How to Solve a Medical Mystery

Meredith GREY: What day did his fever start?

DOC: Wednesday.

Bapu JENA: If you’ve ever watched a medical drama on TV, you’re used to hearing things like this.

GREY: We’re already at day 10.

DOC: What’s day 10?

GREY: Did Parker have red eyes?

DOC: He was asleep the last time I checked on him.

GREY: Let’s go.

Lots of fast talking. Scribbling a bunch of diseases on a white board and dramatically crossing them out. Hunching over petri dishes in a lab doing tests. And of course, let’s not forget, breaking into a patient’s house to find out what’s poisoning them

Gregory HOUSE: Okay. Twenty bucks says I can get through this door in 20 seconds.

On these medical shows, which I got to admit even I love to watch, they always manage to make the cliffhanger come right before the commercial break, and of course they solve the case just before the episode is over. It all looks very exciting. And as someone who’s also a doctor, maybe a little too good to be true.

Well, what if I told you that today we were going to put the diagnostic skills of a real doctor, a guy who you could reasonably call the real-life, but much more functional and friendly Dr. House, under the microscope.

Gurpreet DHALIWAL: No, we don’t break into people’s houses like on House, M.D., to find that pet or that toxin that’s sitting in there. But there’s a lot of thinking that goes on outside the exam room.

That’s Dr. Gurpreet Dhaliwal. He’s a medical school professor at the University of California, San Francisco.

DHALIWAL: I’m a general internist and I work in the emergency department, the inpatient wards of the hospital, and the clinic. And my area of interest is how doctors think, and in particular, how they diagnose.

And today, we’re going to hear him try to solve an actual medical mystery, in real-time. From the Freakonomics Radio Network, welcome to Freakonomics, M.D.

I’m Bapu Jena. I’m a medical doctor and an economist. Usually on this show, I dissect a fascinating question at the sweet spot between health and economics. But today’s episode is a little different. Every one of us needs medical care at some point in our lives, and when we do, it can be scary. Part of what makes seeing the doctor so scary is that we have no idea what’s going on in their head. Why is that doctor looking at my skin so carefully? What’s that on the computer screen they’re looking at? Uh oh, why did they just sigh?

To demystify things a bit, today we’re going to get to hear what happens inside a doctor’s head when they’re seeing a patient with a new medical dilemma.

We’re going to give Dr. Gurpreet Dhaliwal a real medical case to solve. Once he hears the info, he’ll make a diagnosis, and most importantly, explain how he came to his decision. I want to emphasize that what you’ll hear today are his deductions, in real-time. Gurpreet has no idea what he’s about to hear. To help us with this challenge, I’ve asked another doctor to join us.

Sharmin SHEKARCHIAN: Hi everyone. It’s a pleasure to be here. My name is Sharmin Shekarchian. I am an assistant professor affiliated with Stanford.

Sharmin was a student of Gurpreet’s at U.C.S.F. She also leads an effort called Clinical Problem Solvers, which is all about teaching doctors how to be better at making a diagnosis. She’s prepared our case for this episode. And I just want to say that any identifying information about the patient has been scrubbed from this file. All the information is real, from the patient history to the lab result. Okay. Let’s go.

SHEKARCHIAN: Ms. Miller is a 75-year-old woman who came to the emergency room. She had back pain for the past eight years from spinal stenosis. Over the past two weeks though, the back pain has suddenly worsened out of nowhere and the pain was constant in the middle of her lower back and shot down her right hip. She had no physical injury to the back. She didn’t experience any fevers or chills, bowel, or urinary symptoms. She had about 30 pounds of unintentional weight loss over the prior year. She had a good appetite without any vomiting or abdominal pain.

What else do we know about her history?

SHEKARCHIAN: She had coronary artery disease with stent placement 10 years prior. She also had high blood pressure and was on Metformin for diabetes. Her heart medicine included aspirin, lisinopril, atorvastatin. She had quit smoking cigarettes 40 years ago.

Okay, Gurpreet, what are you thinking so far?

DHALIWAL: So, the major problem that we’re contending with here is low back pain, which is exceptionally common. But there’s something else that I noticed, which is that she’s lost 30 pounds. I do want to examine if the weight loss could have happened independently of the back pain to start. But I am also going to consider if the process that’s causing the worsening of her back pain is also causing her to lose weight. So, an example of that would be if there was a cancer or an infection that has set up shop in her back and is causing the worsening of pain, but is also consuming calories and energy in her body and causing her to lose weight. So, I think this is the type of patient where we would get an x-ray at least as a starting point to see what’s happening in the back. And we may need more advanced imaging later.

JENA: Thank you, Gurpreet, for just kind of laying the groundwork for how you’re thinking about what’s important. Sharmin, I’d be curious to hear what other information you were able to obtain.

SHEKARCHIAN: Absolutely. On the physical exam, her temperature, blood pressure and breathing were normal. She looked tired. She had muscle wasting in both temples. Her lung, heart and abdominal exams were normal. She had lower back tenderness. Her strength, sensation and reflexes were normal. She had a normal white count. She had anemia measured by hemoglobin level of 8.5 with the red blood cells that were, on average, smaller than normal reflected on M.C.V. 75. Her electrolytes, kidney function and liver tests were all normal. She had elevated inflammatory markers.

JENA: Gurpreet, help us synthesize that information.

DHALIWAL: There’s a general signal that there is inflammation and a disease that’s been unfolding for weeks or months or even longer. And she has muscle wasting. There’s a special number that Sharmin mentioned, which is the M.C.V. It’s sort of a clue of how big the red cells are. This is a tad on the small side. And when red blood cells are small, that oftentimes clues us in that they are small because the body is low on an essential nutrient, which is iron. And I could then start to think what would be reasons for her to have iron deficiency? There are some cancers, if they are in our stomach or intestine or large intestine, can cause iron deficiency. And so I’m already concerned about the possibility that there might be a cancer like colon cancer. Another one that has that as a characteristic is something called multiple myeloma, which is a bone marrow cancer that can cause a combination of back pain and anemia.

JENA: Sharmin, what other information unfolded?

SHEKARCHIAN: So, next an M.R.I. of the spine showed evidence of disc intervertebral bone inflammation, in both the upper and lower spine. An ultrasound of the heart called a T.T.E. showed thickened heart valves, mild aortic regurgitation, but without any clear collection of bacteria known as vegetation. Her anemia workup was consistent with iron deficiency, and her stool was positive for blood. Blood samples showed a bacteria called enterococcus faecalis.

Wait, what?!?! A cliffhanger? Really?!? All right, people. Hear Gurpreet’s diagnosis, coming up right after this. Can I at least get some medical drama music to take me to the break? Oh, that’s not bad, I like it. Okay, I guess I can see the point of the cliffhanger—

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Previously on Freakonomics, M.D.

We heard about a patient’s symptoms, history and lab results. Now it’s up to Gurpreet Dhaliwal to tell us what he thinks the diagnosis is for this patient. And I want you to know, he didn’t even get a commercial break to mull things over while we were recording. We only gave him 60 seconds to answer after Sharmin Shekarchian asked—

SHEKARCHIAN: What’s the final diagnosis?

DHALIWAL: I previously was discussing the possibility of cancer. And now there’s a signal, eventually a strong signal, that infection is the problem. And the question is, could both of them be present at the same time? So that M.R.I. has showed us that there’s inflammation in the disc and inflammation in the bone. And those are typically caused by an infection. So the question naturally comes, where is the infection from? How did they get there? And we worry about an infection, if it’s present in the back, having come from the bloodstream. And now the question is where did that enterococcus come from? And it now starts to connect with the other idea that we were concerned about, which is if she’s low on iron, why is she low on iron? That makes us think about, you know, something as simple and treatable as an ulcer to something as sinister as a cancer. And given the information here and the weight loss that she had, I’m quite concerned about the latter. So with this combination, the test that she’s likely going to need is a colonoscopy. So my leading suspicion here is that she has a colon cancer, which has led to iron deficiency anemia, and the colon cancer with a small breach led to the enterococcus in the blood. There’s still a slight concern that enterococcus didn’t just land in the back, but on its way, going through the bloodstream, may have landed on the heart valves. Although, we did one test that shows that there was no abnormality on the heart valves, or at least not a significant one, you can do a different type of echocardiogram and get a closer picture to determine if there is or isn’t an infection on the heart valves. And I think that may be warranted in this case.

JENA: Sharmin, did any of those things happen?

SHEKARCHIAN: Dear audience, I promise you Gurpreet who has not seen any of this information that I’m about to read to you. There was still a high clinical suspicion for infective endocarditis. Which is infection involving the inner lining of the heart and the valves. So another kind of ultrasound of the heart called trans esophageal echocardiogram was performed. It showed bacteria growth.

She was treated for enterococcus endocarditis with I.V. antibiotics. She underwent a colonoscopy that showed colon cancer. She is scheduled for a follow-up with oncology and general surgery for management and treatment.

JENA: I mean, first of all, I’m amazed. This is amazing, Gurpreet. Let me just ask you, how quickly did you start to formulate an idea about what was going on, like a sketch of a set of diagnoses that might explain her symptoms?

DHALIWAL: I started forming my hypotheses early on, just like studies show of doctors that they form hypothesis in the first 30 to 60 seconds. The part that got me concerned early on was the weight loss of 30 pounds. And we are trained to see that combination of back pain and weight loss and be concerned about either an infection or a cancer. There’s many other reasons that people can lose weight that would be unrelated to their back. And in some ways we hold out hope for that. But as the evidence kept converging, the simple story that I had that this was a flare of her preexisting condition started to fade to the background.

JENA: Sharmin, how does this make you feel?

SHEKARCHIAN: I’m just really, really glad I have, um, Gurpreet’s number so I can just call him and run cases by him.

JENA: Yeah. Yeah. His number is 1-800 Dr. Dhaliwal.

DHALIWAL: I— I promise you Sharmin would have gotten to the same conclusion, but I appreciate the vote of confidence. You can’t see me, but I’m blushing.

JENA: That set of connections is not something that I would have made. Again, I’m just impressed by how you were able to keep asking that question of why this bacteria, why this anemia, what’s going on in her heart. Amazing.

DHALIWAL: One thing begets another question. We talk about what is the diagnosis, but really there was lots of diagnoses along the way. And each one led to another why. I mean, you could even take that a step further and say, what are the reasons that this person was susceptible to colon cancer? It’s almost this never-ending quest to understand the root cause.

JENA: So, Sharmin and Gurpreet, people who are not in healthcare just got a window into how doctors think. And what would you have people take away? Sharmin, let me start with you.

SHEKARCHIAN: At the end of the day, when I think about medicine, I think that at the core of it is a partnership that’s between a physician and a patient. And we wouldn’t be able to make progress in our diagnosis if patients don’t trust us. If you don’t get the right information from the patient, the right history, then we’re not going to be on the right track.

DHALIWAL: In fact, making the diagnosis is only half of the job. The other half is communicating it clearly and compassionately to the patient and their family. I hope there are lessons that maybe transcend problem solving in medicine and apply to problem solving in all fields. Oftentimes you don’t need to have detailed or encyclopedic knowledge. It’s more important to have a rigorous way of thinking through something. We don’t have to test for everything. But we do have to at least consider it in our mind.

JENA: Gurpreet and Sharmin, I think for most of the people who are listening to this show, this is going to feel like a House M.D., except with Gurpreet, M.D. As an avid viewer of shows like Grey’s Anatomy and House, I’m just curious, when you watch shows like that, what do you think?

SHEKARCHIAN: I think the diagnostic journey during House is fascinating. Although a lot of the things that he does is quite unethical.

JENA: So, you’re saying that House— he doesn’t follow HIPAA. No? Okay.

SHEKARCHIAN: I believe there are a couple of, uh, things that he does wrong. Just a couple though.

DHALIWAL: No. I, you know, I have caught all of those shows. I think most of them I saw in their early iterations. You know, E.R. for instance, was like a staple when I was in medical school. We were so excited. We used to get together and watch it. File it under entertainment. Maybe I’d say Scrubs and E.R. capture the reality of the world a little more than House and Grey’s Anatomy. But the, the one thing I would say all of them do, sometimes to absurdity, is they do show how hard everyone is working to try to figure out what’s going on with the patient. The patient doesn’t get a sense of how much work is happening behind the scenes.

JENA: Gurpreet, Sharmin, I want to thank you for taking the time.

DHALIWAL: Well, thank you so much. It was a real honor to invite me and Sharmin on the show, and you let us do the thing that we love most, which is clinical problem solving. Thank you.

SHEKARCHIAN: Couldn’t have said it any better. Thank you so much.

I first met Gurpreet Dhaliwal about five years ago. I remember I was at a conference with other physicians, and Gurpreet’s diagnostic skills were actually the night-time entertainment. For us, watching an amazing diagnostician unravel a medical case is about as good as a magic show. And if you’ve been listening to this podcast all along, you know I love a good magic show. Shout out to Tricky Tim.

So, on stage, Gurpreet was presented with a case about a young flight attendant who had just returned from a flight to Southeast Asia with a fever and a cough that would not go away.

The doctor presenting the case to Gurpreet told him that the woman had been tested for tuberculosis multiple times, probably at different hospitals, and each test came back negative. For me, that would have ruled out a diagnosis of tuberculosis.

When Gurpreet was asked to make a final diagnosis though, again standing in a room full of 100 doctors, what was his final call? Tuberculosis. And Gurpreet was right. The fourth time the young woman was tested, it was positive.

That night has stood out in my mind for several years now. I was amazed that Gurpreet was confident enough in his deductive skills as a doctor to offer up a diagnosis, on stage, in the face of overwhelming data suggesting the contrary.

Now, while many doctors may not be ready to stand in the spotlight, we are working behind the scenes to solve complex puzzles with high stakes: your health. And we need all the pieces we can get. You got to tell us everything, folks!

If everyone was as curious and warm as Gurpreet, maybe that would feel easier to do, right? That’s why I wanted you all to hear from him today. And it’s worth emphasizing: What Gurpreet did was incredibly difficult because in the real world when you see a patient and have a set of facts, it’s never all the information that you need. There are things that are missing. There’s distracting information. And sometimes there’s just wrong information.

So, how do doctors get better? If you talk to doctors like Gurpreet, who in medicine we sometimes refer to as master clinicians, there is this term that you hear come up frequently: deliberate practice. For these doctors it means that lifelong learning becomes intentional.

Medicine changes rapidly. We have new tests and treatments coming out all the time. I don’t really think it’s possible to be a good doctor without being an active, life-long learner.

In fact, I did a study a few years back that showed that the older a doctor was, the worse the outcomes were for their patients. That may seem a bit disheartening, but we did find that doctors who treated a lot of patients as they got older— these are doctors who were still in the thick of it, learning— those doctors didn’t see the mortality of their patients affected by their age in the same way.

Where I work, Mass General in Boston, many doctors actually wear short white coats. Normally, you only see those coats on medical students. But the purpose for wearing them is for us all to remember that we should always be learning.

That’s it for this week’s episode of Freakonomics, M.D. Thanks for listening, and I hope you subscribe to or follow the show.

If you have any thoughts on the show, ideas, anything at all, I’d love to hear from you. You can email me at bapu@freakonomics.com. 

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. This show is produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Tricia Bobeda and mixed by Adam Yoffe. Our staff also includes Stephen Dubner, Alison Craiglow, Greg Rippin, Joel Meyer, Emma Tyrrell, Eleanor Osborne, Jasmin Klinger, Lyric Bowditch and Jacob Clemente. If you like this show or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.