Blog | Monday, March 19, 2018

Mystery fiction and being a better internist

As a child, mystery fiction captivated me. Probably the Bobbsey Twins, then the Hardy Boys and Nancy Drew started the passion. I remember the TV show Perry Mason, which led me to reading books from the Earl Stanley Gardner series. Lt. Columbo captivated me. Discovering Sherlock Holmes was an epiphany. And throughout my life, I love finding great new mystery authors.

I suspect that my love of mystery fiction made my choice of internal medicine inevitable. While our field has many dimensions, the core of being a good internist is accurate diagnosis. While sometimes diagnosis is straightforward, often the patient's story unfolds much like a mystery novel.

Clinical reasoning has attracted many internists. The field of cognitive psychology helps us understand the road to excellence and the pitfalls along the way.

But recently I have paid much attention to the brilliance of mystery fiction writers. Literature (and yes the mystery genre is literature) often gives insights into the human condition. As I read mysteries or watch mystery TV or film, I often see parallels to our field. Here are a few examples:

“The world is full of obvious things which nobody by any chance ever observes.” Sir Arthur Conan Doyle, The Hound of the Baskervilles

While we often see the patient, our training should teach us to really observe.

“I've learned over the years that sometimes if you ask the same question more than once you get different responses.” Michael Connelly, The Brass Verdict

We learn this truth as students and residents. The attending physician often gets a better answer the next day. Patients think about their situation and often recall details that did not come initially to mind.

“It often seems to me that's all detective work is, wiping out your false starts and beginning again.”

“Yes, it is very true, that. And it is just what some people will not do. They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant.” Agatha Christie, Death on the Nile

How true this is! Our biggest flaw is falling in love with a diagnosis. Sometimes the diagnosis is thrust onto to the patient before we see the patient. We must always re-examine our thoughts for our patients. If the treatment is working beautifully and the patient's respond fits our knowledge, we can stick with a diagnosis, but when the course wanders away from the expected we need the courage to doubt ourselves and everyone else. We must start over from the beginning and not assume anything.

I have found many more great quotes. Many mystery writers have great insights into the detective process. And since we pride ourselves as detectives, I believe we can learn from their wisdom.

If you have quotes from mystery writers that make important points, please share them with me and our readers. I will gladly share them with attribution on this blog and on Twitter.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.