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Think Like a Doctor, and a Journalist

lisasandersLisa Sanders, MD is a primary care physician at the Yale-New Haven Hospital and associate professor of internal medicine and education at Yale School of Medicine. In addition to her work as a physician and educator, she has written the popular Diagnosis column for the New York Times Magazine since 2002, and also writes the Think Like a Doctor column featured in the New York Times’ blog Well. Her compelling stories on solving patient cases were the inspiration for the television series House MD (2004-2012), and she served as a technical adviser to the show. In 2010, she published the book Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis.  Dr. Sanders majored in English as an undergraduate at the College of William and Mary, and worked as a television producer at ABC and then CBS News, where she won an Emmy award. Dr. Sanders made her career switch after completing Columbia University’s Post-Baccalaureate Premedical Program and attending Yale School of Medicine “as part of the 10 percent of the class they reserve for weirdos,” she says.

I was intrigued by Dr. Sanders’ switch from journalism to medicine in her late 30s, as well as her ability to connect the two in her current career as a primary care physician. I follow her stories on medical mysteries and diagnosis and love attempting to solve them each month. In her book and in her columns, Dr. Sanders places great value on hearing the patient’s story in his or her own words. I was able to chat with Dr. Sanders and hear what led her to medicine later in her career, how her column works, and how to be a better diagnostician.

V: Tell me about your previous career. Until you decided to do medicine, what were you doing? Had you thought about going into medicine before?

Dr. Sanders: I would have never, ever gone into medicine in college based on my experience with the people who were pre-meds when I was an English major. When I went to college, which was in the 70s, it was just filled with people who had been focused on going to medical school their whole educational lives, people who had to get absolutely 4.0s in order to get into medical school. Certainly when I was thinking about what I wanted to do as a career, it never crossed my mind to be a doctor. I just didn’t feel like I was one of those people. I eventually became a television news producer at CBS news. I loved doing television, it was a lot of fun, I got to travel, I got to meet somebody different every day. It was so much variety, and it was also the kind of variety that’s in a way passive: you just wait and see what comes at you. Fundamentally, news is about responding to something that happened. After I did it for about 14 years, I thought, okay, I’ve done this, what else? And one of the things that I had really liked covering, and had covered for a long time, was medicine. I thought, oh, these people that I couldn’t stand to be around in college actually turned into very interesting people. And so I thought, maybe I could do this after all, because it has a lot of things that are similar to journalism. You get to ask people anything you want, you get to be nosy, and you get to react to things that happen.

V: What made you want to go into primary care?

Dr. Sanders: It seemed obvious to me. That was just what I pictured when I started medical school. When I did my medicine clerkship, I went to resident reports, which I had never heard of and didn’t know anything about, and saw these cases presented the way they are at the emergency room. I realized while listening to these residents present these cases that this is not a math problem, which is sort of how I had seen medicine. It’s not really a math problem, it’s really a detective story. I was a huge fan of Sherlock Holmes, so to me, that was really interesting.

V: I love reading your Think Like a Doctor column because it’s very reminiscent of Sherlock Holmes. Clearly for each column you approach the patient and providers to make sure it’s okay to tell their story. I was wondering how you do that and what their reaction is?

Dr. Sanders: Not only do I have to do that, they’re really a key part of the story. The beginning of it is for me all about the patient’s experience of being ill. And you can’t get that without the patient. So I just ask them, I say it’s anonymous, and the biggest thing it takes from them is time and thinking about something that they’ve lived. Often they have the idea that their suffering will help somebody else, I think people are actually extremely generous in that way. I think the idea that people will read this and it might help them is an important component to this. I get emails from people all the time that say, “I didn’t know what was wrong, and then I read your piece about this, and went to my doctor, and that’s what I had.” I convey those as much as I can to the patients who helped me. It couldn’t be done without their help.

V: Do colleagues usually pitch these cases to you, or do you look for them?

Dr. Sanders: It comes from everything. Everytime I meet a doctor, I always ask them if they have any interesting stories to tell me, and that provides me with some. Some of the cases come from doctors who write to me. Sometimes it comes from resident report. Sometimes patients write me and say, “Oh my god, you won’t believe what happened to me.”

V: I read that your column was an inspiration for the show House M.D., and that you were an advisor for the show. What was that like?

Dr. Sanders: I got a call from Paul Attanasio and David Shore, who loved my column and thought it would make a great show. They came up with House M.D., and Paul said, do you want to work on this show? I said, “What’s the show about?” and he said, “It’s about an irritable, arrogant, drug-addled doctor who hates patients and loves diagnosis.” I’m like, “Really?” I really never thought it would work, but it did. Of course, I never thought that House was a realistic character. People asked me, aren’t you afraid that House is going to be a bad role model for medical students? I said, if medical students don’t know enough to know that what you see on TV isn’t true, then they don’t deserve to be doctors.

V: I loved your book on the art of diagnosis, Every Patient Tells a Story. What’s the best way to impart the creativity of diagnosis to medical students or residents in their training?

Dr. Sanders: I think you have to explicitly talk about it. We spend a lot of time talking about algorithms and approaches, and those are all really important. But I think the other thing we need to focus on is, sure if you already know something it’s going to be an easy diagnosis, but how do you think through the things that you’re not sure about? How do you approach a problem when there’s a lot of uncertainty? I think we don’t really talk about that. If you’re devoted to having 15 minute patient slots, you’re not going to want something you can’t recognize immediately, because that does not fit into a 15 minute slot. People who give new patients the same slot as old patients, 15 minutes, those people are rarely going to make a difficult diagnosis. It really takes time to get the information you want, think about what it could be, and look for it. I wonder whether there isn’t an argument to be made for doing a fellowship in diagnosis. I’m part of an organization, The Society for the Improvement of Diagnosis in Medicine, and we are starting to create one, and I’m interested in seeing if it turns out to what I want it to be.

V: What’s your advice for medical students and doctors who want to be more creative and want to do writing or other pursuits in addition to medicine?

Dr. Sanders: Recognize that it takes time, and that’s time you’re not going to spend seeing patients, that’s time you’re not going to spend in the operating room, that’s time you’re not going to spend making money. If you’re going to be creative, you’re going to have to make time for it, and that’s not supported in medicine, its’ something that you have to make time for. But I think it’s worth it. To me, the two things together, writing and doctoring, make my career wonderful. Every day I get up excited to come to work. Doctors make very poor decisions about their own careers and their own mental health. I think doctors are so used to trying to defer their own preferences to get something else, that they haven’t figured out what they want and aren’t getting what they want. Learn how to pay attention to your own sources of pleasure, and then pursue them. Because what you do on an everyday basis is what you do.