Reaching Down the Rabbit Hole


Dr. Allan H. Ropper & Brian David Burrell

The essence of this book is that diagnosing a condition relies on taking a thorough, problem-focused history which relies on the skill and patience of the doctor and the memory and communication ability of the patient and their family. While technology can be extremely important, its primary value is in confirming – or disconfirming – a diagnosis, not in generating a diagnosis. The longer most doctors practice, the more that they tend to rely on the patients’ history of symptoms and the signs of a clinical examination. The book is oriented on case presentations in a hospital setting as seen from the perspective of a neurologist with relevance to other areas of health care. The following are just a few excerpts to provide the flavor of the book.

Image result for patients history

            What they hope, what they expect, what they deserve, is that we take the time to listen, because the act of listening is therapeutic in itself. When we do it right, we learn details that make us better doctors for the next patient. The residents may not get this yet. They are focused on diagnosis and treatment, on technology, on scales, titers, does, ratios, elevations, and deficiencies. All well and good, I tell them, but don’t forget to listen.


            Medical textbooks teach you what tests to do to make a diagnosis, but they do not dwell on the simple reality that humans are interpreting the tests. Image result for pediatric radiologist

            That’s what makes medicine medicine. People are letting us in, but we can’t expect them to describe their problem in medical terms, so we reframe what they say in a way that’s usable. We give it coherence. If somebody comes in with numbness or paralysis, with headaches or speech problems, with tremor or confusion, we take the patient’s report, bring it to the level of brain and nervous system operations, then come up with a plan. It can be a very intense chess game – speed chess – because on rounds, we have to act fast. The value we add is the intellectual act of making these moves, and the clarity with which we can do it. Image result for doctor making hospital rounds

            All of us – patients and doctors – cultivate the fiction that science conquers all, that it can provide the cures. How could God have created a world in which it can’t? We need to sustain our faith in science, our paradoxical belief in its divine power. We have always had to believe that, going back to pre-Hippocratic times. “I’m going to give you a potion, it will solve your problem.” That statement promises some control over mortality and destiny. That’s why what we do is as much shamanistic as medical, because society cannot relinquish that hope, the belief in the curative power of something, of medicine, of prayer, of diet, of therapy, of sheer expertise, of connecting with another human being, rather than acknowledge that the universe is like the eye of a dead fish: cold, uncaring, unreflective, unresponsive. Image result for snake oil

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