The Story About When D’Aria Embarrassed Her Doctors and Helped Invent The Five Finger Approach

By David E. McCarty, MD, FAASM

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“A conclusion is the place where you get tired of thinking.”

—Stephen Wright

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In medical charting, back in the days when doctors wrote with fingerpaint onto rolls of newsprint, there used to be a thing called a SOAP Note. It was a mnemonic to organize your thoughts, ostensibly allowing for pristine scientific clarity.

For the SOAP note—the “S” was for “subjective” (this is what the patient says to you), the “O” was for “objective” (this is what you, as the provider, can directly observe), the “A” was for “assessment” (this is what you think is going on), and the “P” was for “Plan” (this is what you actually do).

These notes worked well when the patient came in with simple things, like, say, an injury.

Let’s take a look!

S: Patient presents status-post nail-gun accident. Patient reports “AAAAAHHHHGGGHHHH!”

O: There is a Nail in the patient’s thigh. There is mimimal blood.

A: Puncture wound, s/p nail-gun mishap

P: Removed nail, applied dressing, gave a tetanus shot, wagged finger at patient and shrieked SAFETY FIRST in a really annoying way, six times fast.

So, historical shout-out for SOAP notes! You don’t see them much anymore, because they don’t scale up well. They simply don’t work so hot for chronic complex problems. For issues less obvious than a nail-gun injury, they can fall strikingly short.

 I’ll let all of the above serve as the preamble for the next story I’d like to tell, the story of a 50-year old African American woman whom I got to know pretty well.

I’ve changed her name, and some of the details, because those aren’t what’s important. It’s not actually what happened in this case that was the problem. It’s sort of…what didn’t happen.

If that intrigues you, please read on. This gets better.

The year was 2008. I was brand-new faculty at LSU. Less than a year before, I’d passed my boards—the first multi-disciplinary boards for Sleep Medicine in history, as a matter of fact. I had only just made the decision to abandon my successful primary care practice and come to the med school, full time, to join the world-famous Andrew Chesson, MD in the soon-to-be-formed Division of Sleep Medicine, and help him run the fellowship program.

We had clinic once weekly, back then. It was impossible to know, week to week, who would show up and who wouldn’t. We had a no-show rate of over 50%. The phone tree was difficult to manage. Many of our patients were unfunded, care delivered to them free of charge, and often, they didn’t have phones.

It was a difficult environment for efficient communication. The point here is that you never really knew who would show up, so you didn’t do a lot of early prep for the visits. When someone showed, you reviewed their paper chart, and you went for it.

I opened up D’Aria’s chart on one of  our typical Wednesday clinics. What follows is my re-enactment of the SOAP note I found, dated approximately one year prior, for this patient.

Cue flashback sequence sound effects.

(Re-enactment)

S: Patient presents for follow up of obstructive sleep apnea, AHI 6/hr. No complaints. Reports using CPAP nightly, with no difficulties. No concerns about the equipment.

O: Patient in no acute distress. Vital Signs are Stable. No evidence of dermal irritation from mask.

A: Obstructive sleep apnea, doing well on CPAP 10 cm H2O.

P: Continue CPAP 10 cm H2O, whenever sleeping. Discussed precautions of driving while drowsy. Follow up: one year.

I shuffled through the chart, nonplussed. I looked back at note from the year prior. The same. The year prior. The same.

That darned note basically said the same thing, for five years of follow up. It was just words, functioning like mental placeholders for actual information. They literally might as well have written the words bup-bup-bup-bup-bup.

After reading through five years of chart notes, I still had no idea who this person was.

I could put together that D’Aria had been diagnosed with Sleep Apnea in 2003. At her first visit with a Sleep Medicine provider, her original complaint was “I can’t sleep at night, and I’m dozing off in the daytime.”

This narrative was translated in the note to “insomnia with daytime impairment.” As far as snoring history, the note simply said this: Snoring: Yes, occasionally. She was sleepy alright: her original Epworth Sleepiness Scale score was 21/24. (That’s high, really high. Anything over 10 is high. You can look that up).

D’Aria was sent for a sleep study, and Sleep Apnea was diagnosed, with an apnea hypopnea index (AHI) of 6 per hour. She subsequently underwent a PAP titration study. Following that, she started using CPAP.

That brings us to the five years of follow up, and the “SOAP” notes that ostensibly indicated a successful treatment trajectory.

As I readied myself to go in the room, I figured I was in for a short visit. And that was fine with me, because I had a ton of work to do. When people are doing fine, it’s usually a piece of cake for follow up. Just go in, document that she’s using the thing, and you’re out.

I double-knocked the door, as you do, and made my entrance. D’Aria was there, in the chair, sitting still like a statue, her face expressionless.

“Hi, I’m Dr. McCarty, I’m one of the new Sleep Medicine faculty here,” I said with a big smile.

D’Aria looked at me blankly. She held a mildly banged-up CPAP machine in her lap, with no duffle bag.

“Hi,” she said.

“So, how you doin’ on that darned machine?” I asked, trying to bond.

Didn’t work.

“Fine,” she said. She was looking at the wall.

“Are you wearing it when you sleep?” I asked.

“Yep. I wear it every night.”

No eye contact.

I waited. I counted to five.

“Is it….doing anything good for you?”

She looked me in the face for the first time during the interview at that point. I saw something that looked like defiance.

“I don’t know,” she said finally. It wasn’t a complaining or a moaning tone.  It wasn’t hostile either. It was stated as a simple fact, her eyes opened a tad wider, almost saying I know you don’t care that I just said that, but there it is. That’s what I mean by defiance. I felt it was a very small, but very important risk she was taking.

She blinked at me twice, with that blank expression, and looked away again.

I bit.

“Hm. Let’s explore that. Why’d we start using this in the first place? I saw in the notes that you were having trouble sleeping.”

“Yep.” Still no eye contact.

“So, is THAT any better, now that you’re using the CPAP?”

There was a pause that lasted two whole breaths. She was looking at me in the face again.

“Nope…” she started. I noticed something come back to life in her eyes. The defiance was not there. This time, she looked…curious.

“Well, ok. How about the snoring?”

“I don’t snore,” she said.

I took a breath and was about to say: “Yes you do, it says so, right here in the chart.” But I didn’t say that. What I did say was this:

“Oh?”

And then I waited, and I nodded at her, while we were still looking at each other in the face.

I believe she made a decision in that moment.

That was the moment she stopped speaking in clipped sentences, as if she were in trouble, as if she were being grilled by the principal.

That was when she began to actually talk to me.

“I think I told ‘em that I snored once. But I was heavier then, and it didn’t happen much.”

“Really?” I smiled at her. “How about now?”

“I don’t think I snore, even when I don’t use this thing.”

This is where she smiled at me, for the first time. “Doc, I don’t always use this thing,” she said, bashful. What was that I saw? A touch of shame?

My heart broke.

“It’s OK, they can be kind of hard to deal with sometimes,” I offered.

She smiled again.

“Well, how about the daytime sleepiness?”

“Oh, you mean, the napping at work? Oh, I still gotta do that. I’m lucky my manager lets me sneak a cot into the back store room during lunch, otherwise, I’d fall asleep at the register.”

I chewed on that for a second.

“D’Aria, if you don’t snore, and the machine isn’t helping you sleep, and you’re still having daytime sleepiness, why are you using it? I mean, it doesn’t seem like it’s doing you any good at all.”

Let me put it this a different way:

We’d missed it, that was clear. But WHY? And HOW?

I will never forget what D’Aria said next. She looked me straight in the eye, and said it with a deadpan earnestness:

“They told me I’d have a stroke if I didn’t.”

At this point, I’ll take a break in this narrative to bring you to the whole point of this story. 

D’Aria, when re-tested, had an AHI of 3 per hour, absent snoring, and normal oxygen saturations. When re-tested, we had to to even more testing. In the final wash, we found that D’Aria was suffering not from Sleep Apnea, but from narcolepsy.

Let me put this a different way: we had totally gotten it wrong, and we’d let it slide for five years.

We’d missed it, that was clear. But WHY? And HOW?

As I re-reviewed the S.O.A.P. notes in her chart following her diagnosis, I was forced to swallow an unsettling and horrifying realization: None of her symptoms had ever been addressed! She had managed to make it into the hallowed halls of a world-renowed Sleep Disorders center, and somehow, the system had failed her.

How on Earth could this have happened? I found myself consumed with shame. It felt like a stain.

To be fair, the great Andy Chesson never saw D’Aria (though he did read her original sleep study, making the diagnosis). The task of follow-up was accomplished by fellows and students, with various attending physicians documenting that they had “seen the patient, and agree with the above excellent note.” I started to get my head around the idea that her D’Aria’s personal narrative was a tragic casualty of our fragmented system.

And yet the error was almost impossible to see.

The whole process had nothing out of line, you see? Nothing that would be flagged in a chart review.

Yet, still…

 How does one explain to a 50 year old woman, that for the past 5 years, she had been using a machine that she didn’t need, for the regrettable reason of protection from a Boogey-Man that didn’t exist?

It made my stomach hurt.

It was as if we’d sewn up an operative patient with a few sponges and the scalpel still inside. 

It was a damned embarrassment.

This will never happen again, I said. Not on my watch, anyway.

That was when I began to investigate how medical decision-making errors happen. And when I say: “began to investigate,” what I really mean is “obsessively research.”

Why do smart people make dumb mistakes?

How could this possibly have happened?

Turns out, you can study anything, including the many ways that doctors can jack up their decisions. Those with the keenest interest in this are the ER docs. In the ER, there’s lots of ways to make mistakes, and many opportunities to do so. They’ve turned the post-mortem of mistake analysis into a science.

One reason we make mistakes is because our brains are behavior-efficiency generators. Our brains like to take short cuts. These short cuts are called heuristics. We all use them, all the time, and usually they just save us time (remember auto-pilot driving on the way home from work?).

Sometimes, however, heuristics cause mistakes. Sometimes, they cause intellectual blindness and are the source of errors of logic. These logic errors have been codified and described, like rare wines. Science is wonderful like that.

The error in logic that afflicted the team caring for D’Aria happens to be called a “search-satisficing error.” It leads to a problem called early closure, which is where you exit problem-solving-mode altogether and take a mental nap.

Satisficing is a made-up word, a blended word, like smog comes from the combination of smoke  and fog. English Majors call this type of blended word a portmanteau, which is an old-fashioned high-brow word for a fancy steamer trunk that splits exactly in two. I like that image. It feels like two related words made a conscious decision to pack it up, and go a journey together, to a new destination.

Let’s pack up the portmanteau, gas up the vanagon, and go grab some brunch with our favorite frenemies.

If you commit a Search Satisficing Error, it means that you’ve stopped thinking about a problem when you’ve collected enough data that it is sufficient enough to satisfy as a solution. Hence, the early closure.

D’Aria’s team heard the narrative of “disrupted sleep, snoring, and excessive daytime sleepiness.” You can almost see the light bulb come on, over some medical student’s head, with a feeling of “I know what that is!”

The sleep study at that point confirmed the presence of a mild case of Sleep Apnea.

And, JUST LIKE THAT! A chart legend is born, and a label is given.  From that moment on, D’Aria’s personal narrative was subsumed by the diagnostic title she had been awarded.

For a 15-minute visit with a taciturn patient,

it may just be easier to write no complaints and move on.

 Search Satisficing Errors are easy to make, particularly when information is limited and the symptoms are so nonspecific. Neither native intelligence nor good intentions make you immune to making it, either.  As it happens, our stressed healthcare system is geared toward defaulting toward what gets paid for, and, for the time-stressed providers, the heuristics of driving home take over.

For a 15-minute visit with a taciturn patient, it may just be easier to write no complaints and move on.

It took me a minute to come up with a satisfying solution. I mean: it wasn’t a problem of information deficit. For example: I knew darn well that a lesson about the features of narcolepsy was NOT the solution. What I needed was to develop a decision-making system that automatically defaults to the patient’s narrative, so that the provider would know when to wake up and take a look.

Obsessively, I worked on that concept for the next two years. I needed something practical, easy to remember, and, ultimately, useful as a problem-solving tool.

What I came up with was the Five Finger Approach.

I’m grateful to I admit that I ripped off the idea from a hero of mine, the legendary cardiologist and teacher, W. Proctor Harvey. Dr. Harvey invented a Five-Finger Approach for the cardiovascular exam that I really liked. Medical students out there will probably remember time using the Harvey heart sounds simulator. At that point in my career, I was involved in the simulation-based learning program at LSU, and I taught with the Harvey robot twice a week. You might say I had drunk the Harvey-flavored Kool-Aid!

The Harvey robot, the original Kool-Aid dispenser.

For my mnemonic, I wanted my students to carefully walk their way through a problem, before satisficing themselves with an obvious diagnosis like Sleep Apnea. I thought about the places my fellows might have a blind eye towards asking questions. I thought about the patient’s own circadian cycle, the silent contributor to all sleep-wake complaints. And I thought about the order of the approach.

After working it and reworking it, I finally got my strategy into print in 2010. Since then, I’m happy to report that it has continued to serve me well. I recently had a nice phone call with Dr. Oleg Chernyshev, the current program director at LSU, and I was thrilled to hear that he is still teaching the technique to his fellows, with tremendous success! For me, I’ll simply say that I’ll be forever grateful to D’Aria for helping me wake up. For helping me create my favorite clinical Swiss Army Knife.

Throughout my career, a simple trip through the Five Finger Approach was all that the patient and I would need, to get us out of all kinds of interesting scrapes.

Which brings me to my point, dear reader, and it’s why I’ve been sharing this whole story with you. I wanted you to know the story of where the Five Finger Approach Mountain comes from. I wanted you to know that it was developed to protect individual narratives from the pulverizing effect of a fragmented system. It was designed to prevent a tragic mistake like D’Arias.

The Mountain was designed to protect the Narrative. Your Narrative.

See, I had to tell this story now, at this point in my blog, because everything that follows this depends on it.  My best clinical stories are all about the journey through the Five Finger Approach, where we started, and where our journey got us.

Tales From The Mountain, you might say. 

So I’ll wrap this up with a bit of a DAD joke and just point out that we started with one mnemonic (SOAP notes) and we ended with another (Five Finger Approach). 

SOAP to Fingers…that’s a nice image, in today’s Coviditious climate, don’t you think, Life-Fans?

Stay clean, stay healthy, stay Empowered.

More Tales From The Mountain to come!

Recommended Reading:

McCarty DE. Beyond Ockham's razor: redefining problem-solving in clinical sleep medicine using a "five-finger" approach. J Clin Sleep Med. 2010;6(3):292-296. To read about the Five Finger Approach for yourself, click HERE!

Groopman J. How Doctors Think. Mariner Books. 2008. Great book by a magnificent writer, taking you on a tour of all the interesting ways doctors can really jack things up.