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Behind the scenes at “Diagnosis”

Yale Medicine Magazine, 2020 - Winter

Twice a month, the “Diagnosis” column appears in The New York Times Magazine. In 1,300 words, Lisa Sanders, MD ’97, HS ’00, associate professor of medicine at Yale School of Medicine (YSM), untangles a case that has had doctors scratching their heads as they sort through a patient’s symptoms for clues to the diagnosis.

“I’m interested in the diagnostic process, how you get from puzzling symptoms to an important diagnosis,” said Sanders, who started writing the column in 2002.

Since then her column has spawned a TV drama, House, which aired from 2004 to 2012; provided material for her own books; and recently became a series on Netflix. At first, the column appeared once a month and Sanders did all the research and interviews on her own. But in 2016, when her editor asked her for two columns a month, “I realized I needed help,” Sanders said.

She turned to the Office of Student Affairs, which sent an email inviting medical students to apply for an interesting research opportunity. Sanders’s first hire was Fatima Mirza, a third-year student, who wrote for the Harvard Crimson as an undergrad and served as co-editor-in-chief of the Yale Journal of Biology and Medicine. A year ago, Sanders took on a second assistant, Aishwarya Vijay, a fourth-year student at YSM, who wrote for the Yale Daily News as an undergrad. Mirza and Vijay make the first pass at story ideas that come in via email, at grand rounds, and through the grapevine.

Another YSM graduate who put heavy work into tracking down appropriate patient stories was Michael Gormally, MD ’19, PhD. “Michael helped me set up a system for me to keep track of the patients I am planning to write about,” said Sanders. “Not a week goes by that I don’t benefit from his smart system.”

With the column’s increasing popularity and the debut of the Netflix series in August, emails have poured in, Sanders said. “Right now, I get about 100 emails a day. Before, I got maybe 100 a month.”

How do Sanders and her assistants decide what makes the cut? First, there has to be a mystery.

Each column starts with symptoms ranging from the commonplace to the bizarre that stymie the patient’s doctor or doctors. They may order further tests or consult with colleagues as they seek a diagnosis. “You know it’s a weird case if it’s in my column,” Sanders said.

“Often, it’s a very rare presentation of a common disease, and you want to look at something that has a happy ending,” said Mirza. “If it doesn’t have a happy ending, there’s some sort of big lesson you can take from it that can help other patients.”

“It’s easier to have a case when there is one team or one doctor that made the decision and can really focus and give a full narrative,” Vijay added.

To find those cases, the team sorts through thousands of tips for the 24 that will make it into the column each year. Then they reach out to the doctor on a promising case and obtain a signed release to speak to the patient and obtain medical records. “Until you talk to them you never get the full story,” Mirza said. “You get a two- or three-sentence synopsis from their email and you don’t know if it’s a real diagnosis.”

The students then explain how the reporting and writing process will unfold. “The patients are usually ecstatic,” Vijay said. “They want to get the word out about what they struggled with.”

After initial interviews and a review of the medical records, Mirza and Vijay pass their suggestions on to Sanders. And they note that there are often false starts. “Stories fall through all the time,” Vijay said. “We get halfway down the line and then the medical records don’t work out or the patient has decided that they don’t feel comfortable.”

The irregular schedules of medical students and a working physician, and the unyielding deadlines of a major newspaper make for odd working hours. Sanders and her two assistants are rarely able to meet in person, so they communicate by phone and email. And they’re usually multitasking. “We often have multiple cases and a bunch on the back burner,” said Vijay.

Once she’s chosen the cases for her column, Sanders reaches out to the patient and doctor for more in-depth interviews. There may be multiple doctors on the case, but Sanders usually interviews only the ones who made the diagnosis. Readers often ask how the doctors could have missed what seems in hindsight so obvious.

“Diagnosis is a process,” Sanders said. “You have to go through what everybody has before you can look at what nobody has.”

Sanders typically spends two days on her first draft, then goes over it twice more. Her columns reach the Times on a Monday; by Thursday of the following week they’re online; and by the next Sunday they’re in print.

“When I see it in the paper,” she said, “I know it’s time to write my next one.”