I recently read a very interesting book entitled "How Doctors Think", by Dr. Jerome Groopman.  He is a staff writer for The New Yorker and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center.  His book is an intriguing look at how we physicians go through our day diagnosing and treating patients, and the thought process that accompanies it.  As a medical student at the University of Illinois, we had very traditional training in the basic medical sciences, clinical rotations, and sub-specialty electives.  But as I progressed through the pages, I asked myself, "How did I learn to think?"

The book brought back memories of a clinical case I was involved with several years ago.  Mr. Jones, not his real name, came into my office feeling lethargic and tired.  He was a 51 year old gentleman who worked in the automotive industry as a mechanic.  He stated he had sleep difficulties, loss of appetite, and just a general sense of malaise every day.  He was attended by two of my colleagues in our group practice, and according to his medical record, had a pretty thorough work-up.  He had all the basic tests including a CBC, complete thyroid panel, complete blood chemistries, and several tests checking him for such things as Sjogren's syndrome and lupus erythematosus. He also had a complete cardiac work-up because at one of his previous visits, he complained of mild chest pain. Every physician had seen him and done a thorough history and physical exam. None of my colleagues was able to figure out why Mr. Jones was tired.

He sat in the exam room across from me, looking like a well nourished healthy 51-year-old that really shouldn't be experiencing fatigue. He’d already had every test that I could conceive of running. All of his testing to date was absolutely normal. So I sat there thinking, what am I going to do with Mr. Jones? As he related his history of fatigue, I started combing through the 3 inches of paper stored in his chart. I discovered that approximately 5 years ago, one of our family practice physicians noted that Mr. Jones took vitamins. When I reviewed his medication list, no vitamins were listed. So I asked, "Mr. Jones do you still take vitamins?” The answer was pretty straightforward, "Oh yeah doc, I take a lot of vitamins". He’d started taking vitamins and supplements for the very reason he was seeing me in the office, “fatigue”.  He also had the peculiar idea that if one vitamin was good, two would be better, three might cure my problems, four would give me some pep… you get the picture.

To make a very long story short, Mr. Jones was taking over 120 different types of vitamins and supplements every day. He brought them all in during his second office visit. They filled 3 grocery sacks. I had my office assistant step in the room and take an inventory of this astonishing group of over-the-counter products.  I took this list back to my office and ran it through a drug interaction program, just to see what I would get.  You can imagine my surprise when my computer spit out 12 pages of possible interactions.

Mr. Jones and I started down the path of eliminating the supplements. At the end of 3 months, I had him down to one multivitamin per day, and he felt great. I've often wondered what that encounter would have been like had I not stumbled upon the fact that he had been taking vitamins in a prior note.

Now, back to Dr. Groopman’s book. Physicians begin sizing up the patient's problems as soon as they enter the room. They quickly start formulating a differential diagnoses, thinking of what blood tests they are going to order, what part of the physical exam they are going to target, what historical questions they need to ask, and probably, depending on the time of day, what they are going to eat for lunch. Sometimes they miss, or just don’t think about some of the possibilities.

One of the great tools we have at our disposal today is an electronic health record. It provides a complete, easy to search, medical record where things such as medication lists that contain vitamins can be easily found. Thus, clinical decisions can be made more timely and accurately.  I wonder how much time, money and aggravation we could have saved Mr. Jones if my old group had an EHR? Today they do, and Mr. Jones’ discontinued list of vitamins and supplements now resides in a place that can be easily found.

P.S. It would have that interaction checking real-time, and gave me a warning to boot!! 

Click here for a printed version: Clinical Newsletter August 2008