EP209: The Art of Diagnosis: Insights from Dr. Lisa Sanders

Dr. Lisa Sanders on Diagnosis, Cognitive Bias, and Making Time to Listen

Christine interviews Dr. Lisa Sanders, Yale School of Medicine professor and Medical Director of Yale’s Long COVID Multidisciplinary Care Center, known for the New York Times “Diagnosis” column and consulting on House. Sanders describes switching from Emmy-winning CBS News producer to physician after seeing a sports medicine doctor perform CPR and save a drowning woman, and realizing she wanted to save lives. She discusses avoiding diagnostic cognitive bias by staying aware you can be wrong, keeping a differential diagnosis, and “trust but verify,” sharing a case where she accepted a patient’s self-reported POTS diagnosis and later found hyperthyroidism. Sanders argues diagnostic errors often stem from rushed visits and urges physicians to demand more time, noting she secured hour-long new-patient visits and 30-minute follow-ups. She addresses patients not being believed, especially with post-infectious syndromes like long COVID, POTS, MECFS, and fatigue, and advises support for non-linear career paths.

00:00 Welcome and Guest Intro

01:00 From TV News to Medicine

01:31 The CPR Moment That Changed Everything

03:42 Fighting Diagnostic Bias

04:45 Trust but Verify POTS Mix Up

06:49 Reclaiming Time With Patients

10:45 Why Patients Aren't Believed

12:11 Fatigue and Post Infectious Syndromes

13:45 Advice for Nonlinear Careers

14:43 Final Thoughts and Farewell

Transcript

Christine Ko: [00:00:00] Welcome back to The Girl Doc Survival Guide. Today I'm very pleased to be with Dr. Lisa Sanders. Dr. Lisa Sanders, MD is a Professor of Medicine at Yale School of Medicine and Medical Director of Yale's Long COVID Multidisciplinary Care Center. She is widely recognized for her interest in diagnostic medicine. She writes the long running. Diagnosis column for the New York Times, which inspired the television series House, for which she also served as a consultant. She's the author of Every Patient Tells a Story: Medical Mysteries in the Art of Diagnosis and Diagnosis: Solving the Most Baffling medical Mysteries. A graduate of Yale School of Medicine, where she completed her residency and served as Chief Resident, Dr. Sanders previously had a distinguished career as an Emmy Award-winning producer for CBS News. She brings a rare blend of clinical insight, narrative skill, and investigative rigor to the art and science of diagnosis. Welcome to Lisa. 

Lisa Sanders: Thanks, Christine. It's [00:01:00] nice to be here. 

Christine Ko: Can you first talk about your career journey? 

Lisa Sanders: Sure. My first career after college was in television news. Which I loved. I loved because you could ask people anything, and they would tell you. They would answer your questions. I've always been a very nosy person, and so this really satisfied that part of me. But after a few years, I realized that television wasn't really the right medium for me. I wanted something different. If you don't mind, I'd like to tell you a story about how I decided to become a doctor. When I was at CBS, I was producing a doctor named Dr. Bob Arnot. He was a specialist in sports medicine and loved sports. A lot of the stuff we did together was about different activities that were outdoors. And we were down in North Carolina and rehearsing for an episode the next day where we were gonna be live. He was gonna be coming down these [00:02:00] river rapids, and we were practicing it so that the cameraman could make sure the sound was all right. And suddenly Bob just disappeared from the tiny monitor I was watching him on. I looked up and couldn't see him, and then I finally saw him. He was on the bank of the river pulling this elderly woman out of the water. And then he did something that I'd really only seen on TV. He did CPR, and after a minute, maybe less, she turned her head and about an entire ocean of water came out of her mouth. Then she sat up, and she was fine. And I thought to myself, If I stay in television, the chance that I'm gonna save somebody's life is really small. Up until that moment, I didn't even know that I wanted to save people's lives, but it turns out I did. Eventually I decided to go to medical school and came to Yale and have just stayed here ever since. [00:03:00] There was a moment in the first year of medical school when I was in a classroom for six hours a day, surrounded my 99 colleagues. I thought, Really, can I do this for two years? Just sit. Once I got to third year and saw patients, went into the hospital, got to do things, that was exciting, and I knew that I had come to the right place.

Christine Ko: That's cool. Yeah. I feel like it's not easy to switch careers, so it's really amazing that you did that and also still continued with your journalism in the sense of the Diagnosis column and your involvement with the House series, which I loved. I loved that show.

Lisa Sanders: Me too. 

Christine Ko: You have this ongoing interest in diagnosis and baffling cases, and have you learned something about how physicians, whether early or late in their careers, can avoid cognitive bias?

Lisa Sanders: The awareness that you could be wrong. It has to [00:04:00] always be present. We sometimes forget that because we're usually right. Common things are common, and we're often right. But what I teach residents when I work with them in the hospital, I teach them that before they send me their notes, they have to have at least three possibilities. They must have a differential diagnosis. You have to keep an open mind. I think that so often we forget this, and I think we're much more likely to forget it as experienced clinicians. As new clinicians, where the fear of being wrong is, certainly for me, so intense, and I was so worried about missing something. Now, frankly, I'm much less worried about missing something, which makes me worry that I could be missing something. But when I'm in the moment, it's hard to remember that I could miss something, I now run the long COVID clinic. Very early in my tenure at the Long COVID Clinic, I made a diagnostic error. I saw this woman, she was in [00:05:00] her forties. She came in and she said, I have POTS. POTS is Postural Orthostatic Tachycardia Syndrome. She said, I just want you to help me manage it. So I just accepted her diagnosis of POTS and didn't do the basic tests that I do for people with POTS because she came in with a diagnosis. I treated her, and she called me after a couple of weeks and said, I don't feel any better.

I'm like, Oh, okay. I had just taken her diagnosis for granted. So I said let me send some labs 'cause I quickly, immediately thought of all the other things that can cause this kind of tachycardia. And sure enough, she had hyperthyroidism which hadn't been diagnosed by her primary care doctor, and she'd been sent to me with the diagnosis of POTS. One of the only things from Ronald Reagan that I have ever quoted, Trust, but verify. And I forgot that. And I sent her to an endocrinologist, and she's doing great. Her image haunts me even now [00:06:00] and helps me remember to think more broadly because just because a patient's doctor has said that this is what they have, you have to make sure that's right. 

Christine Ko: Yes. I appreciate that story as well because I think you're right that earlier on when we're newer and closer to training, you remember all of the rare things that you've learned and then progressively the longer you are in practice, common things are common and, most of the time not correct to be thinking of the rare things. Most of the time they don't have the super rare thing, cause it's rare. But every once in a while they do. And I think it is really hard because we're often time pressed. And the longer you are in medicine or in a career, you're often more time pressed, not less time pressed.

Lisa Sanders: In terms of the time, we doctors collaborated with our employers to make us time pressed. We don't [00:07:00] have to be that way. And whenever I speak to doctors, I encourage them to rise up and rebel and get more time. 

Christine Ko: I like this. Can you expand on this? 

Lisa Sanders: When I started this clinic, I was very clear about what I needed. I said I need an hour with my new patient. Period. So I got an hour. I don't know that they were happy to give that to me, but they gave it to me. All follow up patients get a half an hour, and so then you have time to really listen to people and address their concerns. And a lot of times one of their concerns is, Other doctors don't have time to listen to me. That's probably the most common complaint that's not about their physical wellbeing that I get, that doctors are too hurried to get a full history, and research shows that they're not wrong.

Most diagnostic errors happen while the patient is right in front of you. And if you don't have time to get enough information, you're gonna miss things. [00:08:00] If you care about making sure you address your patient's needs, getting more time is important. The older, the more experienced you are, the more power you have, the more leverage you have. I learned this from lots of doctors at Yale. At Yale there's a tradition of doctors practicing into their eighties, and I noticed that some of the senior doctors just had more time and were able to decide their schedules. And I don't know why other people can't do that as well.

Replacing a doctor is a very expensive proposition, and so we all have some leverage. One of the ways you get to be a doctor is that you're compliant. You do the pre-med that they ask of you. Then you do medical school, and then you do residency where they ask you to do all sorts of crazy things. And so this whole tradition of just knuckling under to authorities [00:09:00] is built into how we're formed, and so that makes it much harder for us to stand up for ourselves.

We've ceded control, and I think we should take it back. 

Christine Ko: Being somewhat obedient, that's the way you become a doctor. And people pleasing and inability to say no. Also I've seen my colleagues, sometimes, it's that they feel like they're the only doctor. Of course, right? There's many doctors out there. 

Lisa Sanders: We all think we're the best doctor. 

Christine Ko: There's this feeling of, the person needs to be seen right away, and so who's gonna do it other than me?

Lisa Sanders: If you had room in your schedule for that, then it wouldn't be a problem. 

Christine Ko: Yeah. 

Lisa Sanders: All these things can be addressed. But there has to be a recognition that this is a problem, and then a desire to change it. If we had control, we would be able to be more flexible, but we've ceded control. I think we just have to take it back. There is a risk that doctors will be [00:10:00] replaced by PAs and APRNs for primary care. When they have complicated patients, PAs and APRNs will be the first to say that they would refer them to internists. If there was something that was complicated, you would refer it to an internist. To me that makes a great deal of sense. I think that there's a better way to do it. We're just not doing it that way. 

Christine Ko: That's cool that you have an hour with new patients and 30 minutes with return patients. It sounds like you are able to really listen to the patient. So I guess one way that busy clinicians can try to listen better is to create more time as you have done. Put their foot down and demand, Okay, I need X amount of time with a new patient versus a follow up patient. They can do that.

Having listened to patients over the years, is there something that's taught you about the patient experience of not being believed?

Lisa Sanders: Yes. It's still an ongoing thing where patients have a hard time [00:11:00] being believed. I never saw a patient with POTS while I was a resident. Nobody ever mentioned that diagnosis to me, and I'm certain I saw it but didn't recognize it until I came and started this clinic and started reading up on what people with long COVID had, and the same for MECFS ( myalgic, encephalomyelitis, chronic fatigue syndrome) or brain fog. We don't even have a good name for brain fog, and yet it's probably the second most common problem in long COVID. I had to figure out how to take care of these patients.

Christine Ko: It's hard to recognize something when it doesn't exist until finally it's recognized.

Lisa Sanders: Actually I would say that post-infectious syndromes and long COVID is just one of many post-infectious syndromes. These things aren't really new. They haven't been identified because there's no test.

Christine Ko: Yeah. So it's partially then since post-infectious syndromes have been around for a long time, it's just that it comes back down to that [00:12:00] women, in general, just aren't really believed when they come in with their symptoms. 

Lisa Sanders: Maybe, I think that's historically been true.

I hope it's not still true, but it probably is. Women have very complicated physiology. We have periods and menopause, all kinds of changes. Because of this sort of complicated background, I think it might be harder to identify low grade illnesses. These are symptoms that are like, I'm tired. Fatigue is the number one complaint of the patients that I see. So fatigue, okay. Let's make sure you don't have anemia because younger women bleed every month. Let's make sure that you don't have hyperthyroidism because women are more likely to get autoimmune diseases. You have this list of things that you wanna rule out. When you rule out all those things, what do we end up saying? You should get more sleep. Sleep is important. I'm the first person to say that, but that's not the answer. There are other possible causes of [00:13:00] fatigue that have to be considered. You have to think more broadly about what causes fatigue and be informed about post-infectious syndromes, undiagnosed sleep apnea, chronic fatigue syndrome, which has its own diagnostic profile. For those people, stimulants are not good. This chronic fatigue syndrome is characterized by post exertional malaise, where they're so tired they can actually not get out of bed sometimes. And it can last for days, sometimes weeks. They just have to figure out how to pace themselves. We say, sleep more and get more exercise. These are not therapies that can treat chronic fatigue syndrome.

Christine Ko: Yeah. Diagnosis can get so complicated, right? It's part of the fun of it, but...

Lisa Sanders: It's part of the fun.

Christine Ko: Since you did pivot in your career, do you have any advice for people contemplating a non-linear career path?

Lisa Sanders: It will work out, but it's important to have support. I could have never done this without the [00:14:00] full throated support of my husband. I left an extremely well paying job. Television producers get paid like doctors only sometimes better. I left an extremely well paying job to not just not make money, but to have to pay money for the next four years. So support in all of its senses is important. And try to identify the things that you would like to have more of and less of in your career. Medical schools have changed so much now. Medical students interact with patients very early on. And so you can really see how you feel about being around patients, how you feel about medicine from the start. 

Christine Ko: Yeah. Do you have any final thoughts? 

Lisa Sanders: The great thing about medicine or going to medical school is that you can use it to do anything you want. For many people it can be a wonderful profession and exciting and interesting and [00:15:00] flexible. 

Christine Ko: Thank you so much for your time. I really enjoyed hearing your stories and your thoughts and the advice to rise up. I like it. 

Lisa Sanders: Please, and when you start the revolution, call me. I'll come and help. 

Christine Ko: Sounds good.