The views stated here are those of the author and do not necessarily reflect those of the editors of this newspaper.
To: Editors, Haddam News.
01 26 20
On the importance of “Being a Good Noticer”:
Reflections on the experiences of Mr. Hugh Lofting as recounted eloquently by Mr. Philip Devlin
“Killingworth Author Hugh Lofting and the Great War origins of Dr. Doolittle” Published on Jan 23, 2020 in Haddam Killingworth News
I am sharing with you key connections I made after reading this essay carefully more than once, based on descriptions of the gifts of observations and analysis of what he was experiencing of Mr. Hugh Lofting especially experiences in the Great War and the sage advice proffered by Polynesia the parrot and Tommy Stubbins who had just indicated he would like to grow up and be like Dr. Doolittle. Polynesia speaks: “But listen: are you a good noticer? Do you notice things well?… That is what they call power of Observation-noticing the small things about birds and animals: the way they walk…But that is the first thing to remember being a good notice is terribly important… Simply put, but, oh, so true: Being a good noticer is terribly important.” I have been practicing this essential skill over the past several decades of being a physician both in India and the USA as well as during my travel through Cambodia and VN as a member of Am. Psychiatric Association delegation organized by People to People Ambassador Program
These are the thoughts that sprouted like fresh shoots after a rain after I read Mr. Devlin’s masterful essay. It is a poignant eulogy as well as interesting biographical portrait of Mr. Hugh Lofting. I congratulate him for his exemplary achievement.
The main founts of my recollections are:
My reflections about:
- Arthur Conan Doyle,
Sherlock Holmes with medical ramifications
- TV Characters inspired by Sherlock Holmes mostly Medical Practitioners with one notable exception: Dr. Spock
- An actual Practicing Physician who consulted on the “House” TV series
- The crucial stage in Doctor Patient relationship: Importance of being a good Listener and good noticer during the Physical Examination.
- The Two Systems of thinking postulated by Economic Nobel Prize Winner Daniel Kahneman that have great bearing on our interactions with people especially during medical visits.
- Finally, a manual published by the Chair and faculty of Yale Emergency Dept. on the skill set of providing effective screening, brief intervention and recovery supporting referrals to individuals affected by Substance and Alcohol use Disorders in the tumult of Emergency Room environments.
- Arthur Conan Doyle- the creator of Sherlock Holmes. https://www.arthurconandoyle.com/biography.html
A… the man who most impressed and influenced him was without a doubt, one of his teachers, Dr. Joseph Bell. The good doctor was a master at observation, logic, deduction, and diagnosis. All these qualities were later to be found in the persona of the celebrated detective Sherlock Holmes.{ Dr. Bell sported a Deer stalker hat and the Victorian deerstalker coat- presumably made from Tweed.}
B…Conan Doyle opened a practice in elegant Upper Wimpole Street where, if you read his autobiography, not a single patient ever crossed his door. This inactivity gave him a lot of time to think and as a result, he made the most profitable decision of his life, that of writing a series of short stories featuring the same characters.
C…He deployed his powers of observation and exquisite faculty of reasoning and capacity to connect dots in real life situation in his fight for justice….He extricated himself from his misery by trying to help someone in a worse condition than he was. Playing Sherlock Holmes, he got in touch with Scotland Yard to point out a case of miscarriage of justice. It involved a young man called George Edalji who had been convicted of having slashed a number of horses and cows. Conan Doyle had observed that Edalji’s eyesight was so poor that it was proof the convict couldn’t possibly have done the awful deed. Several years later, this remarkable man, who couldn’t tolerate injustice, was captivated by yet another criminal cause célèbre. The Case of Oscar Slater, which he wrote in 1912, gives a detailed summary of that affair.
D…The toll of the war was cruel on Conan Doyle. He lost his son, his brother, his two brothers-in-law and his two nephews. Mr. Hugh Lofting also suffered in the Great War as a member of the Irish Guards. Dr. Conan Doyle was deeply affected by the slaughter of Horses and Men: While writing a book, which was to be called The British Campaign in France and Flanders, the author was given permission to visit the British and French fronts in 1916. A while later, the Australian High Command invited him to observe their position on the river Somme. Witnessing the Battle of St. Quentin made Conan Doyle say he would never be able to forget the horrors of the “tangle of mutilated horses, their necks rising and sinking,” lying amidst the blood -soaked remains of fallen soldiers.
E…Dr Conan Doyle also wrote about his voyages: He sailed to the Arctic on Whaling ship the Hope. He was appalled by the slaughter of the seals by the crew. “I went on board the whaler a big straggling youth” he said, “I came off a powerful, well-grown man”. The Arctic had “awakened the soul of a born wanderer” he concluded many years later. This adventure found its way into his first story about the sea, a chilling tale called Captain of the Pole-Star.
II. Many prominent TV Icons were inspired by Sherlock Holmesg. House-Monk-Spock and 6 other Characters are inspired by Sherlock Holmes
https://www.handitv.com/lists/house-monk-and-seven-other-tv-characters-inspired-by-sherlock-holmes
There were some common themes including keen powers of observation and analyses and capacity to organize data to establish a more accurate appreciation of the circumstances they found themselves in.
These four great examples:
1. Gregory House on ”House’
Personal demons: Vicodin addiction
Watson: Dr. James Wilson
The Sherlock of medicine, cantankerous Gregory House uses deductive reasoning and psycho-analysis to root out the arcade causes of illnesses. Both characters struggle with drug addiction and play an instrument. In the episode “The Itch,” House is even shown to own a copy of Conan Doyle’s The Memoirs of Sherlock Holmes, in case the parallels were not clear enough. Dr. Lisa Sanders, MD was a real doctor behind Dr. Gregory House’s medical deductive acumen. More follows
2. Spock on ‘Star Trek’
Personal demons: Half-human, half-Vulcan. He alleges his human ancestor linked him to Mr. Sherlock Holmes
Watson: Captain Kirk
The deductive Data may have cosplayed as Sherlock on The Next Generation, but Spock is the only one on this list who is related to Sherlock by blood. Yep, that’s theory. In Star Trek XI, Spock declares, “An ancestor of mine maintained that if you eliminate the impossible, whatever remains – however improbable – must be the truth.” Which is, of course, a Sherlock Holmes quote. Meaning Spock’s human half traces its ancestry to Mr. Holmes. Makes sense, as both characters were highly logical and cold, personality-wise.
3. John Luther on ‘Luther’
Personal demons: Haunted by the darkness of crime, anger management
Watson: Justin Ripley
Creator Neil Cross has said that his character Luther (Idris Elba) is influenced by both Sherlock Holmes and Columbo. That perhaps waters down his Sherlockishness, but he is British and wears tweed, so he has that up on the others.
4. Dr. Henry Morgan on ‘Morgan”
Personal demons: Immortality
Watson: Detective Jo Martinez
Another one-season wonder from the 2014-15 season — peak Sherlock revival, really — was this supernatural series. Ioan Gruffudd’s character, a genius medical examiner, may have operated in the modern Big Apple, but he was secretly closer to Sherlock than most. He was immortal, and was stalked by his adversary and “Moriarity,” another undying man named Adam.
III. The Real Doctor Behind House
http://content.time.com/time/health/article/0,8599,1916602,00.html
Like a modern-day Sherlock Holmes in scrubs, the title character of House can solve just about any medical mystery. That’s not altogether unrealistic, says Dr. Lisa Sanders, the show’s technical adviser. Sanders, an internist and the author of Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, talked to TIME about House’s flesh-and-blood counterparts, how we can teach more doctors to be like them and how patients can help.
So, are there really doctors like House, who seem to be able to diagnose just about anything?
There are. If you go to any community of doctors, they will be able to list three or four doctors who seem to know everything. We all know who they are. Different doctors will name different people, but you’ll come up with a very short list.
My sister and I are physicians. Our friends adored members of the faculty who clearly demonstrated their life saving and tried to emulate them to the best of our abilities with every ounce of strength, in all of our work every day of our training years and beyond.VM
How do they get that way? Are they just smarter than everybody else?
That always helps. But they’re not just IQ-smart. [I can absolutely attest to that statement.VM. It’s a puzzle-solving facility. The most important quality in these doctors is that they just know so much. One of the doctors that I go to when I’m stumped has a screen saver on his computer that says, “Have you kept up with the literature today?” These are people who are constantly learning and adding to an already sizable knowledge base. And they have seen a lot. That’s very important, because a disease on the page is so different from the disease in a person.
One of the recurring themes in the book is the fact that too few doctors sit down and hear out the patient’s story. Why is that? [I totally agree there is clear disdain conveyed to the narrative aspect of the patient’s history while they are in the examining room. VM}
It’s hard to listen to a story that’s not told well. That’s a terrible thing to say, but we all feel this. You know, when we’re at the dinner table and Uncle Dave is telling a long, windy story, what you’re really thinking is, “Where is this going? What is the bottom line?” That kind of impatience is not just limited to the dinner table; that’s often how doctors feel. When you didn’t have any other [diagnostic] tools except that story, you just buckled down and listened. But now that we have other [high-tech] tools, we feel like, “O.K., I’m out of here.”
It seems like you’re trying to get people to think of doctors in a less clinical, more human way, and to recognize that there are emotions on both sides contributing to the successes and failures.
Absolutely. I think one of the great things about House is that often in solving the problem, it’s something in his real life that triggers a thought about his patient. I think fundamentally what doctors and patients both have to remember is that the diagnosis process is a collaboration between two experts: the doctor, who is an expert on the body and disease in general, and the patient, who is the expert on this body and this disease and these symptoms. There’s no way for a doctor to know what the patient is feeling without asking.
You talk a lot about the death of the physical exam too. You attribute that, in part, to another very human response: doctors feeling awkward about touching another person in an intimate way. That’s not something we hear about very often.
I will come back to this in the sections to follow.
IV. Chapter 4 The Physical Examination. This is reference from National Institutes of Healthhttps://www.ncbi.nlm.nih.gov/books/NBK361/ Earl W. Campbell, JR and Christopher K. Lynn.
A. Definition
Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient’s history and pathophysiology. Moreover, it is a unique situation in which both patient and physician understand that the interaction is intended to be diagnostic and therapeutic[and begins to establish the enduing growth and health promoting foundations of the critical doctor-patient relationship.VM]
B. The Context
Almost without exception, some medical history about the patient is available at the time of the physical examination. [It is vital to have some historical data. Rarely, there may be no history, or at best brief recordings of acute events. Information pertinent to the physical examination can be learned from observation of speech, gestures, habits, gait, and manipulation of features and extremities. Interactions with relatives and staff are often revealing. Pigmentary changes such as cyanosis, jaundice, and pallor may be noted. Diaphoresis, blanching, and flushing may provide clues about vasomotor tone related to mood or physiologic abnormalities. Aspects of patient habits, interests, and relationships can be ascertained from pictures, books, magazines, and personal objects at the bedside.
C. The Physician–Patient Interaction
Aside from the hospital room and office, physical examination may occur in a variety of other settings where it is difficult to establish privacy and quiet. The best resource available to the physician to set the stage for the physical examination is to communicate respect and a genuine interest in the patient’s welfare. The patient should be addressed politely and asked to perform the required maneuvers of the examination, a technique far preferable to imperative language such as, “I want you to. …” Patients should be prepared for unpleasant portions of the examination.
Aside from explanations and reassurance, it is not necessary to maintain a continuous conversation with the patient during the examination. Avoid embarrassing the patient. Be certain that draping material is used appropriately and that personal areas are not subjected to undue exposure.[This is critical in establishing a respectful empathic relationship.VM] An examination that ends abruptly may diminish the value of the doctor–patient relationship and may destroy its therapeutic content. The patient may benefit from a brief summary of relevant findings and may require reassurance about what has and has not been found.
D. The Materials. This is the most important single section.
The single most useful device for optimal performance of the physical examination is an inquisitive and sensitive mind.[Pursue the narrative with interest, respect and sensitivity.VM] Next most useful is mastery of the techniques of observation, palpation, percussion, and auscultation. Less important are the tools required for the examination (Table 4.1).
E. The Examination
As the environment affects the quality of the physical examination, it is wise to arrange for quiet and privacy, darkening the room for parts of the examination, and comfort for the patient and examiner. It is important to have a chaperone present during physical examinations according to policies and procedures and patient preference also to an extent. Physicians function as fiduciaries in the process of restoring our patients to their highest level of function and sense of well-being
- The complete examination should proceed in an orderly fashion with a minimum of required position shifts by the patient (Table 4.2). On the other hand, the physician must be able to ascertain the integrity of the various organ systems from regional examinations. For instance, from examination of the head and neck, the physician must identify the vascular, neurologic, lymphatic, skeletal, and integumentary components and must relate them to their complements in other body regions…
F. Conclusion
The physical examination is a key part of a continuum that extends from the history of the present illness to the therapeutic outcome. If the history and physical examination are linked properly by the physician’s reasoning capabilities, laboratory tests should in large measure be confirmatory.
- The physical examination, however, can be the weak link in this chain if it is performed in a perfunctory and superficial manner. Understanding the pathophysiologic mechanism of a physical abnormality is essential for correct diagnosis and management.
- Because of the large degree of variability in observing many physical signs, the following recommendations can be made when reporting and interpreting physical findings. [4 Criteria are provided.VM]
- If these points are kept in mind, the physical exam will fill its proper role in the care of the patient. That is as an adjunct to a thorough history and as a way for the physician to interact physically with the patient.. [This is essence of this authoritative lesson. VM]
V. In the past few sections we have read about different aspects of our thinking prowess which must be integrate to observe carefully and connect the dots with what is known and develop a working hypothesis of the challenges facing both the physician and the patient in establishing a diagnosis and developing a treatment plan to establish the next steps in the plan of care based on mutual respect and principles of culturally competent care with special emphasis on LEP and need for medical interpretation. VM]
This section will elucidate the two system ways of thinking postulated by Daniel Kahneman. Economics Nobel Prize winner.
[This is a good account of the main themes.]
What I learned from Thinking Fast and Thinking slow by Ameet Ranadive
This book contains some profoundly important concepts around how people make decisions. It will help you understand why humans sometimes make errors in judgement, and how to look for signs that you yourself may be about to make a System 1 error. Here are some of the most important take-aways from the book.
We have a Two System way of thinking — System 1 (Thinking Fast), and System 2 (Thinking Slow).
System 1 is the intuitive, “gut reaction” way of thinking and making decisions. System 2 is the analytical, “critical thinking” way of making decisions. System 1 forms “first impressions” and often is the reason why we jump to conclusions. System 2 does reflection, problem-solving, and analysis. [Both these faculties are necessary for medical assessments and developing thoughtful safe, effective compassionate and culturally competent treatment plans. In another section I will introduce you to work of ER physicians under the tutelage of Dr. Gail D’Onofrio , Chair of Emergency Medicine in Yale NH Hospital. VM]
What did we learn?
WYSIATI stands for What you see is all there is. [This is a fatal flaw that can sneak into the interactions between a doctor and patient that can have consensual validation but will lead to not unexpected sometimes disastrous results. VM
System 1 (Thinking Fast) often leads individuals to make snap judgments, jump to conclusions, and make erroneous decisions based on biases and heuristics.
System 1 is always-on, and constantly producing fast impressions, intuitions, and judgments. System 2 is used for analysis, problem-solving, and deeper evaluations. [Even in the ER, Surgical suites Intensive care units and front lines we need to be able to utilize both systems effectively and expeditiously.VM
Most of the time, we go with System 1 recommendations because of cognitive ease. Sometimes, we evoke System 2 when we see something unexpected, or we make a conscious effort to slow down our thinking to take a critical view. [This must be part of the training for persons in different environments, Refresher courses and hands on training is required to keep these skill sets in good stead.VM]
System 1 seeks to produce a coherent and believable story based on available information. This often leads us to WYSIATI — focusing on the limited available evidence and ignoring important but absent evidence. WYSIATI can lead us to jump to conclusions about people’s intentions, to assign causal relationships when there were none, and to form snap (but incorrect) judgments and impressions.
WYSIATI and System 1 thinking can lead to a number of judgment biases, including The Law of Small Numbers, assigning cause to chance, hindsight bias, and overconfidence.
Reading this book has had a profound impact on my own worldview. [I endorse this view. VM]
In the past, I have been taken aback when I observed that someone was “assuming the worst intentions of others.” I have also struggled to understand how someone could create in their mind such a different narrative of past events, despite seeing the same evidence that I had seen. And finally, I have sometimes been shocked by the biases, prejudices and “snap judgments” I have seen from others. Thinking Fast and Slow has given me a new perspective on these behaviors and judgments.
I can now apply some of this knowledge to situations where I see people (or when I catch myself) relying too much on System 1 thinking. We will never be able to avoid relying on System 1 thinking for most of our daily lives. The important thing is to recognize when I or when others are relying on it too much and force more System 2 thinking into the situation.
VI . Screening, Brief Intervention & Referral to Treatment (SBIRT) Training Manual For Alcohol and Other Drug Problems. Gail D’Onofrio MD et al
Overview of the Manual:
This manual is an adaptation of an earlier manual on Emergency Department (ED) clinician administered brief intervention for harmful and hazardous alcohol drinkers. The current manual is designed to provide the medical practitioner with the necessary skills to easily and effectively perform:
1) evidence-based screening,
2) a brief intervention, the Brief Negotiation Interview (BNI) and
3) a facilitated referral to treatment for alcohol and other drug problems.
Special attention is given to decision-making process regarding whether to use the brief intervention to promote a reduction of use or abstinence versus a referral to a formal substance abuse treatment program.
The following sections provide background information on and
- describe the critical components of administering screening tools for alcohol and other drugs in a variety of medical settings (e.g., ED, OB/Gyn, Pediatrics) and
- conducting BNIs for both use reduction and referral to treatment.
Additional motivational and troubleshooting strategies, as well as other helpful resources (e.g., pros and cons of alcohol & drug use, withdrawal checklists, sample BNI dialogues) are provided.
While the manual gives the reader a critical overview of SBIRT, participation in a 2-hour training course, followed by successful completion of a supervised test case is required to be fully prepared to effectively conduct SBIRT encounters with patients.
Suggestions for periodic review of cases and feedback on performance, as well as booster training sessions, in order to ensure effective and consistent SBIRT implementation, are also provided. [I mentioned the need for this earlier. Dr. D’Onofrio underscores this point emphatically. She has spoken about the skill sets used by Gregory House with positive regard.VM
Velandy Manohar, MD,
Distinguished Life Fellow, Am. Psychiatric Association
Medical Director, Aware Recovery Care-CT [ARC], President- ARC In-Home Addiction Treatment, PC [IHAT]
Member, Governance Committee, Community Advisory Board – Office of Health Strategy- CT
