Every Patient Tells A Story Part 4

No one examined Charlie Jackson-until it was almost too late.

The Delirious Doctor As a practicing physician, I understand the temptation to skip the physical exam. A sick patient comes in and you are so focused on the thing that you are certain might kill him that you don't think of looking at anything else. There's a kind of anxiety, a controlled adrenaline-fed panic, when facing a patient who could die before your eyes. You pore over the labs and the studies. You get the consult. You send him to the ICU. But you don't examine him. That's not what doctors do anymore, in part because they no longer know how.

So thoroughly has this lesson been absorbed that doctors-those in training and out-often don't even notice when the loss of this creaky old antique makes a cla.s.sic diagnosis impossible. I frequently attend medical conferences with the hope of finding cases for my newspaper column. I ran across a perfect example of this at a recent conference of the Society of General Internal Medicine, a gathering of academic physicians.

Judy Reemsma, a third-year resident, stood by her poster in the rabbit warren of part.i.tions that make up the display halls where residents and medical students display research and case reports. She spoke with confidence about the case presented in her poster. She should-in this case she was both the doctor who made the diagnosis and the patient.

During her second year of medical school Reemsma became ill and was taken to the emergency room by her fiance, David DiSilva. a.s.signed to the case was Dr. Jack McFarland, an emergency medicine resident and close friend of Judy's.

McFarland, tall and slender with a slight stoop to his shoulders, greeted his friend from the doorway one spring evening in 2004. "What are you guys doing here?" he asked. It was strange to see her there. And shocking for her to be out of the usual scrubs and white coat, dressed in the flimsy johnny coat that marks you as the patient.

As McFarland traded quick pleasantries with David, he tried to a.s.sess Judy's condition. She looks okay, he thought. Her heart was racing; the tracings on the heart monitor sped by at 150 beats per minute. Her blood pressure was high and though she did appear anxious, she didn't look particularly sick.

And then she began to speak. A wild river of words poured from her mouth. Random phrases, meaningless sentences, rapid incoherent paragraphs. There were s.n.a.t.c.hes of sense scattered throughout the discourse but they were nearly drowned in the rushed torrent of speech. McFarland was stunned. He looked at the young man, who nodded. This was why they'd come.

Judy had been fine all day, David told him. He had the day off from work and they'd been together most of the afternoon. She had cla.s.ses in the morning. Came home and studied. They'd gone to the gym and then made dinner together. Afterward, she'd gone upstairs to study. Maybe an hour later she'd complained of stomach pains. And the computer screen looked blurry, she told him. She decided to go back to the bedroom and lie down.

Another hour later he'd heard her fall-he rushed upstairs and found her on the floor crying uncontrollably. When she spoke, her words made no sense and it was clear to him that she was confused. That's when he started to get scared. Coming here she'd been so unsteady on her feet that he'd practically had to carry her to the car.

The patient was twenty-seven, athletic, and had no significant medical problems. She was taking an antidepressant, Paxil, and had been given another, Elavil, to help her sleep. But, David added, Judy didn't like the way the Elavil made her feel so she didn't take it anymore. She didn't smoke, drank only occasionally, never used illicit drugs. As McFarland and Judy's fiance went through her history, the patient moved restlessly on the gurney. At times she would try to answer the questions, but her speech was jumbled-a word salad carrying little useful information. She seemed unaware that she wasn't making any sense.

"I need to examine you; is that okay?" McFarland asked the patient tentatively. She nodded her consent. The lights in the room had been turned off and when the doctor turned on the light, Judy cried out and covered her eyes. "Oh yeah, the light's been bothering her since we got here. That's why we turned it off," her fiance told him. McFarland reluctantly dimmed the lights. She had no fever. Her mouth was dry and her skin was quite warm though not sweaty. The rest of her exam was normal. He tried to perform a thorough neurological exam but the patient was too confused to cooperate. An EKG showed no abnormalities beyond the rapid heart rate.

McFarland thought carefully about his friend, now his patient. For almost anyone with a change in mental status, illicit drugs had to be at the top of the list of possible causes, as unlikely as that seemed in this case. In addition, she had been prescribed a medicine-Elavil-that could cause many of these symptoms when taken in large doses. She had a history of depression, and her fiance had been out of town frequently over the past several months. Was she suicidal? Could she have taken an overdose? That could cause the rapid heart rate and confusion. He knew that a high dose of Elavil causes blood pressure to rise initially, but that the real danger came later when it can drop precipitously. Her pressure was high, dangerously so. Maybe she was in the early stages of the reaction. On the other hand, it was hard for McFarland to believe that his friend had been that depressed. She'd seemed fine when he saw her last.

Perhaps she didn't have simple depression-maybe she was bipolar and her antidepressant had moved her from depression to mania. That could cause the pressured speech, but would it cause the very high blood pressure? And he knew her; wouldn't he know if she was bipolar?

Or could she have too much thyroid hormone? The thyroid is the flesh-and-blood version of a carburetor-working to regulate how hard the body's machinery works. Too little of this hormone and the body slows down. Too much and it speeds up. That could cause the tachycardia and the hypertension and sometimes pressured speech and confusion.

He questioned the patient's fiance. Had she ever shown signs of mania? She had a history of insomnia, and sleeplessness was one sign of both mania and thyroid overload-was she up all night? No, until this evening she'd been fine, he insisted. She had been depressed, but that had all but disappeared after starting the Paxil-and that was months ago. Her sleeping was no worse than usual.

David paused. There was one other thing: after dinner he'd felt a little funny too. Not as sick as Judy, but his heart had been racing and he'd felt a little nauseated-though he felt fine now. They'd eaten some lettuce from their garden that night. Could their symptoms have something to do with that? Hearing this, the resident immediately thought of a patient he'd seen not long ago who had eaten pesticide-tainted vegetables from his garden. That patient had nearly died. But he'd been much sicker than this young woman. Moreover, his symptoms were the opposite of hers; his heart rate had been slow, his blood pressure nearly undetectable. He'd lapsed into a coma not long after arriving in the emergency room-they'd had to intubate that patient because his lungs had filled with water. Overall, a very different clinical picture.

Still uncertain, the doctor ordered some routine blood tests to look for the presence of an infection or an imbalance in her blood chemistry. He checked the thyroid gland. He also ordered a urine test to look for illegal drugs and Elavil, the medication she had been prescribed for sleep.

As the doctor waited for the results of the tests he'd ordered, the patient became more and more agitated. She kept getting out of bed and walking into the chaotic hub of the emergency room. Once she put on gloves and picked up the chart of another patient as if she were at work. Several times the nurses had to guide her back to her own bed. Lying on her gurney, she seemed to talk to people who weren't there, pointing to and batting at creatures no one else could see. At times she quieted down, mumbling words that her fiance couldn't understand.

The results of the tests dribbled in but provided no additional clues. The thyroid hormone was okay. The drug screen was completely negative. There was no trace of Elavil. What was going on?

By dawn the patient's blood pressure had come down into the normal range, but her heart rate remained high. She was less confused. But she was still far from normal. Was this part of some underlying illness? She had an MRI of her brain to look for evidence of a stroke, a CT of her chest to look for tiny clots. Both scans were normal. After four days the patient had completely recovered and she was discharged, her diagnosis still unknown.

At home, Judy was troubled by her brief episode of madness. The unanswered questions were frustrating.

That afternoon she wandered out to the garden to do some weeding, and her attention was immediately drawn to an uninvited guest growing in her lettuce patch. Among the green and purple leaves she and her fiance had planted were several strikingly beautiful white flowers, blossoms that hadn't been there before and that she was certain she'd never sown. Could the early tendrils of this plant have been mistaken for lettuce and ended up in her salad? She pulled the three plants up by their roots, put them in a Baggie, then drove to a nearby nursery.

As she pulled the plants from the bag to show the owner, the woman exclaimed, "Don't touch those plants! They're highly toxic. That's jimson-weed." Also known as the devil's trumpet and sometimes as loco weed, this plant has been known to cause a temporary kind of madness in man and beast for centuries, the woman explained. The symptoms caused by the active ingredient found in this plant are so well known that there is a mnemonic widely taught in medical school to identify its symptoms: mad as a hatter, blind as a bat, dry as a bone, red as a beet, hot as a hare.

As it turned out, the patient had had all the cla.s.sic symptoms: the plant's toxin makes you blind as a bat because it makes the pupils dilate. (This chemical is still used by ophthalmologists for that very purpose.) And she was quite flushed, according to her fiance. McFarland missed both symptoms in the emergency room because he had turned down the lights to alleviate his friend's discomfort. Her mouth and skin were noted to be dry and of course the madness was clear, but this wasn't enough to make a diagnosis. By the time the other doctors in the hospital saw her, most of these characteristic symptoms had resolved.

I asked Dr. McFarland why he thought he had missed such a cla.s.sic presentation of this well-described syndrome. "I've thought about that. A lot, actually. I think my friendship with the patient made it difficult for me to really put on my doctor's hat. I never was quite able to see her as a patient." The doctor-patient relationship requires a certain distance that the resident wasn't able to impose on his friend. "You want to sort of keep your eyes averted, intellectually, when you're taking care of someone you know. You need to dig and yet it's uncomfortable."

But there's something else going on here too. McFarland didn't insist on being able to turn on the light to examine his patient completely. Would he have been that blase if the patient had refused to allow him to take her blood or urine for tests or balked at the idea of a CT scan? Why didn't he insist on having the light up so that he could perform the exam properly? Could it be that he didn't believe that the physical exam would provide any useful information that would allow him to make a diagnosis? Ultimately, of course, that loss of faith becomes a self-fulfilling prophecy. If you don't expect to see something, how hard are you likely to look?

And because he didn't insist on seeing her in the light, he didn't notice that she was flushed or that her eyes were oddly dilated in the bright light of the room. Opting to leave her in the dark, he unintentionally left himself there as well. He missed two essential clues that might have allowed him to solve the mystery of her illness.

The Science of the Senses It's been over fifteen years since Salvatore Mangione published his groundbreaking studies on the loss of physical exam skills among physicians. The studies have prompted active and pa.s.sionate debate but little action, and even as these skills wither in the subsequent generations of doctors, we still have no idea what effect this change may have had on our ability to take care of our patients. Can technology replace these skills? Or will the loss of the exam damage our ability to make a timely diagnosis? With few studies done, we have no better idea of that now than we did in 1993. But anecdotal information suggests that there is a great deal being lost.

Doctors are not known for their rapid embrace of the new. Medicine has held on to the paper chart long after virtually every other industry and profession has made room for electronic efficiency. Physicians are so reluctant to change the way they practice medicine that it takes on average seventeen years for techniques well established by research-such as giving an aspirin to a patient having a heart attack-to be adopted by even half of those in practice. In other words, it usually requires an entire generation of doctors to turn over for a single new practice to become routine, part of medical "tradition."

Medical training itself has not effectively changed since the end of the nineteenth century, when Sir William Osler developed the hospital-based residency system as a method for standardizing and inst.i.tutionalizing medical apprenticeship. Changes that have been imposed on doctors-for example, the eighty-hour workweek-have been derided and abhorred by them from coast to coast.

And yet physicians and even patients have seemed willing, even eager, to abandon the physical exam, painstakingly developed over the past two centuries, and allow its erosion to advance unchecked. Undoubtedly medicine's characteristic conservatism has contributed to this loss. The almost pathological unwillingness to change the way new doctors are trained in the face of a rapidly transforming environment has helped bring about one of the most radical changes to how medicine is practiced in its history.

Nonetheless, over these years there has also been a growing sense that the physical exam can make an important contribution to our ability to understand the patient and his disease. With this acceptance has come a new set of once unaskable questions: Which parts of the physical exam are valuable and worth saving? Which parts could and should be disposed of? And once we get a better handle on which are worth saving, how can we incorporate this into the education of our new doctors?

In the next few chapters I will examine each of the several parts of the physical exam, looking at the way each works to provide clues to the mystery of the diagnosis. We'll look at each part in the order we are taught to perform them: first by observation, then by touching, then by listening. Each method of evaluating the patient directly through our senses provides immediate and essential information. Each has its own limitations.

Once the exam is broken into its component parts, can we then identify which parts are important and useful and should be kept and what turns out not to be so valuable after all? If it is possible, if we can separate out those parts of the physical exam that are useful and discard the parts that are not, we will be left with a physical exam that is leaner but keener. If not, and the physical exam is lost, we will end up with a health care system that is slower, less effective, and more expensive-a high-tech, low-touch system that fails patients along with the doctors who care for them.

CHAPTER FIVE.

Seeing Is Believing.

Dr. Stanley Wainapel walks carefully to the door of his office to greet his first patient of the day. It's a brutally humid July morning and even here, deep in the recesses of Montefiore Medical Center in the Bronx, a heavy dampness has overwhelmed the air-conditioning. Wainapel is a tall man in his early sixties. A shock of sumptuous white hair frames a handsome round face creased with lines that deepen when he smiles. His light brown eyes are magnified behind black wire-rimmed gla.s.ses that he adjusts frequently.

Wainapel runs the Department of Rehabilitation Medicine at Montefiore. He introduces himself to Anna Delano, the heavyset, middle-aged woman who has come to see him about her painful knees. As she makes her way to the chair in front of his desk and carefully lowers herself into it, he commends her for braving the humidity and apologizes for the ineffective air-conditioning.

Anna looks up at Wainapel still standing in the doorway. "Are you talking to me?" she asks, voicing her confusion in a nasal New York accent. "Because, you know, you're not looking at me."

Wainapel whips his head around to the spot where the voice now originates. Embarra.s.sed, he smiles, revealing a deep dimple. "Sorry," he tells her, "I have a vision problem."

Here's the nature of Stanley Wainapel's vision problem: he's blind. Wainapel was born with a form of retinitis pigmentosa, a rare genetic disorder that started him out in life with severe night blindness and tunnel vision. Over the years, the narrow windows through which he could once see became progressively smaller until they finally closed completely, leaving him unable to perceive any color or shape, and very little light. In his right eye, his "good" eye, he can sometimes detect movement. In his left eye-nothing.

Because of the indolent course of this disease, Wainapel could see well enough to make it through college, medical school, a four-year residency in rehabilitation medicine, and the start of an extremely productive academic career. Wainapel says he feels certain that his visual defect hasn't kept him from being a good doctor. A successful career culminating in his current role as director of rehabilitation medicine, and a crowded schedule, suggest that he's right. My question is: how is that possible?

Vision has long been considered the most valuable of our five senses. Biologically it is certainly preeminent. More than 50 percent of the human brain is devoted to sight. Thinking may be how Descartes knew his world, but for the rest of us, seeing is believing. We trust what our eyes tell us. When Chico Marx, pretending to be Rufus T. Firefly (Groucho Marx) in the 1933 film Duck Soup Duck Soup, is caught red-handed with another woman, he denies the obvious infidelity and demands indignantly, "Who are you going to believe? Me or your own eyes?" It's funny because for most of us, that's no choice at all.

The same is true in medicine. William Osler emphasized the importance of observation in medicine: "We miss more by not seeing than by not knowing," he taught his students. Even the language of patient care emphasizes the central role of vision. We "see" patients in the office; we "watch" them overnight in the hospital. We tell patients what to "look out" for. We "oversee" their care.

Well before a doctor begins the refined maneuvers that make up what is usually considered the physical exam, she will start to collect information on the patient as soon as she lays eyes on him. Is he young or old? Does he look healthy or sick? How does he walk? Is he in pain?

Once the patient actually gets to the exam room, much of the physical exam relies on what doctors can see-they look at the skin and the eyes, peer into the ears and mouth. They check the color of the tongue, the nails, the stools. Many of the tools used to perform the exam allow better views of the ears, nose, mouth; the equipment used to measure blood pressure, temperature, oxygen saturation, and blood glucose report this data visually. The tests ordered to provide additional information about the patient often convert that data into a visual form: diagnostic imaging is the most obvious, but an EKG is a visual representation of the electrical activity of the heart, and an electroencephalogram (EEG) represents the working circuitry of the brain. Of course, these studies are often interpreted by specialists-doctors don't always read them themselves. Still, given the importance of sight in medicine, it's hard to imagine making a diagnosis without it. How can a doctor "see" patients if she can't see the patient?

No one seems to know how many blind physicians there are practicing in the United States. A Google search ("blind physician") turns up a dozen names. Reading up on those that I found, I see that most work in specialties like psychiatry, where routine patient contact consists primarily of listening and talking. A couple, like Wainapel, have gone into rehabilitation medicine. I wanted to meet Stanley Wainapel to understand the value of vision in the practice of medicine and in making a diagnosis. Who would better know the true worth of that sense than one who once had the ability to see and now must work without it?

Confronted with the patient's confusion that morning, Wainapel deftly deflects the woman's question with humor. "I'm not looking at you because you are so beautiful I had to turn my eyes away." They both laugh and once the discomfort of the moment pa.s.ses, Wainapel moves confidently back to his desk and starts asking the patient about her knee pain.

It started almost a year ago, she tells him, and has been getting steadily worse. She'd seen her doctor. He sent her to two surgeons. Predictably both recommended surgery. She came to Wainapel because that option had no appeal. "I've lost thirty pounds and that helps, but not enough. It's hard for me to even walk. Now I've got to use a cane." She also complains of wrist pain for the past couple of weeks. As she tells her story Wainapel sits forward slightly, his head c.o.c.ked, eyes fastened on the patient's face-a picture of close attention. He asks her a few questions and jots down notes on a pad. From where I'm sitting I can't see what he's writing, but I notice that he uses his left thumb to keep his place on the page as he writes up the details of her complaint.

After reviewing her medical history and medications, he asks her to sit on the examining table that takes up the other half of the room. I watch as he skillfully touches and maneuvers her shoulders, elbows, wrists, and hands to identify the source of her wrist pain. "It really hurts right there," she tells him as he holds her wrist. "Here? Okay. Hmm." Eyes closed, Wainapel lightly touches her forearm to identify the origin of the pain. "That's between the ulnar stylus [the prominent bony b.u.mp on the pinky side of your wrist] and the pisiform [the furthest outside bone of the wrist]. Hmmm. No numbness? No weakness?" (No and no.) "Sounds like a sprain of the ulnar collateral ligament. No trauma?" (No.) Wainapel moves on to her knees. He a.s.sesses their range of motion-her gasps reveal how much her knees hurt with even ordinary movement. He feels her ankles and feet; he checks for evidence of swelling and joint instability. He asks her to lie on her back so that he can evaluate her hip joint. Sometimes pain felt in the knee actually originates in the hip. But not in this case. She has full range of painless motion in the hips.

They return to their seats and Wainapel walks her through his thought process. The wrist pain probably comes from a sprain-perhaps from the way she pushes herself up from a chair to stand. Still, it's essential to make certain it's not a fracture. One of the small bones in the wrist can break and pain may be the only clue-so she'll need an X-ray. About the knees-he'll need to get the X-ray report from her orthopedic surgeon. Until then he recommends physical therapy, Naprosyn (an anti-inflammatory medication like ibuprofen), and a trial of a glucosamine and chondroitin combination, an over-the-counter remedy sold in health food stores for joint pain. He reviews the evidence on this second medicine: "Studies have shown that the glucosamine and chondroitin combination doesn't repair joints, but it can bring some relief in the group of patients with the most painful knees. If it can help you move, why not give it a try?"

As he speaks, I look around the office. I wasn't surprised that Anna hadn't immediately known that her doctor was blind. Nothing about him or his office suggests that he has any disability at all. In addition to the usual framed degrees, his office walls are covered with colorful oil paintings, photographs, posters. Bookshelves loaded with medical textbooks and references cover an entire wall. Wainapel wears gla.s.ses-not dark gla.s.ses, regular gla.s.ses. And his eyes appear to focus on your face when he's speaking-so long as you don't move. The only clue to his vision deficit is the two white canes discreetly tucked away against the bookshelf.

Before the patient leaves, Wainapel dictates a letter to the patient's doctor. He easily reels off a precise summary of all the patient has told him. "This way they can see that I have no secrets and that I remember everything. That it's my eyes that are affected-not my brain. And, of course, if I make a mistake, the patient has a chance to correct me." I steal a look at the notes he'd taken while talking to the patient. They are unreadable-not in the cliched way that doctors' handwriting often is, with squiggles and lines that require careful deciphering. Despite his best efforts he's written his notes so that the dozens of lines of large loopy script are overlaid on top of one another-condensed into a single line of thick, indecipherable scribbles. I'm surprised. It's easy to forget that he can't see. Luckily he doesn't depend on these handwritten messes. He routinely dictates his notes on the visit and they are typed and placed in the chart. If for some reason the dictation system doesn't work and his report is lost, Wainapel tells me earnestly, his secretary can use these notes to reconstruct it. Hearing this, I make no comment. He can't see the mess his notes have become and it doesn't seem necessary for me to point it out to him.

As the visit draws to a close, Wainapel calls in his secretary, who writes out the prescriptions along with the referral for physical therapy. She positions Wainapel's hand so that he can sign the pages in the proper spot, then walks the patient out to her desk to schedule a follow-up appointment. In all, a perfectly ordinary encounter.

After the patient has gone I ask Wainapel why he didn't let her know he was blind before she came-if only to prevent that awkward social moment. He seems surprised by the question. "Why should I?" he asks. "If it were important for my work as a physician I would, but it's not." With a sly smile he adds, "If I can find the patient, chances are excellent I'll be able to help them. With me, locating the patient is the hardest part of my job.

"Observation is certainly the most important component of the physical exam, but there are other ways to observe than with your eyes," Wainapel tells me. He is a good listener, he points out. He prides himself on his ability to get the full history, to allow the patient to tell him what he has, and considers himself an expert in the physical examination of the musculoskeletal system.

"I knew I was going to be blind and so I made my choices based on that," he adds. "And because of these choices-my specialty for one-I think I can be an excellent doctor who happens to be blind. I don't know that I could say that if I were in another specialty." What makes this specialty better? "A lot of things. There's the obvious: the patients who come in to see me have problems in parts of their bodies that I can examine directly. I'd make a rotten surgeon or ophthalmologist-they need to be able to see in order to do their job. I can do mine with my hands, my ears, and most importantly, my brain."

Comparing his practice to my own, I get a sense of how his specialty allows him to excel despite his limitations. The patients who come to see him are in pain, but the causes are chronic, not acute. The arm or leg they complain of is unlikely to be broken or infected or bleeding. He's not that kind of doctor. And because of the chronic nature of their problems, he has the time to accurately diagnose and treat most of the patients who come to see him.

And yet even within this specialty there are cases where the loss of sight has made a diagnosis difficult. Wainapel tells me about an elderly woman who'd come to him for rehabilitation after hip replacement surgery. Before her surgery she had been active and healthy, she reported-limited only by the pain in her hip. After the surgery she remained weak and unsteady on her feet despite weeks of rehab. She still needed a walker to keep from falling and had difficulty getting through the strengthening exercises. Wainapel was stumped. He examined her repeatedly. The surgical wound was well healed. The joint was freely mobile. Her strength and reflexes seemed normal, and yet she was unable to get around on her own.

A social worker provided the clue that solved the case for him. She was struck by the fixed, sad expression on the woman's face. Could she have Parkinson's disease? she asked Wainapel. It was a good thought-and something he couldn't have seen. "I walked over to the patient and by golly she had cogwheeling and everything." Cogwheeling is a jerky motion in the joint when that joint is pa.s.sively moved-a cardinal symptom of Parkinson's. The disease slows voluntary movement and causes instability. No wonder she wasn't getting better. Once her newly diagnosed Parkinson's was treated, the patient improved rapidly.

Of course, from Wainapel's and the patient's point of view, this case wasn't a failure but a success. He was able to help this woman return to her previous state of vigor and activity-eventually. And yet the case shows that even in the narrow range of patients seen in this specialty clinic, there are those for whom sight plays an important and irreplaceable role. It was a success ultimately because in the patient population Wainapel cares for, there is time to figure things out. That is not always the case in other specialties.

The Look of Illness In medicine, sight becomes essential when rapid a.s.sessment and action are required. You can't imagine, for example, a blind emergency room physician. In an emergency you need to be able to collect information about the patient rapidly, efficiently. You never know what is going to come through the door and so you have to be ready for anything. Throughout medical school and residency training, I was told repeatedly that I needed to learn what "sick" looks like because it would provide one of the most important clues about how ill a patient really was.

This is not a new idea. Some of the earliest writings we have are devoted to describing this look. Hippocrates begins his work on prognosis with this clue: "If the patient's normal appearance is preserved, this is best; just as the more abnormal it is, the worse it is." He goes on to describe the face of someone who is going to die: the nose is sharp, he tells us, the eyes sunken, the temples fallen in, the skin stretched and dry with a dusky color. Hippocrates approaches the difficulty of caring for a patient who is too sick to survive with the same pragmatism that characterizes the oath that still carries his name: "By realizing and announcing beforehand which patients were going to die, [the physician] would absolve himself from any blame." This wisdom has been handed down through the centuries of medicine in all its various forms.

By the time most doctors finish training, they have at least one story about the patients who taught them what sick looks like. It's one of those rites of pa.s.sage that can't be forgotten. Jennifer Henderson was the patient who taught me the look of the critically ill. And it was in caring for her that I discovered the unexpected limitations of this a.s.sessment. Caring for Jennifer, I learned that recognizing sick is only a first step.

I met her on my first night on call in my first year of training. I still remember the excitement and terror that long-antic.i.p.ated event carried for me. Clark Atkins was the resident charged with supervising my training that first month. He had been an intern himself until just three days earlier when this new year had started and he had risen from intern to resident. Now it was Clark's turn to pa.s.s on what he'd learned. We hurried to see a new patient-Jennifer-who had already been moved out of the emergency room to a private room on the fourth floor.

One of the most important decisions that must be made about a patient, Clark instructed as we climbed the stairs to the patient's floor, is how much supervision and monitoring that patient will need. Emergency physicians are usually good at making this determination, but because it is so important, it's essential to see the patient for yourself to make certain you agree with their decision. I stopped to jot this down in the little book I kept for recording the secrets of patient care, then hurried to catch up.

Jennifer was sitting up in her bed, leaning forward, an arm planted on either side of her knees. A plastic oxygen mask fogged with breath arched over her nose and mouth like some modern version of a harem girl's veil. She looked up dully as we entered the room, distracted by the work it took to breathe. The thin chart from the ER said that she was thirty-one years old, but to my eyes she seemed much older.

She was a small woman-slender with delicate facial features coa.r.s.ened by what had probably been a very hard life. Her curly bleached-blond hair was marred by a thick stripe of black at the part. Her eyes were a light blue color that might have been strikingly beautiful once but now seemed washed out, lifeless. Her skin was tanned and leathery from the sun, and as she spoke a block of unexpected darkness along the line of her cigarette-stained teeth revealed that she had lost a couple. Her arms were wiry, her clavicles protruding, and the skin on her face looked a size too large. The muscles in her neck were prominent and contracted with every breath she took as she struggled to bring in enough air despite the oxygen provided by the mask.

Clark nodded at me encouragingly and I stepped up to the bed and introduced myself. I explained that we were her doctors while she was in the hospital and asked her why she had come. She hurt all over, she told me. She was a heroin addict. She was doing okay. Until last week. Then she got this headache. Her sentences came out in short bursts, a few words at a time, punctuated by deep breaths. She'd had night sweats. And a fever. And now she felt out of breath. All the time. And it hurt. When she had to breathe.

She suddenly looked up in distress, and her body convulsed in a paroxysm of coughing. She grabbed a tissue and held it against her mouth under the mask. She gasped for air as the spasm tore through her upper body. Tears streamed down her face. Finally she was quiet. She wiped her mouth with the tissue, then showed me the dark b.l.o.o.d.y sputum. "I think. I'm dying," she gasped, drying her face with the edge of the sheet. I tried to rea.s.sure her that she would be okay, but I worried that she might be right.

On exam, she had no fever but her heart was racing and she was breathing more rapidly than normal. And despite being on an oxygen mask getting 50 percent oxygen (normal air contains only 20 percent oxygen), she still wasn't getting enough. The oxygen saturation of her blood was 90 percent (normal is 100 percent). Her neck was stiff. She couldn't lower her chin to her chest, a sign suggestive of meningitis, an infection in the lining of the brain. When I listened to her chest, there were coa.r.s.e crackling noises-like the noise of a crisp sheet of paper slowly being crumpled.

The blood work sent by the ER doctors showed an elevated white blood cell count. Her chest X-ray was dotted with white cloudlike ma.s.ses a little smaller than golf b.a.l.l.s.

At the nursing station Clark and I reviewed the data and tried to put the story together. She clearly had more than one infected organ system: she probably had pneumonia, and meningitis seemed likely too. As an intravenous drug user, Clark reminded me, she was at high risk for accidentally injecting bacteria from her skin directly into her bloodstream. From there, these aggressive bugs can go anywhere and infect almost any part of the body. It seemed likely that these bacteria had infected her lungs and possible that they had infected her heart and her brain as well. The emergency room docs had already started her on several broad-spectrum antibiotics. We needed to get a head CT and a lumbar puncture to look for an infection in her brain and an echo of her heart to look for infections there.

As I wrote the orders, Clark's pager went off. It was the ER. There was another admission waiting for us downstairs. He looked toward the patient's door, clearly torn about whether we were done thinking about this patient or not. When the beeper went off again he stood, reviewed what else had to be done, and left me to finish up as he ran down to the emergency room.

When I had finished my note, I put it in the chart and went in to see the patient once more. She was lying back on the bed now, but if anything she looked worse than she had earlier. Her hair was drenched with sweat and her chest heaved with every breath. I needed to go down to the ER but I couldn't bring myself to leave her alone. Did she really look worse or was it simply the anxiety of a brand-new intern? I didn't know, but what I did know was that I afraid to leave her room, afraid that she really was dying.

The respiratory therapist came in and gave the patient a breathing treatment with albuterol-a medicine to reduce wheezing. Desperate with uncertainty, I followed him out of the room and asked him how he thought she looked. "I've seen worse," he told me before hurrying off as his beeper sounded.

I stood frozen at the doorway. I didn't want to leave because she looked so sick and yet I couldn't think of anything to do. Why was I more worried than the resident or the respiratory therapist? They had certainly seen more sick people than I had. And yet I couldn't shake this concern. I pulled out the card on which I'd written Clark's pager number. I had to talk with him to figure out what I should do. Before I could dial the number, David Roer, the attending physician, strode up. He was in his early forties and had dark hair and an open pleasant face. He greeted me with his usual cheer and asked me about the patient. I gave him a brief report and told him of my concern and then followed him into the room. He spoke with Jennifer briefly, then did a quick physical exam. I trailed him back to the nursing station, eager to hear his a.s.sessment. "This patient is on the verge of respiratory arrest." His tone was kind, without a hint of reproach. "She really needs to be in the ICU. She's probably going to need to be intubated."

Hearing those words, shame flooded over me. And relief.

Of course this is what she needed. Why hadn't I thought of this? My cheeks burned as I buried myself in the business of transferring the patient to the intensive care unit. Once she'd been moved into her new home, I ran down to the emergency room to see our next admission. The rest of that call day was a blur of admitting more new patients, following up on studies, and getting sign-out on the patients cared for by the other house staff as they headed home.

By the time I had finished all the tasks on my to-do list and trudged up to the sixth-floor call room, the predawn sky was beginning to lighten. I was tired but couldn't sleep. I went through every step of what had happened with Jennifer and tried to figure out how I had gone so wrong in the plans I had so carefully put together for her-plans that didn't take into account her most pressing and life-threatening issue, her breathing. It was right in front of me. And when her condition worsened so quickly-as I think it must have-I saw too that she was sick, dangerously sick, the kind of sick I'd heard so much about. The real surprise to me was that recognizing that she was sick had not helped me know what to do about it. I don't think I figured this out that night but what I learned over the course of that month-and relearned many times over the years of my specialty training-is that, as important as it is, recognizing what "sick" looks like is only the first step.

In fact, several studies have demonstrated that the recognition of what "sick" is, while much touted by residents and many experienced physicians, has not been shown to be accurate or effective in guiding medical decision making. In one study done at Yale, John Mellors, then a fellow in infectious disease, followed 135 patients who came to the emergency room with a fever and no obvious source of infection. The decision that had to be made at that time was whether these patients had a virus-in which case they could safely be sent home for rest and TLC-or whether there was a chance that they had a bacterial infection that would require them to take antibiotics. All of the patients in the study had blood cultures and complete blood counts drawn, a chest X-ray and a urinalysis performed. The decision to either admit the patient or discharge him, with or without antibiotics, was made after all the results except for the blood cultures were reviewed.

All of the patients enrolled in the study were followed throughout the course of their illness. Then the researchers compared how sick the patients really were with how sick the physicians had thought they were when they were initially seen in the ER. The doctors were wrong far more often than they were right. Many of the patients who were judged to look quite ill and were admitted were discharged soon afterward with no medical interventions taken. And four patients, a.s.sessed as being "not toxic" and sent home without antibiotics, were ultimately found to have significant bacterial infections and had to be called back to the emergency room to get antibiotics. One of those patients died not long after being discharged from the emergency room, well before the doctors even had the chance to call him back in.

Other studies have also found that our instincts, our intuitive responses, to a "sick"-appearing patient are frequently wrong. Recognition that a patient appears sick is important, it turns out, but it's not sufficient. As the Mellor study showed, patients can look extremely sick and not have a dangerous illness. Other patients, and this is particularly true of the elderly, can look remarkably well-at least for a while-despite a life-threatening infection. How sick a patient looks is just a clue, a single piece of data. Alone it is practically meaningless.

So what will help predict sickness? Concrete measures. Abnormal vital signs are key-a blood pressure that is too low or too high, a heart rate or respiratory rate that is too fast or too slow. Abnormal skin color or mental status. We are very good observers of abnormality. However, we often respond immediately and viscerally to a patient's condition before we've even identified the abnormality that's the cause of the concern. The fear I felt in Jennifer's room was such a response. I recognized sick but hadn't gone the next essential step of identifying what was causing the fear and so I didn't know what to treat.

When the attending first saw Jennifer, he immediately recognized that she was dangerously ill. He then noted the abnormal respiratory rate, the effort she was expending to breathe. She was using the muscles in her neck and shoulders to perform an act that is normally simple and effortless. Moreover, despite the hard work she was doing, she still was not getting enough oxygen into her bloodstream. These are ominous signals. As a medical student I had read about how patients working this hard to breathe can tire out and die. I knew it and yet that knowledge didn't help me. I saw-it's probably how I knew she was sick-but I didn't recognize what I saw and so was unable to figure out what to do.

I followed Jennifer's course over the next week. As predicted, she wasn't able to sustain the effort it took to breathe and was intubated the next morning. Her blood cultures grew Staphylococcus aureus Staphylococcus aureus, an aggressive and destructive bacterium that lives on the skin. It is a disastrously common infection among intravenous drug users. Despite the powerful antibiotics, she continued to deteriorate. Her blood pressure dropped so that she needed medications to keep her blood circulating effectively. Then her kidneys failed. Her blood stopped clotting. After seven days in the ICU, Jennifer's heart and lungs failed her and she died.

I don't think the delay in getting Jennifer to the ICU had a major impact on her prognosis. I made important mistakes in my training-we all do-mistakes that hasten or even cause death in those at the boundary between life and death. But I don't count Jennifer among my mistakes. She had a severe infection and precious little reserve. Nevertheless, I think of her often. Those minutes of terror and confusion I felt standing powerless in her room served as a visceral reminder throughout my training (and even now, occasionally) that the big picture isn't enough in medicine; that the overall impression of a patient is worthless without looking further and paying attention to the specific measurements of health or sickness that were behind the impression in the first place.

Research into human perception reveals that we have developed a remarkable ability to quickly gather visual data and come to a conclusion without even noticing the steps we take to get there. Studies in perception show that this rapid automatic use of our eyes is by far the most efficient way to collect visual data. And most of the time, that's good enough. Not so in medicine. Inexperienced doctors, like my intern self, need to learn to make themselves work backward from the conclusions they reach, attend to the details that got them there, and translate what they see into the language and numbers of medicine. Only then can we at least try to help the patient.

Noticing What You See Sherlock Holmes perhaps expressed most succinctly the lesson I learned. "I have trained myself," Holmes tells his amanuensis, Dr. John Watson, "to notice what I see." It's an important distinction.

"You have been in Afghanistan, I perceive." With these first words Holmes initiated the quirky relationship with the man who would become his closest friend and most devoted follower. Watson, in London recovering from war wounds sustained in Afghanistan, is shocked by the man's declaration. How could he possibly have known this? Had he been told? "Nothing of the sort. I knew knew you came from Afghanistan." He retraces his reasoning. Watson's military bearing suggested some time spent in the armed services, Holmes tells him. The deep tan indicated a recent return; his wasted physique, some kind of intestinal fever. And his injured arm pointed to a war zone. you came from Afghanistan." He retraces his reasoning. Watson's military bearing suggested some time spent in the armed services, Holmes tells him. The deep tan indicated a recent return; his wasted physique, some kind of intestinal fever. And his injured arm pointed to a war zone.

Of course it is an easy enough trick to pull off in fiction. However, Arthur Conan Doyle based his most famous character on a Scottish surgeon named Joseph Bell, for whom he'd worked during his medical training. Like Holmes, Bell frequently wore a deerstalker cap, smoked a pipe, and was often observed using a magnifying gla.s.s. But the most important trait they shared was a keen eye for detail combined with remarkable deductive powers.

Stories about Bell sound like snippets straight out of a Holmes story. In a preface to one of his books, Doyle describes his debt to Bell in developing Holmes as a character and provides examples of Bell's Holmes-like abilities. Seeing one patient, a young man in street clothes, Bell immediately asks the man if he was recently discharged from the military. He was. Was he a noncommissioned officer in the Highland Division? He was. Stationed in Barbados? Yes, how did he know all this? Like Holmes, Bell delighted in revealing his observations to the patient, the medical students, and the doctors observing him. Doyle quotes Bell's response: "'You see gentlemen,' he explain[ed], 'the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilian ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British.' To his audience of Watsons it all seemed quite miraculous until it was explained and then it was simple enough. It is no wonder that after the study of such a character I used and amplified his method when in later life I tried to build up a scientific detective."

Doyle clearly recognized that Bell's powers of observation were extraordinary. He referred to himself and the other doctors who witnessed these remarkable instances of detection as "Watsons." Yet Holmes and his model, Bell, firmly believed that this kind of close observation of significant details could be taught and sought to instruct those around them. "From close observation and deduction you can make a correct diagnosis of any and every case," Bell wrote in a letter to his now famous student, Arthur Conan Doyle. With practice, he suggested, the power of observation can be sharpened, improved. Doctors, he seemed to suggest, can teach themselves to "notice what they see."

Learning How to See Medical schools across the country have recently joined ranks with the historic Joseph Bell in striving to teach medical students to be better observers. One of the first efforts came from Yale. Dr. Irwin Braverman, a professor of dermatology for over fifty years, had long been frustrated by the difficulty students had in describing findings of the skin. It might have been a knowledge deficit-easily remedied with books, pictures, and tests. But Braverman suspected that what his students princ.i.p.ally lacked was the skill of close observation. Too often they wanted to cut straight to the answer without paying attention to the details that took them there.

"You teach students to memorize lots of facts," he told me. "You say: 'Look at this patient. Look at how he's standing. Look at his facial features. That particular pattern represents one disease, and this pattern represents another.' We teach those patterns so that the next time the doctor comes across it, he or she comes up with a diagnosis." What's missing, says Braver-man, is how to think when an oddity appears. That requires careful and detailed observation. After years of teaching he still wasn't certain he'd found the best way to communicate that complex set of skills.

In 1998 Braverman came up with a way to teach this skill. What if he taught these young medical students how to observe in a context where they wouldn't need any specialized knowledge and so could focus on skills that couldn't be learned from a book, where the teaching would force students to focus on process, not content? He realized that he had a perfect cla.s.sroom right in his own backyard, in Yale's Center for British Art. The course, now part of the curriculum, requires first-year medical students to hone their powers of observation on paintings rather than patients.