eyes, said, So, Doctor, is it contagious? And it was clear that I mean, there was just an absolute disconnect, right? And what we thought we were communicating and what the patient was understanding.

Tyler Johnson: [00:32:10] Let me Lisa, I know that you've sort of been saying that you're not a cancer specialist, which is fair enough. But the thing that you are actually, if not world renowned recognized specialist, is in figuring out medical mysteries or really dwelling in that place of uncertainty that you were talking about a little while ago. For listeners who may not be aware, if you're a fan of House, the television series, to the degree that there's a real person behind the the television avatar, I guess that's Lisa's sort of second television career is being the doctor behind the doctor on House. I'm curious if you can just walk us through sort of your mental footsteps, like help us to walk us down the path when you are contacted, either in your own clinic or by someone who refers a real medical mystery case to you where a person has maybe seen multiple doctors and nobody is sure what's going on and they're trying to come to an elusive diagnosis, like what goes on in your head to try to figure out the answer to a really tough to crack case like that?

Lisa Sanders: [00:33:22] So let me correct you for a second, please. I and other people make the analogy between medicine and mystery. Invoke as housed in Sherlock Holmes. Not to get too subtle and nuance on you. But I'm not actually Sherlock Holmes. I'm what? Watson was the doctor. Watson was the writer. I'm once. I write about, for the most part, other people's amazing diagnoses. I'm not putting myself down in any way. I'm just saying that that's not really what I do. I do see mystery patients because there are lots of patients who don't see or recognize the difference between the storyteller and the story. Who read my columns. And somehow because I wrote them, I solved them even though in my column. I identify the doctors who make the diagnosis always 100% of the time unless they don't want to be identified. So I'm not like House House's Sherlock Holmes. I'm I'm Wilson. I'm the oncologist. Best friend. You know, I'm. I'm the storyteller. So I think that if that job is being the storyteller of strange diseases has given me any assist in making a diagnosis. It's that it gives me a broader differential because I know things that that exist that I've heard about and written about and seen patients who have weird stuff and and many people have not. You know, and one of the few things we actually know about diagnosis is the doctor who is most likely to make a difficult diagnosis is the doctor who's seen it before. That's why we have clerkships. That's why we have residency, so that we can be exposed to as many things as possible. So, you know, I, I do what everybody does. I try to collect the right information. I go through people's records scrupulously. I try to figure out the questions that haven't been asked. And I go from there. But I'm as amateur at it as everybody else. You know, this is something we all want to be good at.

Henry Bair: [00:36:04] Hmm. So you talk about how you are. You are the storyteller, and you do tell a lot of stories about medical mysteries you share them with. I mean, Netflix has it's huge. You reach a huge audience now. And I guess my question is, what is your hope that readers of your columns and your viewers of your show can glean from these stories?

Lisa Sanders: [00:36:26] The first thing I wanted to do was to show that it's a process, that it's not the multiplication tables, that it's not something that that is obvious. Well, let me be clear. Most of the time it's obvious you come in with the fever and malaise and upper respiratory symptoms in the middle of flu season. That is the very definition of a no brainer. Somebody who has a history of COPD, comes to the hospital with a terrible cough and a wheeze. You know, it's a very good chance they have COPD and most of the time, most of what we see is going to be like that. So it really is a no brainer. But just because what you have is not a no brainer. Doesn't mean the doctors are paying attention. It just means it can be hard. And that's what I was interested, that it's this process or can be this process to figure things out. That was what was interesting to me, and I wanted patients to understand that this is a process and that this is how it happens. They gather information, they try to figure it out, and that doesn't work. They ask their friends. I mean, that's sort of what happened in my Netflix series. You saw you know, you heard patients talking about what their doctors had been through and then talked to their doctors.

Lisa Sanders: [00:37:52] And then we talked to the biggest room we could find. You know, that's that's what doctors do. We go into the next room and talk to the people in the cafeteria and go have this weird patient who has this what? And often the doctor will go, oh, yeah, I saw that. Once it's plotted, you go out and it'll be enlightening. And so in diagnosis, what we try to do is go to the biggest cafeteria ever, the readers of the New York Times and the watchers of Netflix to try to figure out these very difficult cases because one doctor's brain is not enough. In my column, people are always saying, when are we going to get a I? Because patients in particular want it to be the multiplication tables. They do not want it to be a mystery. They want an answer and they want it now. And I totally get that. But I look forward to the day when I is there. You can just feed in those symptoms and boom and as it comes out. But we are so far from there right now. So far that's I'm not holding my breath until then. We just have a lot of really smart. Well-educated, well-meaning people trying to figure this stuff out. And that's what my column is about.

Tyler Johnson: [00:39:13] It's so funny to listen to you because it reminds me that I think I had this vague idea when I was a medical student and then even later as a trainee that at some point there was like a magical thing that happened. Like maybe it was the night after your last night as a resident and before your first day as an attending, that there was some sort of like magical heavenly download into your brain of all of the medical information, because clearly the attendings knew all of it. But what I realized as an attending is that really at least a large portion of the reason that attendings look so smart is because they're the ones asking questions on rounds. If everyone was just peppering them with questions all the time, I wouldn't know a lot of the answers because I have to go back and ask colleagues and look things up and whatever. So the idea of the omniscient attending is is unfortunately not really very accurate.

Lisa Sanders: [00:40:02] I mean, we all know doctors who know everything, you know. I mean, but it's not an accident here at Yale. One of my heroes, this guy named Tom Duffy, was a hematologist. He's retired now, but he seemed to know absolutely everything. And you know what he pretty much did? He was he was a resident at Johns Hopkins. He was a chief resident, Johns Hopkins. And he read every single day of his life. And when he got here to Yale, he read every single day of his life. He always went through resident report after resident report. That case was interesting, and that was most of the time interesting to him. He would read the patient's chart, go visit the patients, you know, and learn about a read about the disease. I mean, he really knew everything, but it didn't. It's not like it comes down to you from heaven. It comes down to you while you're sitting in front of a journal trying to figure stuff out.

Tyler Johnson: [00:41:05] Yeah. I remember one time when I was a fellow here in hematology oncology, there was this patient who was who was horribly, horribly sick and and I was just desperate. And I talked to every consultant I could find and looked in every journal article. And, I mean, I just did everything I could think of and exhausted all my resources and could not figure out what was going on with her. She actually ended up dying from from this what turned out to be an infection that she had. But months later, I was talking with this guy who is a 90 something year old hematologist who had been at the hospital almost literally since it was built and who was like the Yoda of hematology here. And I was still at that point ruminating, not with food about this case, trying to figure out what was going on. And I mentioned the outline of the symptoms to him, and he just leaned back in his chair and folded his hands in his lap and said, Oh, yeah, that was this super rare kind of infection that I had never even heard of. And then I went and looked it up later, and sure enough, it was all of the hallmark symptoms. I was just flabbergasted. I mean, it was just like easy as a breeze on a Sunday afternoon. He just knew it. Boom. Anyway, it was really impressive.

Henry Bair: [00:42:16] Listening to you, Lisa, I can hear the passion and the joy you have for talking about diagnoses, about listening to the patient and giving them their story back in a way that is conducive to healing. So my next question for you is what advice do you have for fellow clinicians and medical trainees on listening to patient stories? And what are some of the biggest obstacles right now in the way of doctors eliciting patient stories and listening to them?

Lisa Sanders: [00:42:46] Well, thank you for that question, because that's an important question when we talk to our friends to find out to find out what's happening with them, we have no trouble collecting all of the information we need. But it's not like talking to your friends when you're talking to a patient, when you're talking to a patient. You have to be collecting complex data and trying to fit it together all in real time. And I think that that can be stressful for a doctor. I think it can be stressful to be confronted with all the kind of uncertainty that comes with hearing a patient's story. They don't give you the information in the way that you might like it. They don't give it to you if complaint. He symptoms an important review of systems. They don't do that. They tell you their story and you have to relax enough to listen through the story and and be alert for all the hidden clues that are there. It can be very stressful. And I think it's that sort of stress and anxiety that makes it hard for doctors to listen. It's much easier to take somebody's first few sentences and run with that. And that might be the whole story, but it might not be.

Lisa Sanders: [00:44:09] So you have to make yourself be quiet. Look at the patients, nod, you know, let them feel like they have all the time in the world to tell their story. And then when they've told their story, then you can pepper them with the questions that need to be answered. But it's very hard to push your concern down and let a patient tell you their experience. And I think that our system is not set up to support that. We have on average, 15 minutes for one. We're all afraid that the patient is going to use that up. Just talking and talking and talking. We're not going to be able to come up with any patients, just be talking. But that's not the case. I mean, it's been studied. I mean, when you let patients talk. They have a story that they've been working on. You're not the first person they're telling it to. Probably. Probably they've told it to their mother, their spouse, their friend at work. They worked on this this story. And we have to have faith that, in fact, it will only last a couple of minutes. We'll have plenty of time to hear it when it's been studied.

Lisa Sanders: [00:45:31] The longest story in these studies that have been done where patients were allowed to talk as long as they wanted with a physician, was giving them encouraging signs. And, you know, people rarely talk more than two and a half minutes. That gives you a lot of time on the other side of that. You just have to have faith that you're going to have enough time to figure it out. Or if you don't, you can always just have them come back. I mean, you don't have to figure it out right that moment. But it's our own expectations that we're going to be geniuses get in our way, I think. Not to mention patients expectation that we're going to be geniuses. And it makes it hard for us to listen. It makes us hard enough to ask the questions that are going to help us see the impact that this illness has on the patient in his life, which might be coloring the way the story is told. I mean, there's a lot of information that has to be gotten out and you have to just relax enough to get it. So I would say that you just have to listen. You have to shut up and listen.

Tyler Johnson: [00:46:41] So, Lisa, you have been so generous with your time and we know that our our our is getting close to a close. But I wanted to ask, as happens with many so called "weirdos" who come into medicine, I think you've been able to achieve this really unusual fusion, right where what was you sort of the impulse that you previously channeled into working in television, you've now been able to channel some of those same skills into writing books and into this very long running column in The New York Times and and other similar forays into media. And then on top of that, you practice yourself and you teach how staff and medical students at medical school and all the rest of it. If you could just design or articulate what you hope, the legacy of all of that writing and speaking and teaching and practicing is what what impact do you hope that all of your work will have had on the field of medicine when when you're all done?

Lisa Sanders: [00:47:48] I'm not sure how to answer that question. Let me take a stab at it. I think that the patient's story and the medical story too often gets lost. We have a lot of algorithms. When somebody comes into the hospital with COPD, we know what to do for them because we have this whole algorithm for how to deal with people who have COPD or. I think that. What I'm hoping is that the human aspect of medicine, in addition to the as medicine is cherished, because it's only when both of those things live on side by side that real medicine, real healing can possibly happen. I avoid the word healing because people think it's too woo woo. But really, that's what we're here for. That's why we went into medicine. And especially why I went into primary care internal medicine. I don't want to just fix people. I want to heal or help them. And in order to do that, you have to see both who they are. And what their disease is and work with it both ways. But it's only by doing both parts together that the patient will really benefit. And that's what I hope my stories. Like television. Even House knows that. That's why he ends up sitting on the bedside of so many of these episodes, sitting at the bedside to actually talking to the patient. And that is why so many of his diagnoses come that way. Because he knows that both. Even him.

Tyler Johnson: [00:49:45] That's great. Well, thank you for those parting thoughts. And again, thank you so much for your time, your writing, your care and for all of the good work that you've done in the field of medicine. And we really appreciate you spending this hour with us.

Henry Bair: [00:49:59] Thank you very much, Lisa.

Lisa Sanders: [00:50:01] Well, thank you so much.

Henry Bair: [00:50:05] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:50:24] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:50:38] I'm Henry Bair.

Tyler Johnson: [00:50:39] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.