A Listening Tour

Israel, Gout, and the Pitfalls of the Chart

© Photo by Bertie

My first job out of residency was inpatient director at the Family Medicine program at Columbia University. I was a Hospitalist, in charge of a team of residents taking care of the sickest patients. You might think I would be intimidated to take such a job just out of residency and indeed I was. 

After all, the spread separating me from a third-year resident was less than the spread separating a third year from an intern: who was I to tell them what to do? Luckily, I had three things going for me: a mentor who helped me manage difficult personalities; no shame when it came to looking stuff up; and specialist consultants.

One of those consultants was an infectious disease doc named Neville Clynes. Dr. Clynes was a character. Lean, intense, and energetic with a bushy head of hair and glasses, he was essentially the only ID at the Allen Pavilion - the community hospital in Inwood where the Family Medicine residency was based - and he ruled the roost.

Let’s just say you wouldn’t want to be the one going in or out of a patient’s room without Purell-ing your hands if he was walking by - and that was way before Covid.

Clynes was wicked smart and not one to suffer fools gladly. He was notorious for making the interns cry when they presented a case to him. His sharp tone and probing questions tended to make them feel like idiots. I think he is retired now, which is probably for the best. These days he would probably get canceled - even if (or especially if) his victims deserved it for not being well enough prepared.

But I respected Clynes, and over the years he taught me many things. One of them - call it Clynes’ dictum - was to listen to the patient. Now, you might think that the importance of listening to the patient was not something that needed to be taught - but you would be wrong. 

In fact, most doctors in the hospital don’t do a whole lot of listening to the patient - they mostly listen to other doctors. 

One of the first things you learn as an intern is how to write a skeleton note - an outline of the admission note that you have to write for a new patient. Full admission notes can run several pages long, including the history, exam, labs, studies, and assessment, capped off by a detailed plan of treatment. When you consider that you may have six or more admissions a night - not to mention all the work that needs to be done for existing patients on the service - shortcuts and efficiencies become essential.

Both the intern and the supervising resident have to write their own separate admission notes, and the intern will quickly notice that the resident’s note is mostly complete by the time they meet the patient. The information gleaned from other notes in the chart, labs and radiology reports, and turnover from the ER staff leaves a little room for information straight from the horse’s mouth, but not much.

After that, it only gets worse. As the chart expands, with specialist notes, attending notes, and progress notes, it can feel like you hardly need the patient at all, except to confirm what you ostensibly already know. 

Of course, cutting out the patient entirely would feel negligent. But as anyone who has ever been hospitalized will tell you, the time spent on team rounds at the bedside always seems surprisingly brief. If you are a family member and leave for a bathroom break at the wrong time, you’ll miss it!

Clynes would always drag you back to the patient. 

Once, we had a patient on our service who was admitted from the ER with a diagnosis of foot cellulitis, a soft tissue infection. The top of his foot was warm, red, and painful, and he had an elevated white blood cell count. Pretty classic, except that he was not responding to antibiotics. Could he have osteomyelitis, where the infection goes deeper and involves the bone? 

Clynes was consulted. He met with the team, heard the story, looked dubious, and marched them to the bedside. There, he elicited a prior history of redness and pain in the same area that had occurred years before and also took a long time to resolve despite treatment with antibiotics.

It turned out the patient didn’t have cellulitis at all - he had gout. 

Clynes suspected this because he knew that the dorsum of the foot is the second most common site for a gout attack, after the big toe. But he clinched the diagnosis by returning to the patient and establishing that this was a recurrent event, the hallmark of gout. 

He probably berated the residents and they probably felt mortified, but I doubt they forgot the experience and I have no doubt that they are better doctors because of it.

Sometimes I try to apply Clynes’ dictum to other areas of life.

Last week we were on vacation in Israel. Those who follow the news know that this is a particularly perilous and momentous time for Israel. In addition to the usual external threats of war and terrorism, Israeli society is being pulled apart by internal tensions and divisions not entirely dissimilar to those in America and other liberal democracies around the world. 

On one side are secular, liberal, “Blue State” Israelis, who serve in the army, support the economy and pay most of the taxes. On the other side are observant, conservative, “Red State” Israelis, who tend to feel marginalized and belittled, and are flexing new-found political power. At issue are proposed laws affecting the power and composition of the Supreme Court.

First, I read the patient’s chart: I listened to podcasts, read articles, spoke to people, and tried my best to understand the issues. And, of course, based on my understanding from afar, I developed solid opinions about who was right and who was wrong.

Then I got to the bedside. Landed in Israel. Saw friends and family. Accompanied them to one of the demonstrations that are roiling the country. Spoke to Israelis - including, of course, cab drivers, who always feel weirdly like the pulse of the nation. Got a feel for things from the people who had the most at stake. 

In many cases what we heard from actual Israelis was sharply at odds with media or pundit accounts. Things were left out, twisted, minimized, decontextualized, or just plain wrong. The mood of a crowd, a facial expression, or tone of voice often said more than words.

In this case, too, Clynes’ dictum paid off - or rather, its converse: how little you can know when you don’t listen to the patient.

Meanwhile, I can’t say I came away with a definitive diagnosis. The patient doesn’t have cellulitis and she doesn’t have gout. The long-term prognosis is also opaque - although at least for now, Israel remains vibrant as ever; creative, pluralistic, and full of life.

What I did come away with was a renewed appreciation for going to the bedside; a reminder to be skeptical of opinions derived solely from the chart; and the belief that talking and listening - in person, face to face - is the key not only to tricky medical diagnoses but to many of the problems that bedevil us today.