Calling Dr. Sacks. Stat!

An unpublished interview with the neurologist and author that’s as timely today as it was 40 years ago—maybe more so

Like many of you, I’m a fan of The Pitt. The show is inspiring because, in the midst of the battlefield of an overwhelmed ER, Dr. Robby and his staff remain dedicated not only to diagnosing and treating patients, but to honoring the humanity of the wounded and sick in their care by simply taking the time to talk to them. Oliver Sacks exemplified the same ideal, the ideal of the human touch in medicine. In his practice as a neurologist and in books like Awakenings and The Man Who Mistook His Wife for a Hat, he shared with his readers the sense of wonder and discovery that sprang from his devotion to knowing the person behind the patient. In 1987, I had the opportunity to interview Dr. Sacks. I’ve been rereading the transcript and believe the good doctor’s wit, intelligence, and insight are particularly relevant today, at a time when a broken American healthcare system favors efficiency over empathy and patient satisfaction scores over quality of care. In this first of two parts, Dr. Sacks reflects on his diagnostic methods, the shortcomings of medical education, walk-in clinics, and the lessons to be learned from the patients he’d seen that morning. Dr. Robby would certainly concur.

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Since your writings are so concerned with the thought processes of your patients, it would be interesting to know how your own mind works as you make a diagnosis. How would you describe your methods—are they intuitive or analytic?

My approach is a mixture of both, in which I go from tiny observations to large ones. On the whole, most of the people who come to me in a hospital have their diagnoses; they've had strokes and head injuries and tumors, and I'm less interested in diagnosis than in trying to define the problem that they have and the resources which can be mobilized internally and externally to deal with it. So, on the one hand, I go through the usual routine methods of examination and interrogation and thinking, but I also feel at liberty to improvise.

What would be an example of a way in which you might improvise?

Well, as I have made clear in my books, I regard everyone as an individual and not just as a case to be diagnosed. All sorts of human considerations enter in. For example, this morning I was seeing a patient, an intelligent man, a former engineer with a frontal lobe hemorrhage. He is clearly brain-damaged in some ways, but clearly intact in others. I inquired about his reading and found out that he still reads and enjoys Scientific American. Finding that out and talking to him about science, on the one hand, is supportive and reminded him that I respected his state. But it also may allow us to find out more about the nature of frontal lobe syndrome, and in ways which can be unexpected. For instance, this man told me that he feels he has lost the scientific spirit he used to have. He no longer is driven by a feeling of scientific curiosity, but he’s still interested in doing mathematical problems and puzzles. Whether this is a depressive symptom or whether it's an alteration of cerebral and intellectual functioning caused by the brain damage, I’m not sure. But one problem I find with the analytical approach to diagnosis with a patient like this is that while his neuropsychological evaluation speaks of matrices on which we can chart and graph various difficulties he has, it doesn't mention something like scientific curiosity. The only way such information can be discovered is through human contact with the patient. So it doesn’t suffice for me to make a diagnosis of a ruptured anterior communicating artery aneurism with frontal-lobe damage, I want to know exactly how the thought processes, emotions, and intellectual powers are affected.

Picking up details can be crucial, then.

Yes, I think the diagnosis occurs from the moment someone enters the room, the way they stand or sit or look, or for that matter, if they're late coming to the clinic or if they're early. I believe one must examine everything minutely, both medically and in the person's life. I was once told off by Medicaid, when they were looking through patient charts, that I was writing too much. But when I got them to look more closely, they admitted that I'd included not only everything they wanted but a good deal more.

Do leaps of intuition occur in most of your cases?

It depends. If someone comes in who has developed a numbness in three fingers following a game of bowling, there's not too much jumping around to be done.

Do you think, in general, that medical education prepares a doctor to consider the individual patient in the detailed way you describe?

No, in fact, it's sometimes not entirely allowed. Certainly, when l have students, I drill into them that they must be systematic, because if one jumps around too much, one may forget to look at something. There's great sense in the old system. However I do think it unfortunate that the rigid format of medical presentations and writing doesn't permit for natural movement of mind, or the reconstruction of one's own thought processes as one faced a patient. This gets edited out, replaced by tabular, quantitative observations, which are considered to be better form, though I’m not sure that they are. Indeed, I'm sure that they're not. I think we very much need a qualitative element in biological and clinical description. I mean, for example, the engineer who reads Scientific American has an IQ evaluation of 142. Now, this is not a very useful figure in someone with severe intellectual difficulties. It's a rather startling figure because it's so good, but I think one needs to replace this number with more of a picture of the patient's intellectual landscape, the physiognomy of his mind.

You are a master diagnostician of diseases that bridge the gap between physical and emotional. What tips you off that a seemingly psychiatric disorder is indeed organic?

One of my jobs is working half-time at the Bronx State Hospital, where I'm employed to make sure that such organic disorders don't escape notice. I talk to the patient, I do a careful examination, and if I find something plainly the matter neurologically—an abnormal reflex, a dilated pupil, some sort of unexpected intellectual defect—that is a clear clue that something organic is the matter. Usually things are more complicated. Again, using the example of the brain-damaged engineer, it's been observed that he may suddenly do something very inappropriate like unzip himself and piss in the middle of the corridor or a conversation. One could wonder if this is psychiatric, but I know this sort of thing tends to occur in the context of frontal lobe syndromes; there are alterations of judgement and self-evaluation even in the presence of excellent formal intelligence. And, if I speak to him he doesn't appear regressive in any way. So, again, it is likely that there is something organic behind this behavior.

Do you feel that there are purely psychiatric illnesses without biological, or chemical, or genetic factors involved?

It’s possible that people may be predisposed to psychiatric disorders that are then triggered by events in their lives. For example, among the Amish—where there are three different forms of manic-depressive disorder—a manic-depression gene has been found. While the people who have this gene are not doomed to become either manic or depressive, they're more vulnerable to stresses and psychic injuries of one sort or another and, under conditions that may merely make the rest of us anxious, they may become manic-depressive. One doesn't know how much of the behavior is biologically determined and how much is circumstantial. I think there’s a danger that the pendulum will swing too heavily and too exclusively either way, as has happened here in America, where between about 1930 and 1960 everything was very strongly analytical, and from about 1960 onwards it's been perhaps too strongly biological. It seems to me that the two need to go together.

You work with elderly patients and are familiar with the particular problems they face. With the graying of America, physicians are seeing increasing numbers of cases of memory loss and cognitive impairment, possibly caused by Alzheimer's. But aren’t there also treatable causes of dementia?

Yes, and such causes are too frequently overlooked. Again, this morning, which could be any morning, one of my patients had a low serum B-12. I'm not quite sure what this means, but in this hospital, if a patient comes in with any hint of dementia or even some sort of transient confusion or agitation, we will always get a serum B-12. I vividly recollect what started us doing this. There was one patient who'd been transferred from another hospital diagnosed with incurable dementia, who had an abnormally low serum B-12. We started her on B-12 injections and her dementia disappeared. She’d lost three years in a state of dementia and, as it turned out, it was reversible. One has got to look carefully. There may be something mechanical or surgical that has gone wrong. I think I probably see more transient confusions from excess medication and multiple medications than anything else. Sometimes two or three doctors are prescribing drugs for these patients, so they end up taking a dozen or more medications. With so many drugs, muddles can easily happen.

And that is especially true for in elderly patients?

Yes. Another thing to look out for—again, I'll use an example from this morning, when one of my patients was coughing quite a bit. I went over her chest carefully—neurologists will still listen to chests. I couldn't hear anything, but I couldn't help wondering if she was developing a pneumonia, which one sees very commonly in the elderly. Pneumonia or urinary infections, but especially respiratory chest infections can present as confusion before being evidenced by the stethoscope or chest x-ray. The elderly brain becomes very vulnerable to all sorts of things, including, it would seem, to being in the hospital. I saw two other patients this morning, both of whom were elderly women who were living independently at home until they fell and broke a hip. Then they came to the hospital and both of them became confused. Now, I don't know whether it’s the trauma, whether it's the pain, whether it's the anesthesia, whether there are complications of surgery, whether there are drug-interactions, or whether it’s the dislocating effects of being removed from one's usual autonomy and being turned into a hospital case. But this is a very common cause of confusional states in the elderly, some of which don't clear and others of which can be slow to clear.

In your opinion, has the physician's neglect of the human touch contributed to the bad feelings between patients and doctors in America, as seen, for instance, in increasing numbers of lawsuits?

It's a combination, I think, due partly to unreasonable expectations of perfect remedies on the part of the patients, and partly to a lack of listening and personal attention on the part of the physician. Interestingly, in Australia, where I was a month ago and have a brother who's in general practice, an entrepreneur has inaugurated clinics all over the country that are open 24 hours a day. Many of them, not coincidentally, are located next door to McDonalds and are playfully called medical McDonalds. These clinics have become the fix-it places and body shops for people, where you can go at any time and get yourself fixed. Patients are seduced by this fast-medicine image, but I expect to see a reaction in the other direction. Many of these patients are going to find that quick fix-its are not enough and that they need care and personal contact with a physician.

[To be continued next week… ]