● 저자 : 리자 샌더스 Lisa Sanders
● 소감
책의 제목이 많은 것을 알려주고 있습니다. 모든 환자들은 자신의 아픈 것을 치료받기 위해 병원을 찾아가서 의사에게 상태를 설명합니다. 그리고 의사는 환자에게 들은 이야기와 다양한 검사 결과를 종합하여 진단을 내리고 그 진단에 맞춰 처방을 줍니다. 대부분의 진료가 이런 단계를 거치게 됩니다.
이 책에서는 다양한 환자의 사례를 통해 의사가 얼마나 쉽게 오진을 할 수 있는지 보여줍니다. 한편으로는 어떤 의사들은 원인을 찾지 못해 고생하는 환자들을 위해 포기하지 않고 원인을 찾아냅니다. 정확한 진단을 내렸을 때 몇 주부터 몇 년간 고생하던 환자들의 증상이 금방 개선되는 것을 봅니다.
다양한 사례들은 의사들이 진단을 내리는 과정이 얼마나 중요하고 환자의 생명까지도 영향을 줄 수 있다는 점을 보여주고 있습니다. 또한 저자 자신이 의학을 공부한 사람으로서 이야기를 흥미진진하게 구성해서 읽는 과정 자체가 의료계를 이해하는 시간이면서 다양한 의학용어에 대해서도 익숙해질 수 있는 기회였습니다.
특히 숙달된 한 명의 의사가 되기 위해서는 얼마나 많은 사례를 경험하고 찾아 읽고 습득해야 하는지 잘 알게 되었습니다. 왜 '인턴'이나 '레지던트'와 같이 병원에서 잠도 줄여가면서 다양한 환자를 함께 치료하며 도제식 학습을 해야 하는지 알 것 같습니다. 그 과정을 통해 선배들에게 어떻게 진단하는지 배우고, 의학 저널을 읽으며 세계의 다양한 나라에서 나오는 케이스들을 습득하는 것입니다.
한편으로는 의사가 아무리 다양한 사례를 연구한다고 하더라도 인간이 가진 한계가 있기 때문에 모든 것을 알 수는 없습니다. 그리고 특정한 나라에서 자주 발생하는 질병은 진단하기 쉽지만 다른 나라에서 유입된 질병은 진단 경험이 없기에 알기 어렵습니다. 그래서 AI라고 하는 인공지능 로봇 등의 컴퓨터를 활용한 진단이 기대가 됩니다. 환자의 상황을 잘 듣고 컴퓨터에 기입 혹은 입력함으로써 가능한 질병의 종류를 제시할 수 있다면 의사의 기억에만 의지하는 진단보다 훨씬 치료에 가까워질 수 있습니다. AI가 전적으로 할 수는 없고 의사가 최종 판정을 내리는 것입니다.
이 책은 의학에 대한 일반 상식책으로 번역된 것은 없는 듯 합니다. 하지만 영어 독해를 조금만 한다면 즐길 수 있겠습니다.
● 책에서 발췌: 원서에서 영문으로 그대로 인용해 적습니다.
도입 14페이지) At the birth of medicine, millennia ago, diagnosis (the identification of the patient's disease) and prognosis (the understanding of the disease's likely course nd outcome) were the most effective tools a doctor brought to the patient's bedside.
Intro15) We now have at our disposal a wide range of tools-new and old- with which we might now make a timely and accurate diagnosis. And as treatment becomes more standardized, the most complex and important decision making will take place at the level of the diagnosis.
Intro17) Despite all the available technology, the tools doctors often rely on most are the most old-fashioned-a phone, a respected colleague, a mentor or friend.
Intro20) In Wilson's disease, the liver lacks the machinery to regulate copper, an essential mineral found in the diet.
Intro21) It can be a messy process, filled with red herrings, false leads, and dead ends. An important clue may be overlooked in the patient's history or examination.
6) Nor is there any other way to obtain this information. Talking to the patient more often than not provides the essential clues to making a diagnosis.
12) She went to Google and entered "persistent nausea improved by not showers." She hit the enter key and less than a second later the screen was filled with references to a disease Hsia had never heard of.
14) In medicine, the patient tells the story of his illness to the doctor, who reshapes the elements of that story into a medical form, into the language of medicine.
28) Indeed, the ability to create this spare and impersonal version of the patient's story is the essential skill in diagnosis.
Development of a large library of these illness scripts has been the goal of medical training since long before it was described this way.
32) Doctors are constantly adding to the number and richness of the illness scripts in their heads. Every patient contributes. Lectures can too.
33) Dr.Nancy Angoff is the dean of students at Yale Medical School. She watches over the one hundred students of each class as they wend their way from student to doctor. She concerned that medical education spends too much time on focusing the students' attention on the disease and not enough time on the patient.
41) The physical exam was once the centerpiece of diagnosis. The patient's story and a careful examination would usually suggest a diagnosis, and then test, when available, could be used to confirm the finding.
42) Yet despite this uneasiness, doctors and even patients increasingly prefer what they perceive to be the certainty of high-technology testing to a low-tech, hands-on examination by a physician.
43) How can we have generations of who make it through residency and sometimes subspecialty training without improving their skills in the physical exam?
44) the rising cost of hospitalization has focused efforts to shortening patients' time in the hospital.
56) The patient's story contained the diagnostic tip-off up to 70 percent of the time.
57) This handful of studies suggests that a thorough physical examination can play a critical role in making a timely diagnosis-a role that cannot be duplicated by even the sophisticated tests we now have available.
58) The experience of being ill can be like waking up in a foreign country. Life, as you formerly knew it, is put on hold while you travel through this other world as unknown as it is unexpected.
68) And his potassium-an essential element in body chemistry, regulated by the kidneys-was dangerously high.
75) Medical training itself has not effectively changed since the end of the nineteenth century when Sir William Osler developed the hospital-based residency system as a method for standardizing medical apprenticeship.
83) Throughout medical school and residency training, I was told repeatedly that I needed to learn what "sick" looks like because it would provide one of the most important clues about how ill a patient really was.
88) Then the researchers compared how sick the patients really were wich how sick the physicians had thought they were when they were initially seen in the ER.
91) In a preface to one of his books, Doyle describes his debt to Bell in developing Holmes as a character and provides examples of Bell's Holmes-like abilities.
93) The course, now part of the curriculum, requires first-year medical students to hone their powers of observation on paintings rather than patients.
97) Researchers call this phenomenon "inattention blindness" because we often fail to notice an object or event simply because we are preoccupied with an attentionally demanding task.
98) Perhaps Osler was mistaken when he said that more diagnoses were missed because of not seeing than not knowing.
110) There's mounting evidence that the hand of the doctor provides information that can't be gained from the cool eye cast by its technological replacements.
111) Twenty years ago, Alfredo Alvarado, an emergency room physician in Florida, developed a method of separating patients who may have appendicitis from those whose pain probably comes from something else.
119) These days, it's commonly taught as a method for diagnosing carpal tunnel syndrome, an overuse injury of the median nerve that cause numbness or tingling in the thumb, first finger, or second finger.
124) "Our findings on physical exam feel like shades of gray while test results literally appear in black and white."
126) Neither is good for the patient. And we forget that for many diseases the diagnostic standard is still the physical examination.
133) Technology is eroding, melting away this ancient, massive, and essential part of the way a physician knows the human body.
136) The utility of the device, ultimately called the stethoscope (from the Greek stethos, chest), was immediately apparent to Laennec.
168) Often, as in Carol Ann's case, the diagnosis will be made without a test, based on the patient's geography and symptoms, and cinched by the presence of the typical rash, known as erythema migrants.
171) The danger of this diagnosis and treatment is twofold. First, it puts patients at risk of serious side effects from the powerful drugs that are used. Second, this erroneous diagnosis can postpone diagnosis and treatment of other disease, leaving patients even worse off than when they started.
173) The earliest and most common symptom of Lyme disease is an expanding circular rash, which usually appears around the site of the tick bite within a few weeks.
175) But an even more important complication in testing for Lyme disease is that once the body does make antibodies, they stick around-for months or years-as protection against future infections.
189) Until there is one, and possibly long afterward, concerns about missed diagnoses of Lyme will continue to be a source of confusion and contention for doctors and patients alike.
197) Many studies show that diagnostic errors often exact a tragic toll. Diagnostic errors are the second leading cause for malpractice suits against hospitals.
198) Anyone interested in learning even more about this important issue should check out Jerome Groopman's outstanding book on the topic, <How Doctors Think>
199) Half of all the errors made were due to a combination of ad systems and sick thinking.
203) But errors can also arise from interpretations of data we're not even aware we are making, thanks to assumptions and biases that we bring with us from our lives outside the hospital.
213) Yes, doctors are human beings and, thus, are prone to biases, distortions of perspective, and blind spots.
214) But there is shame in not checking or catching the error.
215) Medical knowledge has grown to vast that no single human can know it all-no matter how much experience they have, no matter how many patients they've seen, and no matter how many textbooks they've read, no matter how many journals they keep up with.
238) Would a kind of super-efficient, integrated, intelligent computer system eliminate all diagnostic challenges? Would it replace doctors?
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