There is a photo of a young woman that I like to show medical students when I lecture on the topic of the treatment of autoimmune diseases. It shows a “before-and-after” headshot of a twenty-something patient: the “before” shot was taken about a year prior to the onset of her illness. It depicts a pretty young woman with shoulder-length auburn hair and sparkling green eyes. The “after” shot was taken at a time when we were struggling to control her raging lupus nephritis. I ask the students to describe what they see: her cheeks are bloated and covered with a deep red butterfly rash, there is some patchy acne over her chin, and her previously thick mane of hair has thinned considerably. Her eyes have lost their sparkle. The smile has disappeared. Most of the students quickly surmise that what they are seeing are the ravages of long-term corticosteroid use in a woman whom they guess may have lupus.
We move on to the second case. This one is a bit trickier—it is the photograph of a lovely middle-aged patient of mine, Mary C., who has had rheumatoid arthritis for more than twenty years. She passed away a few years ago, but while she was alive, Mary loved attending these sessions in person so that she could show off her charming face. She had a most unusual complexion for a woman of Irish ancestry; it featured a bluish gray tinge. She would regale the students with her colorful account of how her appearance once led an experienced infusion center nurse to mistakenly call a “code blue” because she thought that Mary was experiencing severe respiratory difficulties and turning blue in the face. In fact, her slate gray appearance was merely depicting the telltale sign of chrysiasis, something we rarely get to see these days following the demise of gold salt therapy. The students generally miss this visual finding, although last year, one sharp student recounted how she had seen a similar facial discoloration in a patient treated with amiodarone. These teaching sessions made me wonder about all those times in our daily practice when we fail to see what should be obvious, missing the diagnosis that is literally under our nose.
One of the more egregious examples of this phenomenon occurred many years ago when I was a second-year medical student. I elected to spend three months on a neurological service to see whether I was destined to become a neurologist. (I guess not!) One of our patients was the head neurosurgical scrub nurse who was admitted for evaluation of a variety of neuroendocrine anomalies. Three years earlier, she had undergone bilateral carpal tunnel surgery for release of both of her entrapped median nerves. The following year she was diagnosed with type I diabetes, and more recently she began to notice that she could no longer fit her previously slender fingers into the same-sized surgical gloves that she wore her entire career. Even a lowly second-year medical student could realize that she was displaying all of the features of a textbook case of acromegaly. The bizarre part of the story was that the preeminent neurosurgeon whose specialty was the resection of pituitary tumors was the same surgeon who had worked with her for the past ten years and had performed her carpal tunnel surgeries. Despite seeing patients with acromegaly who were referred to him from all over the world, he missed this diagnosis in a person who worked alongside him nearly every day for the past decade!
These teaching sessions made me wonder about all those times in our daily practice when we fail to see what should be obvious, missing the diagnosis that is literally under our nose.
The Art of Diagnosis
It goes without saying that teaching the techniques of the skillful physical examination has lost some of its luster in medical school and residency training curricula. There are a number of reasons why the emphasis has shifted away from careful clinical evaluation to expediting patients’ problems with the help of lab tests and imaging studies ordered following a cursory physical examination. First, there is the time squeeze—clinicians are expected to see a rising number of patients at an ever-quickening pace. Second, there is the medico-legal-financial need to spend so much of the precious face-to-face encounter documenting the findings of this foreshortened exam. Third, there is the allure of expensive imaging and laboratory technologies that promise an expedited, focused work-up of the patient. Of course, labs and imaging studies are an essential part of the medical evaluation, but too many clinicians seem to wholly rely on these tests rather than spending a few extra minutes focusing on careful clinical observation. Fourth, there is a shortage of effective clinicians who have both the time and commitment to teach trainees the dying art of the physical exam. There are some notable exceptions, such as Abraham Verghese MD, senior associate chair for the theory and practice of medicine at Stanford University in Palo Alto, Calif., who is on a mission to revive the lost art of the physical exam that requires some old-fashioned touching, looking, and listening. With each passing year, fewer medical schools and residency programs are either willing or able to allocate the requisite funds to compensate clinicians for their teaching time and effort.