Six Tips for Building a Partnership
Epilogue: Engaging Your Doctor
Appendix A: Multiple Hypothesis Generation
Appendix B: Analysis of Competing Hypotheses
Appendix C: Indicators Generation
Appendix D: Key Assumptions Check
Appendix E: Premortem Analysis
Appendix F: Structured Self-Critique
In medical school, one of the questions I was taught to ask a distressed patient was, “Do you have a sense of impending doom?” What a silly thing to say, I thought. Who even talks like that? I have labs and tests that will answer that question better. ECGs, for example, can tell me much more than a patient could ever relate. I practice in the nation’s capital, and it is easy to send a patient down the street for fancy imaging, nuclear tests, or even the “million-dollar workup,” paid for by his insurance.
That being the case, why would I ask such a ridiculous question? Why would I put my diagnosis at the mercy of a patient’s answer to this outdated textbook question? Who would know best? The patient or a trained physician?
By the time Randy Pherson walked into my office, I had run out of diagnostic testing options that would explain his ever-persistent shortness of breath. We had spent five years exhausting the pathways of modern medicine. I had sent him to multiple specialists who ordered scores of diagnostic tests and prescribed multiple treatments. Unfortunately, every path led to a dead end. So, I fell back to asking that old school question: “Does Randy exhibit a strange sense of impending doom?”
Asking that question likely saved his life that day. Randy was tired, frustrated, and at the end of his rope. His face had that look of impending doom, which I had learned about but never encountered until that day. I told him to drive immediately to an emergency room. He protested, saying he would go right after two appointments that afternoon. I countered in no uncertain terms: “You must pick a hospital and drive there now. Non-negotiable.”
Over the course of my career, I learned that no matter what diagnostic tools doctors have at their fingertips, the most important route to effective treatment is old-fashioned face-to-face communication, eye contact, and spending quality time with your patients. Specialists should treat the patient, not just order and process test results.
Randy and I are grateful that one emergency room doctor listened to him—although it took a lot of prodding. Physicians need to talk—and better yet, listen—to the patient. They should ask open-ended questions, despite time constraints. They should encourage patients to tell their story instead of just responding to their questions. Doctors need to review patients’ data, not just focus on their test results. They should pick up the phone and converse with specialists. Above all, doctors need to learn how to collaborate, brainstorm, and personally engage. It could prove the difference between life and death for those “tough” cases that comprise Randy’s “5 percent.”
Patients have much to learn from Randy’s story as well. They should take responsibility for their own bodies and embrace the concept of preventative medicine. Patients should get annual exams so their doctor has a baseline for tracking their health. The average primary care provider has over three thousand patients under his or her care, and it is hard to remember everyone. If you see your doctor annually to get that wellness exam, we will remember you when you return and need our help. The wellness visit is our opportunity to engage and learn about you and your lifestyle when you are well. When you come in with a medical problem—as in Randy’s case, with severe shortness of breath—then your doctor can better gauge the severity of your condition.
With Randy, the objective findings did not match the subjective complaints, but I knew him and saw him often for well visits and sick visits. That knowledge buttressed my confidence in my belief that something was very, very wrong. Doomsday wrong.
As a primary care provider, I am forever humbled by the limitations of modern medicine and amazed at the human body’s ability to adapt. What follows is Randy’s story of persistence, physical adaptation, and lessons learned in his (our) journey through the pitfalls of modern medicine. I am grateful he is here to share his story with all of you.
Sandy Ibrahim, MD
Medical Director, Inova VIP360
Fairfax, Virginia
January 31, 2019
Randy Pherson and I were fellow analysts and friends over long careers at the CIA. We worked together closely in the final years of our careers on the National Intelligence Council where I served as chairman for four years. Randy was an outstanding National Intelligence Officer (NIO) for Latin America during a turbulent time in the region. He was widely respected for his energetic advancement of analytic tradecraft in the information age and for his aggressive outreach to outside sources of expertise in the early post-Cold War period—passions that he brought to improving the quality of analytic tradecraft after retiring from the CIA.
In his thought-provoking book, How to Get the Right Diagnosis, Randy notes that intelligence analysts and medical personnel face similar challenges in collecting reliable data to reduce uncertainty and sharpen diagnoses. He reveals how the methodologies and practices he employed so successfully in the US Intelligence Community can also help fill data gaps and contribute to a more complete and accurate medical diagnosis. In this book, he methodically lays out practical prescriptions for prevention, response, and recovery.
Both of us were avid runners who prided ourselves on staying in shape to meet the demands of our often-stressful work. Yet we both surprised ourselves and shocked our families and friends by having life-threatening medical conditions. Randy’s story, typical of an intensely curious analyst with a healthy bent toward skepticism, is about his forceful challenge to medical experts. The experts believed they had a better grasp of available data on his evolving diagnosis than he did—and turned out to be wrong.
My story parallels Randy’s in many ways. It begins with my own failure to question flawed assumptions about the correlation between apparent good health and immunity from heart disease. I was an in-shape nonsmoker, a sensible eater with no significant family history of diabetes or heart disease. With eight marathons under my belt, I continued to jog regularly, swim every day, and play tennis twice a week. I thought I was in top condition until I almost died from a heart attack after a stressful day in the rugged hills of western Croatia. Unlike Randy who took charge of his medical care, I blame myself for not working with a primary care physician to monitor a growing blood pressure problem related to cholesterol. The alarming data would have been discovered had I sought it—what we sometimes refer to as an “unknown known.”
The