face value the statements of the NIH patient who was secretly using laxatives. The opposite situation, he knew, could also apply. In either setting, the case demanded continued thought and investigation.

When Falchuk told me that "the picture didn't fit," his words were more than mere metaphor. That sort of instinct may, of course, be wrong. But it should not be ignored, because it can cause the physician to recognize that the information at hand may have been improperly "framed." Doctors frame patients all the time using shorthand: "I'm sending you a case of diabetes and renal failure," or "I have a drug addict here in the ER with fever and a cough from pneumonia." Often a doctor chooses the correct frame. But a self-aware physician knows that accepting the frame as given can be a serious error. Anne Dodge was fitted into the frame of bulimia and anorexia nervosa from the age of 20. It was understandable that each of her doctors received her case in that one frame. All the data fit neatly within its borders. There was no apparent reason to redraw her clinical portrait, to look at it from another angle. Except one. "It's like DNA evidence at a crime," Falchuk explained. "The patient was saying 'I told you, I'm innocent.'" Here is the art of medicine, the sensitivity to language and emotion that makes for a superior clinician.

Falchuk almost rose from his chair when he showed me the pictures of Dodge's distorted small intestine taken through the endoscope. "I was so excited about this," he said. It was the sweet pleasure of the detective who cracks a mystery, a legitimate pride in identifying a culprit. But beyond intellectual excitement and satisfaction, he showed his joy in saving a life.

Intellect and intuition, careful attention to detail, active listening, and psychological insight all coalesced on that December day. It could have been otherwise. Anne Dodge, with her history of anorexia nervosa and bulimia, could have developed irritable bowel syndrome. But Falchuk had asked himself, "What might I be missing in this case? And what would be the worst thing that could be missed?"

What if he had not asked himself these

Falchuk almost rose from his chair when he showed me the pictures of Dodge's distorted small intestine taken through the endoscope. "I was so excited about this," he said. Intellect and intuition, careful attention to detail, active listening, and psychological insight all coalesced on that December day.

questions? Anne Dodge, her boyfriend, or a family member could have asked them—perhaps many years earlier. Of course, patients and their loved ones lack a doctor's training and experience. Or they may feel inhibited about asking questions. But questions are perfectly legitimate. Patients can learn to question and to think the way a doctor should.

Simple Questions
In Anne Dodge's case, it was Falchuk who asked simple but ultimately life-saving questions, but to answer them he needed to go further. And Anne Dodge needed to agree to go further, to submit to more blood tests and an invasive procedure. For her to assent, she had to trust not only Falchuk's skill but also his sincerity and motivations. Language, spoken and unspoken, can give information essential to a correct diagnosis and persuade a patient to comply with a doctor's advice. "Compliance" can have a negative connotation, smacking of paternalism, casting patients as passive players who do what the all-powerful physician tells them. Without trust and a sense of mutual liking, Anne Dodge probably would have

deflected Falchuk's suggestions of more blood tests and an endoscopy. She would have been "noncompliant," in pejorative clinical parlance. She would likely still be struggling to persuade her doctors that she really eats 3,000 calories a day while she wastes away.

My admiration for Myron Falchuk increased when we went on from Anne Dodge's case to discuss not his clinical triumphs but his errors. Again, every doctor is fallible. No doctor is right all the time. Every physician, even the most brilliant, makes a misdiagnosis or chooses the wrong therapy. This is not a matter of "medical mistakes." Medical mistakes have been written about extensively in the lay press and analyzed in a report from the Institute of Medicine. They involve prescribing the wrong dose of a drug or looking at an x-ray backward. Misdiagnosis is different. It is a window into the medical mind. It reveals why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge.

Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80% could be accounted for by a cascade of cognitive errors, like the one in Anne Dodge's case, putting her into a narrow frame and ignoring information that contradicted a fixed notion. Another study of 100 incorrect diagnoses found that inadequate medical knowledge was the reason for error in only four instances. The doctors didn't stumble because of their ignorance of clinical facts; rather, they missed diagnoses because they fell into cognitive traps. Such errors produce a distressingly high rate of misdiagnosis. As many as 15% of all diagnoses are inaccurate, according to a 1995 report in which doctors assessed written descriptions of patients' symptoms and examined actors simulating patients with various diseases. These findings match classical research, based on autopsies, which show that 10% to 15% of all diagnoses are wrong.

Ultimately, medicine is a mix of science and soul. And in order to practice it well, doctors must draw on both.