JOHN DONVAN, HOST:
This is TALK OF THE NATION. I'm John Donvan in Washington. Your doctor tells you that what you have is serious, very serious. And while some of us may simply take in that news and then follow our doctor's advice on what to do, put ourselves into that doctor's hands, many of us choose a different course almost right away, not just to take one doctor's word for it but to exercise a distinct patient privilege: going out to find a second opinion.
Case in point Dawna Harwell, she is a horse trainer and a cancer survivor who joins us now by phone from her home in Collinsville, Texas. Dawna, welcome to TALK OF THE NATION.
DAWNA HARWELL: Thank you, how are you?
DONVAN: We're good, thank you, and we want to use you as our case history to launch this discussion. So you were told in 2008, not that long ago, that you likely had ovarian cancer. So what happened after you received that news?
HARWELL: After I received that news, I - they still weren't conclusive on what I had. So I wasn't comfortable with my doctor, so I made an online request to MD Anderson and did a self-referral down there and went down for a second opinion or, actually, a diagnosis, a definite diagnosis.
At that point, I went back and forth between a couple of departments and was finally decided that I had follicular lymphoma after a surgical biopsy, because none of the other biopsies were conclusive, and none of my other tests were conclusive.
DONVAN: So you were right, that your first doctor was wrong?
HARWELL: They just didn't have any idea, and it wasn't...
DONVAN: Right or wrong?
HARWELL: Right or wrong, and they weren't - didn't seem that concerned about it, and yet when it was finally diagnosed, it was a Stage 4 diagnosis.
DONVAN: Well, one question right away: What gave you that feeling that you needed to go for a second opinion?
HARWELL: Just because I was being bounced around between doctors.
DONVAN: And what difference, the bottom line, what difference does it make that you made that choice to go looking for another opinion?
HARWELL: The difference is it probably saved my life, because I wasn't - they made sure to know exactly what I had before I was treated. Even - there's so many different forms of lymphoma that until you know exactly which one you have, I mean, you can be given the wrong process of treatment.
DONVAN: And how are you doing now?
HARWELL: I'm good. I am in remission and clean and on six-month checkups.
DONVAN: Great news. And finally, what would be your advice to somebody who has that same nagging feeling you do?
HARWELL: Don't hesitate. I mean, that's - you know, that's what it's all about. Those records are your records, and if, you know, when you're given a, you know, any type of diagnosis that it's, you know, severe like cancer or anything like that, I mean, always go for a second opinion.
DONVAN: Dawna, thanks very much for sharing your story.
HARWELL: You're welcome.
DONVAN: All the best to you. We would like to hear from our listeners who have their own experiences with second opinions. Patients: What happened when you asked for a second opinion? And doctors: We want to hear your side of this, too. Our number is 1-800-989-8255. Our email address is email@example.com, and you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
Later on in our program, one of the most popular crime writers in America, Elmore Leonard, on the return of the show "Justified." But first we're going to continue our conversation on getting a second medical opinion. Laura Landro is the assistant managing editor of the Wall Street Journal, and her piece, "What if The Doctor is Wrong?," ran earlier this week, and she joins us now from Palm Springs, California. Laura, welcome to TALK OF THE NATION.
LAURA LANDRO: Glad to be here.
DONVAN: So how common is Dawna's story of a second opinion actually uncovering a misdiagnosis or a non-diagnosis in the first place?
LANDRO: Well, you know, it's unfortunately a little more common than you realize. There's all sorts of statistics out there. Diagnostic errors can be, you know, as many as 15 percent of the time, in cancer diagnosis 12 or 13 percent, in some cancers 50 percent if they're very hard to diagnose.
And there are some statistics out there, as well, that say 30 percent of people who sought a second opinion on their own and about 18 percent of those who were required to do so by their insurance company found that there was disagreement.
DONVAN: And what's the process of resolving a disagreement?
LANDRO: Well, that's - you know, sometimes a third opinion is necessary. You know, in fact, Medicare will pay not only 80 percent of the cost of a second opinion when there's a major surgery or procedure, but they will pay for the cost of a third opinion, as well, at the same rate, with the idea that you need to get some kind of consensus.
Now obviously, sooner or later you're just going to have to make a decision, and you could go on getting opinions forever if you could afford it, but there is - when you have a major procedure that's life-altering, life-saving, potentially, you really do, you owe it to yourself, as Dawna said, to get the best advice you can.
And remember that not all doctors are going to agree on everything. Their treatments may differ. Their approach may differ. How aggressive they're going to be may differ.
DONVAN: Well, I wanted to get to the treatment issue, and you've already gotten to it. I mean, there is not just the issue of what's wrong but there very much could be disagreement and difference of opinions on what to do about it.
DONVAN: What are some of the classic choices that you've come across in your reporting where somebody had a choice between two difficult or two perhaps confusing options to make?
LANDRO: Well, there are so - you know, prostate cancer is one of the classic examples. You know, there are - there's so much discussion right now when you're diagnosed with prostate cancer. Do you want to take this high-tech, robotic surgery? Do you want to have incontinence and impotence as a possible side effect? Do you want to do watchful waiting?
And a lot of that's going to depend if - there's a wonderful book out now, Jerome Groopman and his wife wrote, called "Your Medical Mind," and it's about trying to discern what your own values are. Are you someone who really wants to just get at the problem right away and be really aggressive, you want to cut that cancer out, you want to go for the surgery?
Or are you more of a less aggressive, let's see if something less invasive works first? And you and your doctor have to sort of work those things out together.
DONVAN: So there is not necessarily a right scientific medical answer on what to do.
LANDRO: Not always, in fact rarely, probably, unless it's like this is a really aggressive cancer, it's going to kill you in two weeks, you'd better get out there and do something about it. (Unintelligible) pointed out earlier.
DONVAN: I want to bring some listeners - excuse me for interrupting - into our conversation. And Kate(ph) is in Pensacola, Florida. Kate, welcome to TALK OF THE NATION.
KATE: Hi, I had just been diagnosed with cancer and went through a surgery technique and then after that was presented with chemotherapy options and of course radiation following that. The second opinion after considering chemotherapy, was that this - the initial prognosticating index that the first doctor gave, was using data from 1992. And other prognosticating indexes showed that chemotherapy was of no measurable benefit in my case.
So I really urge listeners to look at the statistics that back up what your doctor is trying to do. Maybe he's trying to sell you something that, you know, has $5,000 to $55,000 in cost benefit per treatment, like chemo. And then when it comes to radiation, I was presented initially with only one type, which is on rather old machines where they were trying to sell time, had significant damage to peripheral organs such as the lungs and the heart, and wasn't told about 15 other types of radiation that are more up-to-date, more focused, less damaging.
And all this can be learned by personal research on the Net, although it took a tremendous amount of time to find this out.
DONVAN: Yeah, I was going to say, Kate, it sounds like you needed to do an awful lot of work and to have a lot of energy and a lot of push on this yourself.
KATE: Yes, and it was disappointing that my doctor didn't want to educate me because he wanted to sort of send me down the mainstream pipeline that's endorsed by, you know, his insurance, indemnification, to send you through chemo and wide-beam radiation. And it is the most profitable of things. So, you know, you have to bear in mind that that may be a motive for some large doctors - some large hospital groups.
DONVAN: Kate, thanks very much for sharing your story. Laura Landro of the Wall Street Journal, is it the case sometimes that doctors themselves will seek a second opinion? And I've heard of cases where they'll put together a team from across several disciplines to try to help them...
LANDRO: Well, that's like a tumor board. If you go to one of these big breast cancer centers, they'll have a tumor board because, you know, the surgeon may want to do surgery, the radiologist may want to do radiation, and they may be able to come up with what's the best thing for this patient. Let's reach a consensus within our organization.
You're also seeing a lot more pathologists within their own institutions will have a second pair of eyes, what they call secondary review, because pathology, it's a little bit of an art, so is radiology. You're looking at images. You're looking at slides, and you're trying to figure out what is that, and things can differ.
We've seen this happen in my family, where things were read one way, and, you know, it was read to be a tumor, and it turned out to be scar tissue. So, you know, with someone more experienced looking at it - and you do have to really hope that within - I think you can count on a lot of doctors, well, they're trying to do the right thing.
DONVAN: Yeah, I don't know if you'll mind doing this, but I know because you alluded to it in your Wall Street Journal piece that you actually had a serious medical condition, and you went for a second opinion.
LANDRO: Oh, yes, and I've written a book about it called "Survivor." Before the TV show, I had the name. But anyway, yes, I was diagnosed with leukemia, now, 20 years ago, CML, and the only - you know, I knew I had to get a bone marrow transplant, but there were three different approaches to the transplants being done at three major cancer centers.
And I really had to study the data and look at the long-term survival rates and look at, you know, what was going to be best for my disease, my condition, my stage of disease at the time that I had it.
And, you know, it was kind of a tough call, but in the end, I went with the center that had the most experience, the Fred Hutchinson Cancer Research Center in Seattle, and which also had the best long-term disease-free survival for people with my situation.
And it was tough. You know, I had to 3,000 miles away from home, and I was fortunate to have insurance and an employer who allowed me to do that.
DONVAN: When you say it was tough, do you mean that it was wearing, or do you mean that you had to fight to get this?
LANDRO: Well, you know, it was - you have to remember this was 20 years ago now. I think, you know, people often ask me will doctors get mad. And at the time, I think doctors were not used to - my doctors in New York weren't used to having someone question here's what you're going to do and ask them, you know, come in with note papers and ask them questions and give them statistics that I pulled down off of, you know, medical studies.
They weren't used to that. I think - this was - I'm really dating myself here, but this was before the Internet, and...
DONVAN: Yeah, but you were a reporter, so that helped.
LANDRO: I was a reporter, and I was a little bit at - obviously at a big advantage for that, and I had a lot of friends who were scientists, and I pulled together a team of people who really helped. And you can do that as an individual, as well.
But I really had to make a decision that was a tough one, because it meant leaving where I had started, you know, down the process, and it also meant again going 3,000 miles from home. And - but it was very much a decision, it was also based on a feeling about the doctors, a feeling about the hospital, a feeling about - that they cared, you know, a little bit - you get a little into, not just the diagnostics, but how do I feel about the treatment (unintelligible) people.
DONVAN: We're hearing that same note from Dawna, that it's a feeling that you get. Laura Landro is assistant managing editor for the Wall Street Journal, and you can find a link to her piece "What If Your Doctor Is Wrong?" on our website. Just go to npr.org, and click on TALK OF THE NATION. Laura, thanks very much for joining us on TALK OF THE NATION.
LANDRO: Thank you so much.
DONVAN: We're talking about medical second opinions, when to get one, how to ask, and up next we're going to be talking with a doctor about the doctor's side of second opinions and when it may not make sense to get one.
Patients, tell us: What happened to you when you asked for a second opinion? And doctors, we do want to hear your side, too. Our number is 1-800-989-8255. I'm John Donvan. This is TALK OF THE NATION from NPR News.
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DONVAN: This is TALK OF THE NATION from NPR News. I'm John Donvan. Most of the time, when we go to the doctor's office with a problem, we get a diagnosis: a sinus infection maybe or a sprained ankle. And then we follow the doctor's advice. End of story.
Sometimes, though, there is much more at stake, and patients will go looking for a second opinion. One recent study of cancer cases showed that about nine percent of original diagnoses were later changed as the result of the patient getting a second opinion.
So patients, we want to know from you: What happened when you asked for a second opinion? And doctors, we'd like to hear your side of this as well. Our number is 800-989-8255. Our email address is firstname.lastname@example.org, and you can join the conversation at our website. Go to npr.org and click on TALK OF THE NATION.
So we're taking your calls, and we want to now speak with Ryan(ph) in Denver, Colorado. Ryan, you're on TALK OF THE NATION.
RYAN: Hi, this is Ryan. I think that my comment would be that whenever a patient feels uncomfortable or uncertain about their physician or the diagnosis, I really recommend that they get a second opinion. I think that patients need to feel very confident and trusting in their physician, and if there's any equivocation, and certainly if it's grave or life-threatening, then I like for them to have that second opinion.
DONVAN: Are you speaking to us as a doctor?
RYAN: I am.
DONVAN: Oh, OK.
RYAN: I'm a younger physician, and you know, I think that it's important that the patients really trust in the relationship that they have before you embark on any particularly aggressive treatment plan. The other thing that I would suggest to patients is that if they feel the need for a second opinion, I really do think that they should discuss that with their primary doctor, and oftentimes, you know, I can try and help facilitate that.
I can provide them all of the records that we have so far, the tests that we've done, and you know, maybe suggest that, oh, this research center really specializes in what we think you have, and that might be a good place for you to start looking...
DONVAN: All right, thanks very much, Ryan, I appreciate your call. I want to bring now into the conversation Dr. Leonard Lichtenfeld. He is the deputy chief medical officer for the American Cancer Society, and he joins us from the studios at their offices in Atlanta, Georgia. Dr. Lichtenfeld, welcome to TALK OF THE NATION.
LEONARD LICHTENFELD: Thank you, John, pleasure to be with you.
DONVAN: So we've heard and just heard from a doctor and from several patients who have been talking about their experiences in seeking second opinions. I have a few questions, and one of them is actually put - I was going to put to you, but it comes in the form of an email. Del(ph) from Florida puts it this way, and it's very blunt. He says: Doesn't asking a second opinion insult the doctor? How could it not? You're saying that you don't trust his opinion.
And I would assume that maybe that inhibition exists in a lot of patients, that they feel they're going to make an enemy of the doctor if they say I want to go somewhere else for more advice.
LICHTENFELD: Well, when you have a life-threatening condition, such as cancer, it's your life, it's your decision, and if the doctor gets insulted, maybe it's time to get another doctor. I think that many physicians will understand that when you get into a complicated medical circumstance, that having another set of eyes and ears, so to speak, to go over things is not a bad idea.
And I think that many physicians that I know will actually encourage people if they have a question to seek a second opinion. So if your doctor is going to be insulted, let your doctor be insulted; it's your life, take charge, do what you need to do to make yourself comfortable.
DONVAN: How does it work among you, though, as colleagues if you were to give a second opinion that essentially, let's say, corrects or updates or turns out in the end to be better than your colleague's? Does that put your colleague in a bad light? You know, say it happens more than once or twice or three times.
LICHTENFELD: Well, you know, I don't think it puts the colleague in a bad light. Understand, as was mentioned earlier in the prior segment, medicine, there's a lot of art to medicine, as well as science. So not everything is as clear-cut, and different people have different approaches.
And as Ryan just mentioned, sometimes you may have a better comfort level with one doctor versus another, and that's a very important consideration. I can't emphasize that enough. So you know, I will say I've seen situations, and I think something to be cautious about, I've seen situations where someone who – a surgical opinion, asks for another opinion, and they gave them somebody else in the same group; that got a little testy because I don't think the second doctor necessarily wanted to overrule the first doctor.
They know each other, work with each other every day in the same hospital, same - essentially the same practice. But you know, again, it comes down to the bottom line: Life-threatening conditions, serious conditions. If you have the option and opportunity and the time to get the second opinion, and you feel that you would feel better from having that opinion, do it and not hesitate.
DONVAN: And is there any etiquette to this that we need to know about?
LICHTENFELD: I don't know that there's an etiquette. Ryan also made another excellent point. Hopefully you have someone who's your primary source of care. Unfortunately, not everyone has that these days, but a primary care family physician, a primary care internist, can be a critical ally in helping you get through that process.
The etiquette simply is once you've made the arrangement, the decision to do that, is to say to your doctor this is something I want to do, and this is not necessarily a reflection on you personally, but this is important for me and my family, and just make that doctor aware that you're pursuing that second opinion.
DONVAN: Jim from Rochester, New York, you're on TALK OF THE NATION.
JIM: Yes, I have been complaining for a year, a year and a half to my primary physician about a coughing and clearing my throat and phlegm situation. And finally I bugged him enough where he sent me to a throat doctor. And the throat doctor concluded that I had laryngeal, pharyngeal acid reflux and to see him in a couple of months and take a couple of pills that he said and a diet.
I somehow just couldn't buy that. So I had an upcoming appointment with - for a colonoscopy. So I decided to go in to see my doctor that was going to do the colonoscopy, because he is a little familiar with that area, he comes - I guess he's from the throat down, and he considered doing an endoscope, an endoscopy, which we had done, and he spotted something and said I should go to a throat doctor.
And I said I just got through two weeks ago, and he said, well, it may be a tumor, and the long story short, I went back, and in effect they did find that it was a throat cancer, actually a tumor on my tongue. And Stage 2, and then I did my seven weeks of radiation.
But my point is that I was basically misdiagnosed. I was a self-advocate and moved on and asked another doctor and got the right answer. It was...
DONVAN: I'm curious, Jim, you're the third caller to mention that something bothered me, something didn't feel right with me. And I want to ask Dr. Lichtenfeld, the lesson seems to be to listen to your instincts on this.
JIM: I have a comment later on that one.
DONVAN: Sure, stay on with us, Jim.
LICHTENFELD: I don't think there's any question that we know our bodies better than anyone else. And when something is amiss, and you're not comfortable with the answers you're getting, it is perfectly appropriate to seek that other opinion. Now, there comes a time when you say the repetitive opinion-seeking might not be appropriate or productive.
But it comes down to the fact that we know ourselves better than anyone else does, and I think we always have to keep that in mind. And the other point I would make is that in our medical system today, unfortunately, it's becoming a lot more fragmented, and that means more of us going forward are going to have to be responsible for our own health, be our own advocates and take charge and take responsibility of how we live, what we do and how we obtain our medical care and how we engage in seeking that care.
DONVAN: Jim, you wanted to add something else?
JIM: Yes, yes, and amen to that, and my radiology oncologist told me that - she said I always listen to my patients because invariably they are correct. And my type of cancer, by the way, which is a very important situation I would like to get out there, was caused by HPV virus, human papillomavirus, which is similar to what Michael Douglas the actor has.
And I think that I was getting not the runaround, but I wasn't getting the attention because I'm a non-drinker, non-smoker, and this was caused by a virus, which...
DONVAN: Let's see how...
JIM: And my primary physician was not aware of...
DONVAN: Jim, I'm sorry to jump in. I just want to see how your experience compares to our next caller's, and thanks very much for your call.
JIM: Thank you.
DONVAN: Thank you. I want to bring in Marjorie(ph) from Charlottesville, Virginia. Hi, Marjorie, you're on TALK OF THE NATION.
MARJORIE: Oh, well, hi. I'm not a patient. I just wanted to make - this great discussion, I wanted to make the comment that I've been in the health care industry for about 40 years, watching development and changes. And we're - you know, we've gone from a system that was very paternalistic, where the patient really had no, not many rights and not much responsibility, to a system where we are trying to become more consumer - more of a consumer.
And so we have not only rights but responsibilities as patients to educate ourselves, to follow our instincts, and there's just really in this day and age, with online resources, there is just no excuse for not being able to access journals and educating yourself as intensely and deeply as you can about any diagnosis you get, not just getting a second opinion, which is, you know, essential sometimes, but also having - being armed with knowledge so that you...
You know, because there - I see instances with patients who, because they dove into something, they really became an expert in their particular diagnosis. I mean, they knew as much, if not more than their particular physician.
DONVAN: Marjorie, I hear you on that, and I thank you for your call. But I do want to put the other side of that to Dr. Lichtenfeld, which is the - we are talking about people coming in and asking for second opinions, seeking second opinions when we're talking about complicated cases such as cancer and complicated treatments. Prior to your being an oncologist, you did primary care, did you not?
LICHTENFELD: I have been a primary care internist at one point in my career. Yes.
DONVAN: So at that level, you might be dealing with aches and pains and sore throats, and let's say something like a chronic nerve problem, somebody has sciatica. And you know what they need to do for sciatica, which is, essentially, is to, I think, in most cases, to ride it out, maybe with some painkillers. But there's not a great deal to be done.
A patient who comes in seeking a second or a third or a fourth opinion because they're frustrated by the pain, or a patient who comes in with something discovered off of the Internet because of that kind of research that Marjorie's talking about, and that kind of energy and devotion, would that sort of patient not drive you crazy after a while?
LICHTENFELD: The patient is - partnership is the best way to approach medical care. So I will never say to somebody, don't go to the Internet. I will say at some point, you have to have trust in the people who are caring for you, because they are - hopefully, have your best interests at heart.
But I think what happens sometimes is that there's a lot of information on the Internet. In fact, I wrote an editorial recently on the topic, calling it basically the Wild - similar to the Wild West. It's untamed. And so there's quality information on the Internet, and there's information on the Internet that's not quality. And it's sometimes very hard to tell the difference.
And you can see someone - for example, the back pain that you're mentioning. People will seek the answer, the right answer, which is sometimes - for many patients, don't do anything particularly different. Call me if there's a particular change in your condition. They don't accept that and they want something else, and eventually they may end up in certain treatments. They may end up in surgery.
When they - the benefit, shall we say, for the risk, is not worthwhile. And we know that. Now, that doesn't mean back surgery's bad, but it means that some patients may drive the process to the point where something gets done to them by someone that is not really in the patient's best interest.
DONVAN: You're listening to TALK OF THE NATION, from NPR News.
We're talking about the issue of second opinions. Our guest right now is Dr. Leonard Lichtenfeld, deputy chief medical officer for - chief - deputy chief medical officer for the American Cancer Society. And we're taking your stories of seeking second opinions on medical procedures and medical diagnoses. And I want to bring in Brian in Portland, Oregon. Brian, hi. You're on TALK OF THE NATION.
BRIAN: Hi. Thanks for taking my call. Yeah. I just wanted to talk about how it seems that doctors are very well-trained at doing, like, emergency room diagnoses where they can diagnose within 17 seconds, which I believe is an actual statistic. But when it comes to a more complicated case, they seem very flummoxed. And I don't think doctors have any training in trying to figure out a more complex case. And I just - I wonder if there's any movement to train doctors better in that way, because it seems if they come up with a first diagnosis in 17 seconds, and if that's wrong, then they have no idea.
DONVAN: Hmm. Dr. Lichtenfeld?
LICHTENFELD: Well, I can't speak to making a diagnosis in 17 seconds, and I would go back to a comment that was made earlier. Sometimes - not sometimes. I felt all the time, you had to really listen to what the patients had to say, because if you listen carefully, you might get a clue as to what's going on.
Let me address what I think the real concern is today. We are not training primary care physicians in this country. And as part of the training of primary care physicians, they have experience across a broad spectrum of illnesses. They are taught - particularly internists and family physicians - are taught how to bring the pieces of the puzzle together.
Instead, we're having a fragmented system, highly specialized, people going off in different directions, and nobody - captain of the ship, shall we say - nobody in charge, nobody who's bringing all of it together. That's the risk we have. And the point - if the point is that we're not able to have a person to synthesize all of this, that's valid. They're becoming a vanishing breed, and our health care in this country is going to suffer as a result of that.
DONVAN: Thanks very much for your call. I want to bring in Peter in Naples, Florida. Peter, you're on TALK OF THE NATION.
PETER: Good afternoon. I went to a urologist at one point and - for a totally different problem. And during my inspection, the fellow found what he thought was a bump on my prostate. And he was very excited, very urgent to get me into the surgery and get a biopsy. I felt really, really rushed, kind of pressured by this guy, so I went to both my family physician and another urologist. And as it turned out, neither one of them felt that I have any problem at all, that I didn't have any cancer. And I just, you know, I felt so glad that I did that and just, you know, relieved.
DONVAN: And, Peter, why did you trust the second opinion versus the first opinion?
PETER: Well, I got two more opinions, one from a primary care physician and one from another specialist.
DONVAN: Well, I guess that's what Laura Landro was talking about earlier in the program about consensus, because I wanted to ask, Dr. Lichtenfeld, again, it's just I do wonder, you know, when do you stop getting opinions? Given, as you say, it's an art form, diagnosis.
LICHTENFELD: Well, you know, feeling a lump in a prostate is obviously unsettling. I can't speak to any individual case, and sometimes some doctors are better at feeling things than other doctors. So it's very hard to say. But having seen, I guess, it's four different doctors, you've come to the opinion that there's nothing there, clearly, you're aware of the situation. And I assume that you're going to follow over time. And sometimes taking time is not the wrong thing to do. And in this case, that may - particularly with prostate cancer, that's not bad advice.
DONVAN: So just to some up - and we only have about 25 seconds, Dr. Lichtenfeld. I asked you before where's the etiquette of it, and what I really meant is do people need to be shy about telling one surgeon or one oncologist, I am going to talk to somebody else? Can you just say, I'm going to do that?
LICHTENFELD: It's your health. It's your life. Don't be shy. Do what you think is right for you. If you want second opinion, go get it.
DONVAN: Thanks very much. Dr. Leonard Lichtenfeld is deputy chief medical officer for the American Cancer Society. He joined us from studios in Atlanta, Georgia. And coming up, Elmore Leonard once said: I try to live out the parts that readers skip. It's a rule that has worked well through 45 novels and a number of movies and TV shows. The crime writer joins us next to talk about his latest. I'm John Donvan. It's TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.