The Limitations of Medical Knowledge - Dr. Lisa Sanders, Author of the "Diagnosis" Column for The New York Times

Shiv Gaglani: Hi, I'm Shiv Gaglani. Many of the physicians we've interviewed over the past two and a half years have interesting side gigs as entrepreneurs or public policy experts, but our guest today has, I think, the most interesting and visible side gig of all. Dr. Lisa Sanders is an associate professor at Yale School of Medicine in Primary Care Internal Medicine, but also finds time to write the popular “Diagnosis” column for The New York Times Magazine, which was the basis for a Netflix documentary series, the Fox TV series House MD, and several books she has authored. Her most recent is a collection of her columns titled Diagnosis: Solving the Most Baffling Medical Mysteries. Dr. Sanders also maintains a clinical practice and is the medical director of the Long COVID Clinic at Yale New Haven Health. I first met Dr. Sanders several years ago when we were just starting Osmosis and we had her on our blog at the time, Leaders in Medical Education, so I'm really looking forward to catching up with her and hearing all the great things she's been up to since then. So, Dr. Sanders, thanks for taking the time to be with us today.

Dr. Lisa Sanders: Well, thanks so much Shiv, for inviting me.

Shiv Gaglani: Our audience has probably read your column, because they're obviously very interested in pursuing careers in medicine, but may not know your career journey. Do you mind giving us a little bit of a window into the kind of non-traditional route you took to become a physician?

Dr. Lisa Sanders: Okay, let's see. Well, when I graduated from college, I had no thought at all of becoming a doctor. I thought maybe I would go to New York and maybe be a writer or maybe be an editor. I didn't do either. I ended up in television as a producer for a morning news show, and that's when I first saw medicine in a real way -- I mean, divorced from the stressed-out pre-meds that I went to college with -- and I thought it was fascinating. I covered medicine with a variety of correspondents for several years, and then I thought, “Eh, maybe I could go to medical school myself.”  So, I had to do all my pre-meds because by then, you know, whatever science courses I'd taken were so out of date and I hadn't taken all of them. 

I went to Columbia, which has a very robust post bacc pre-med program, and then applied to medical school, and I got into Yale.  Yale always accepts one hundred medical students, and they sort of reserve ten spots in every class for the “weirdos.”  I was one of the weirdos. You know, I had many weirdo friends. One of my colleagues was a professional baseball player, another one was from Salomon Brothers, another was an architect and another one had a Ph.D. in physical chemistry -- whatever that is -- and medicine just seemed like a great fit. I must say, I've loved it pretty much ever since we got out of the classroom and started going to the wards. The classroom was hard. Sitting still for eight hours while mostly old white men droned on was not easy. But once I got to the patient part, I was like, "Oh, this is where I'm supposed to be."

Shiv Gaglani: Yeah, absolutely. I know, a bit of that backstory, being non-traditional and Yale being a great place for people with non-traditional backgrounds and I'm sure that's why you've stayed there all this time. Plus, the obvious proximity to New York. But you started med-school at I thirty-six, is that right?

Dr. Lisa Sanders: Yep. Yeah, late bloomer or an early midlife crisis, depending on how you look at it.

Shiv Gaglani: Well, I love this. Many of the guests we've had have had zigzag careers. For example, one physician spent the first few years of his career as a monk at a monastery.

Dr. Lisa Sanders: Oh wow.

Shiv Gaglani: This nontraditional aspect is really interesting and as you know, I did two years of med school, took time off to start Osmosis, and I'm gonna go back to med school next year as a thirty-four-year-old. So, the nontraditional path has been interesting. I'd love to pick your brain about what advice you have for people like that. Say they're in their thirties or forties or fifties and they're like, "Maybe I should be a doctor." What were the hardest or maybe best pieces of advice you got for being nontraditional like that?

Dr. Lisa Sanders: You know, you want to do what you want to do. So do it. I have to say there have been so many older students and nontraditional students in these last couple of decades that I don't even feel like it's an oddity to be odd anymore. I would say that the hardest thing is the lack of sleep, mostly during residency. I have to say, the only thing I would have done differently in medical school is that when people sent me home at night -- because I was pregnant during a lot of my clinical years, and so people would say I should go home -- I'm sorry I did that because the middle of the night, I found as a resident, is where so many interesting conversations happen. But I felt like going home early. I missed out on a lot of that. Medicine is good, but the medicine happens all the time. The surgery happens all the time. But the conversations, those are different. They really happen in the middle of the night -- with patients, with doctors, with my colleagues. I'm sorry I missed out on that.

Shiv Gaglani: Well, that's a very interesting thing to say and certainly something I'll take into mind when I go back to the wards. Now, you started your career as a journalist, you went and finished med school, what made you decide to basically become such an expert in diagnosis and the diagnostic odyssey, because there are so many things you could have differentiated into as a clinician. I know in your Netflix documentary, you talk about how initially approaching medicine you thought it was like the multiplication tables -- you put in an input, you get an output -- but it's more like Sherlock Holmes, where you get twelve potential outputs and you have to narrow it down. It's more of an art in that way than just a science. So, what got you so fascinated in clinical decision-making and diagnosis?

Dr. Lisa Sanders: Oh, you know, I had covered medicine for maybe ten years and so I thought I understood how medicine works. When I got to the first day of my internal medicine clerkship -- which was about halfway through my clerkships -- I went to resident report. If you've ever been to resident report, they usually present a patient from the time they come into the door until a diagnosis is reached and they tell it that way. I'd never heard a story told that way before. You know, usually, diagnosis is the second thing you know, or maybe even the first thing you know about the patient. You might not even know how they presented. You might just know what their diagnosis was. All the textbooks were, at the time, organized that way -- by diagnosis -- and so this whole thing of walking through it the way a doctor walks through it...I thought it was amazing. I'd never seen that before and so I thought that was really exciting and things that are intellectually really exciting just don't come along that often. You know, things that really make you go “wow” just don't happen that often. When I was in this meeting, my mind was blown. I still remember the case that was presented because I'd just never seen information presented that way before. 

So, a friend of my husband's got a job at the New York Times and called me to ask, “What can doctors write?” I said, “There's this story. I'd never seen it before and you've never seen it before.” But he was like, "Oh, that is so interesting" in a way that you could tell he did not think it was interesting at all. 

Shiv Gaglani: (laughs)

Dr. Lisa Sanders: So, I said, "No, no. This is really how doctors talk to each other. It's not how they talk to their patients. It's how they talk to each other. This is the watercooler conversation that people have in the hallways."  

I sent him you know, the New England Journal, and, you know, Mayo Clinic Proceedings where they have these sort of mysteries -- a doctor think through a diagnosis. He was like, "Oh, that's really so very interesting." And then he left the Times to go write a book and his replacement thought it was interesting. So, they actually hired a real doctor writer, but that didn't work out and so this other editor called me said, "Look, this is not really working out. Do you want to take a shot at it? Because otherwise, we're going to trash the idea." And I said, "Absolutely." And my husband held my hand because I hadn't written anything for a really long time. I’d never written anything for publication since I wrote for The Flat Hat at William and Mary. So, my husband, who is a wonderful writer, and a fantastic editor, helped me through my first few columns and they forgot to tell me to stop. So I haven't.

Shiv Gaglani: That's awesome. That's very much like a Tom Brady story where he was second string and luckily for him, and for the Patriots, the first string got injured and he subbed in. I feel like we're all benefiting from the fact that whoever that original physician writer didn't work out for whatever reason. 

So, you've obviously had quite an impact with the “Diagnosis” column and I mentioned some of the popular culture, Netflix and House, that it influenced. I'm curious, there was a change when you made the Netflix documentary where you went from writing about solved cases in “Diagnosis” to then using crowdsourcing to get these diagnoses. I think the first episode of your documentary talked about a nurse in Nevada, Angel Parker, whose diagnosis came from a metabolic testing lab in Turin, Italy, of all places. And there are many examples of that. Can you tell us a bit about the crowdsourcing aspect? Is that still being used, whether it's for the “Diagnosis” column or at scale? Then we're going to transition that into the new form of crowdsourcing, which is AI, and I would love to get your thoughts on how AI has and is influencing the diagnostic odyssey.

Dr. Lisa Sanders: To be honest, I'm not sure that crowdsourcing added a lot. The reason I thought it would be useful, and the way that it was useful, was that it made sure that we didn't leave out anything that should be considered. I mean, the number one reason that a diagnosis is missed is because the doctor never thought of it. So, if we could just get that list to something that included the reasonable possibilities, I thought that would help make a diagnosis. I have to say that with Angel Parker's disorder, I'm not sure we really needed the crowd because she had this very distinctive symptom. By the way, she wasn't a nurse at the time, because if she was a nurse, she might have had the tools to figure this out herself. 

But it's only like a handful of diseases that will give you Coca-Cola-colored urine. It's just extremely rare and so, once you think about those few diagnoses, you've got it. When we crowdsourced for Angel, of course, we got those diagnosis plus two dozen more. We got fifty or sixty diagnostic possibilities and a lot of them came from people who were Googling. A lot of them came from people who had friends who had problems with dark urine. But Coca Cola colored urine, that's pretty rare.  But I think that it was useful in other ways.

First of all, it proved something that I've always thought, or that I thought since I started writing about diagnosis, which is that doctors are not the only people who can make a diagnosis. People can think about their own illnesses; nurses can make diagnoses; physical therapists can make diagnoses; veterinarians can make a diagnosis. I wrote a column for a while that was really the basis of the diagnosis television show, called “Think Like a Doctor” where I would present a solved case and challenge the readers to figure out the diagnosis. I would just stop right after the data was available for a diagnosis to be made and ask people, "What do you think it is?" The next day, I would say what it was. I cut it off after six years because it was too much work...it was fun, but it was a lot of work. Towards the end of that column, the last three or four cases were solved by this couple of veterinarians. I was like, "What?!"  But they were incredible. They were students, and so they had a lot more time. It was amazing. So, lots of people can make a diagnosis and that was one of the reasons I wrote my “Think Like a Doctor” column and it certainly proved that and I think we also saw in the diagnosis show that lots of people who have different ways of knowing medicine can do this difficult thing: make a diagnosis.

Shiv Gaglani: I love that. It speaks to our vision, which is everyone who cares for someone will learn by Osmosis. It’s almost like Martin Luther’s Ninety-five Theses: you don't necessarily need the priests to communicate to God. You don't need the doctor, the neurosurgeon or neurologist to communicate to you about your diagnosis. If you are an engaged patient, and you have the right tools and motivation, you can potentially get pretty far there. 

Dr. Lisa Sanders: If you talk to any patient who has an unusual disease, they will tell you -- and it will be true -- that they are the experts. Their doctors often have never seen what they have, and so they're the ones who are the source of information, or at least, the stimulus to look up the information to find out what to do. So, not only are doctors not the only ones who are needed to make a diagnosis, the treatment as well can come from the patients who are, or can be, the real experts. 

Shiv Gaglani: And they have deep skin in the game, obviously, which is important. One of the reasons I reached out to you again after a couple of years was that our big focus in recent weeks on the podcast has been rare diseases, because we're coming up on the fortieth anniversary of the Orphan Drug Act. The question is, what does the next ten years look like in terms of solving these 7,000 plus rare diseases? The diagnostic odyssey, as you know, is four to nine years, and crowdsourcing is one idea, but I don’t think there won't be enough time for a clinician to learn about all these rare diseases, and so that's actually a good transition into clinical decision support and AI.

What are you seeing? I'm sure there are many companies and groups that have approached you about your work and saying, "Hey, can you look at our decision trees?" We're recording this episode a month after a company called OpenAI came up with this tool called ChatGPT, which you may have heard of. It's blowing up the tech circles and Twitter. What are your reflections on AI? Do you think diagnosis will go from being an art to truly being a science in the next five, ten, fifteen years?

Dr. Lisa Sanders: No, and I don't think AI will solve that problem. I think it's inevitable that we will get to a Star Trek, you know, what was that thing called...

Shiv Gaglani: Tricorder.

Dr. Lisa Sanders: ...tricorder, where something will be able to look into the body and actually see what's wrong. But you know, AI doesn't have the ability to get information other than through what we already have. It's true that they can organize it better, and that can be useful especially with tests. Maybe that will be useful. It might remind you of things that you had forgotten about. So, I think it's going to be important, but it won't make this a science because bodies are too variable. Symptoms are very variable. I'm just not sure we're going to get to a science anytime soon because people are so different. The way they tell their stories is different. The way they interpret symptoms is different. 

If, as we think, diagnosis is based in large part on patient history, that's always going to be this kind of squirrely thing that I think is going to be difficult to take into consideration as a computer. But maybe I could be wrong. Maybe AI will get to be incredible. But I think that what they can do is look at patterns of things and recognize something that might not even be known or might not have been seen by other people. For example, I understand that in looking at retinal imaging, AI came up with a new observation of a disease that hadn't been identified previously. It was an AI diagnosis, and that's amazing. So maybe that will happen, but I think as long as you're dependent on doctors eliciting the history -- the tests that they order are determined by the doctors -- then I think the diagnosis is still going to be tough.

Shiv Gaglani: I agree, and I think one of the limitations of all AI systems -- not just in medicine -- is the datasets and the training behind the datasets. There's obviously a lot of talk about the ethics and biases depending on what the data sets are for clinical trials. As they say, ‘garbage in garbage out,’ which is why having a caregiver or a clinician who can elicit an accurate diagnosis through a history, a physical and lab results matters. I think that's a wise thing you just shared about the need for a clinician. AI may change what we do as clinicians, but that's a good thing. 

Dr. Lisa Sanders: I think that is a good thing and I think that it will eventually require doctors to recognize the importance of getting a good history, which requires good people skills. I am sure that you looked around in your medical school class and noticed that not everybody there was charismatic. 

Shiv Gaglani: (laughs)

Dr. Lisa Sanders: Not everybody there was comfortable talking to people. Not everybody there helped people feel relaxed enough to share. This turns out to be an extremely important characteristic or quality in doctors that we don't look for in any way, I think. Even in medical school. I did an interview for Yale. I guess most medical schools now have interviews, but I'm not sure what the purpose of them is. If you have somebody who is awkward and a poor communicator interviewing you, how are they going to know if you have these people skills or not? So, I think that the great thing about helping with the memory load -- which I think AI can help us with -- will be that we can focus on some of the qualities that really make a difference in getting the right diagnosis.

Shiv Gaglani: Yeah, that's well said and I agree. It'll be interesting when I go back to med school ten years later. The maturity I think I've developed over the past several years running a company and scaling it is incomparable to when I was a twenty-one-year-old going to med school and didn't know anything. I did business school in between and business schools, I think, have a better approach where you can't just do the theoretical business school. You've got to spend a couple of years in the workforce because with topics like culture and managing people, textbooks or case studies aren’t enough. You need direct experience and maybe that's why nontraditional students like yourself not only may stick around medicine longer -- because they've matured more as a person so they're making that decision knowing more about themselves -- but then they hopefully will develop more of the soft skills that ultimately are the more important skills, or will be over the next couple of decades.

Dr. Lisa Sanders: I think they've always been important, but I think that they're going to be even more important.

Shiv Gaglani: Well, I wanted to get into what you're doing now and the Long COVID clinic we mentioned. Can you talk to us a bit about that and any other things that are top of mind for you? It's been a couple of years since we spoke and we'd love to catch our audience up.

Dr. Lisa Sanders: Well, I don't start the Long COVID clinic until I finish with my current job, which goes to the end of this year. So, I've just been doing a lot of thinking and reading about long COVID. What amazes me, to be honest, is how much skepticism there is about whether this is a "real" diagnosis. You know, a million people get sick, and some large portion of those people have these symptoms that linger on for months, sometimes years. I'm just not sure this is mass hysteria. The circumstances that allow or encourage mass hysteria are very different from what we're seeing with long COVID. Moreover, there's some physiology involved, things that can be measured. 

One of the first things we heard about long COVID is people feel sick, but all the tests are normal. That's because the right tests either weren't available or weren't considered. We do have a hard time measuring many of these symptoms. How do you measure brain fog? How do you measure some of the other symptoms that raise a lot of skepticism? On the other hand, there are things that are very easily measured. Many patients who have long COVID have these fluctuations in their blood pressure and heart rate that can be measured if you do it right. 

I think the big surprise for me was how much skepticism there is surrounding this diagnosis and let me just say, I don't go for all the trendy diseases. I never bought into chronic Lyme. There is post-Lyme, but that's different than chronic Lyme, where apparently you don't even have to have Lyme to get chronic Lyme. So, that's been my biggest surprise so far. But I'm excited to get started and I'm excited to see what I can bring to this. 

There are already super specialists at Yale who are seeing these patients. People who have palpitations or these variations in their heart rate or chest pain or all the kinds of things that they have are calling cardiologists and pulmonologists and neurologists and psychiatrists. They're already doing that. It's not like that doesn't exist. It's just that I will be somebody who can help them. My team will be able to try to identify what's really going on and direct them in, I hope, a more effective trajectory. So, I'm very excited about getting started. I start in January, so we can talk after that.

Shiv Gaglani: Definitely. I'll be very excited to hear how that happens. That's another topic why I think there are limitations to AI because there are diseases, or our understanding of diseases, that are just being shaped in real time. Like, very few people knew what a coronavirus was five years ago, and now everyone seems to. Long COVID similarly. So, it's unlikely that a system that needs training, like an AI, will be able to help with these kinds of nascent diseases. It'll be exciting to watch your trajectory there. 

Two other questions, and then we'll let you go for the day. As you know, we're a teaching company. We like to fill in knowledge gaps. If you could snap your fingers and teach any group of people -- clinicians, patients, public -- any topic, what would it be and why?

Dr. Lisa Sanders: I think that patients do not understand how little we actually know in medicine. I'm not sure if doctors understand this, either. Very early in my career as a medical student, I came home to my husband and I said, “You know, I think if people had a better understanding of how little we actually know, they take a lot better care of themselves.” Because I think that there's an assumption that if we get sick or if we get injured, somebody can fix us. I'm just not sure that people understand that that is not always the case. In fact, maybe even mostly not the case. So, I think people need to appreciate how little we know about this magnificent, mysterious body we live in and this mysterious and incredibly dirty world we live in. That would be what I would want people to think about.

Shiv Gaglani: Well, that's a great bit of advice. We've never heard that in our episodes. It's the moral hazard where it's like, ‘oh some surgeon will be able to fix me for my obesity’ or whatever diseases and things you're suffering from. Very interesting. Lastly, our audience has grown quite a bit since last we spoke. I think when we had you on the blog, we had maybe ten thousand or fifty thousand people and now we have a couple million.

Dr. Lisa Sanders: Congratulations. That is so fantastic. Wow! Wonderful!

Shiv Gaglani: Hopefully someday we'll get as big as The Times column you have where I'm sure you have hundreds of millions. But, what advice would you give to our audience about meeting the challenges of the current moment in healthcare or in society and approaching their careers?

Dr. Lisa Sanders: Be open. The world is a lot more complicated than medicine makes room for. Medicine is a lot more complicated than medicine makes room for. Be prepared for all the uncertainty. You know, the way we are trained, right up until the moment you step into the wards is in an environment of certainty. We're asked a question, there is a right answer. It is knowable and immediately knowable. Once you get away from the classroom, that kind of certainty is an illusion. Certainly there are people who have things, but you can't rely on, for example, a history. Somebody comes to you with the history of this, that and the other disease. Maybe they have those diseases, but maybe not. There's a lot of uncertainty and you just have to be willing to accept that and work with that and be flexible in what you think. I think the key to being a good doctor is being flexible, allowing yourself to see things as they are and being open for what you don't know.

Shiv Gaglani: I think that's great advice, not just for clinicians, but people in general...to question their knowledge and update their knowledge over time. We may have published this paper after we last spoke -- I don't know if I mentioned it to you before -- but in medicine, whether it's the MCAT or USMLE, there is a right answer or best answer and it's multiple choice which is not how patients present, obviously. One thing we did early on, and we published this paper in Annals of Internal Medicine, was we asked for confidence level before you get the answer. So, when you say A,B,C,D, or E, you have to rate your confidence—either I have no clue, I'm feeling lucky, or I'm sure. And we found that male medical students and female medical students had very different confidences but the same accuracy. Male medical students tended to be overconfident, which could obviously lead to diagnostic error. Female medical students were less confident, which could lead to defensive medicine, or not high value medicine. It was a pretty interesting result and I think that self-awareness that you've encouraged our audience to pick up is something that I hope they take seriously.

Dr. Lisa Sanders: I have a question. When you looked at that, were people uncertain about the right things? Like, were they more likely to be uncertain about the things that they got wrong or not? I can't remember who said it, "It's not what he doesn't know. It's what he does know that's wrong that worries me." You know, did you find that to be the case...that people were very confident and still wrong?

Shiv Gaglani: Yeah, that’s a really good quote. I think it’s Mark Twain who said it. Fortunately, there was high calibration and there were actually cultural differences too, in addition to gender differences, as far as how people approach that confidence. I think Malcolm Gladwell wrote a book about aviation in South Korea versus in the U.S. where confidence and hierarchy play a role in this, too. So fascinating. 

Anything else you want to leave our audience with before we let you go? 

Dr. Lisa Sanders: No. What are you going to go into in your last two years of medical school? Do you have any thoughts now that you've been peri-medicine this whole time? What are you thinking that you might do your residency in?

Shiv Gaglani: It's a really good question. Part of what influenced me to go back to Hopkins, specifically, and finish med school there is I'm very excited by consciousness and the brain. Like, neuro-engineering, neurology, neurosurgery. My mentor was a neurosurgeon. It’s unlikely I'll do that long of residency, though, to be to be honest. Also, Hopkins, along with Yale have great centers for psychedelic studies and so with regards to consciousness and mental health, I’m very excited about the role that psychedelics can play in helping people become more self- aware, and maybe just become better humans as a whole.

Dr. Lisa Sanders: Well, fascinating. Do stay in touch. I want to see your papers that you write. I'm sure they'll be interesting.

Shiv Gaglani: I definitely will. Dr. Sanders, thank you so much for taking the time to be with us and more importantly for the work that you've done over your career to help individual patients and make diagnoses more accessible to the general public.

Dr. Lisa Sanders: Well, thank you very much. It was a pleasure.

Shiv Gaglani: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.