Every Patient Tells A Story Part 6

She did.

"And her blood pressure is low?"

It was.

"Would you say that you thought she had pain that was out of proportion to what you found on physical exam?" she asked.

Absolutely.

"Those are the cla.s.sic symptoms of ischemic colitis."

Like so many terms in medicine, the words themselves tell you much of what you need to know about this disease: ischemia-from the Greek isch isch, restricted-and hema hema, meaning blood. Restricted blood flow to the colon. It's a disease most commonly seen in the elderly, often under conditions of a significant infection. I knew about this ent.i.ty, of course. It's in my Harrison's Harrison's-the textbook I used to learn about diseases. But the "pain out of proportion to the exam" isn't in Harrison's Harrison's. Or in any of the other textbooks I'd reviewed. It's part of the oral tradition in medicine, picked up-like so much else-the hard way, by not knowing. Still, I should have at least included it in my list of possibilities. She was a perfect setup for it. My face burned as I realized that, of course, ischemic colitis was the most likely diagnosis. And I had missed it.

"Just remember, the reason you took this miserable, low-paying job was because of the education." Cynthia smiled as she repeated back to me the words I'd said to her once as an intern. As I hurried back to the patient's room I boiled with frustration. How was I ever going to master all this? I read the textbooks, the little books of clinical pearls, the countless journal articles, and yet with a cla.s.sic presentation of a cla.s.sic little old lady disease I'd missed the boat. Internal medicine seemed suddenly, once again, completely overwhelming. It is vast; it is constantly changing; it is unmasterable. A resident I'd known during my intern year had recently shared with me her decision to leave internal medicine and go into dermatology. Why? I'd asked. She said, "Because I want to be right more often."

With the diagnosis of ischemic colitis in mind, it was easy to reconstruct what must have happened. The patient had an infection, which caused her blood pressure to drop. She had hardened and narrowed arteries-that was why she had the heart bypa.s.s surgery years ago. Low blood pressure and bad arteries together can cause some parts of the body to be starved of new blood and oxygen. The pain she felt was the tissue dying for lack of oxygen. It's a terrible disease and often requires surgery. Mortality is high-in part because only those with multiple illnesses and poor overall health tend to develop this disease.

The room was quiet when I returned. The morphine finally allowed the patient to sleep or at least to stop moaning. And her blood pressure had crept up with the additional fluid. An X-ray confirmed the diagnosis of ischemic colitis. I called the patient's primary doctor and, at his request, the surgeons.

Additional admissions sent me scrambling down to the emergency room. I returned a couple of hours later to see how the patient was doing and what the attending physician had done. She'd been evaluated by the surgical resident, who wanted to take her to the OR. New labs suggested that there was dead tissue that needed to be removed.

Her family did not agree to the operation. She had already made her wishes known to them-no extraordinary measures, no surgery. They would control her pain, the family instructed, and see what happened. If she survived, so be it; if not, at least let her slip away peacefully. Her daughter would be in as soon as she could get there. I went in to see the patient before I left that morning. The room was quiet but now filled with light from what looked to be a glorious summer day beyond the window. She lay unmoving on the bed; her eyes remained closed but the muscles of her face were finally relaxed. The delicate pale skin of her face draped gracefully over her cheekbones, like a sleeping beauty never found by her prince.

Although there was nothing I could do for her, I dropped by to see Carlotta the next night, and the night after that. She never woke up when I called her name or touched her thin shoulder. The room slowly filled up with cards, colorful drawings, and flowers. "We love you Grammy," neatly outlined in black and roughly crayoned in primary colors, was taped to the wall across from her bed so that it would be the first thing she saw when and if she opened her eyes. Toys stored on the deep window ledge suggested at least one grandchild or great-grandchild was a regular.

When I came by the fourth night the room was empty. The cards and drawing were gone; the bed, crisply made, waited for its next occupant. Standing in that doorway, I said my own goodbyes to this woman. This is how every doctor learns, often by standing at the bedside of the patients she didn't save. And this is how doctors pay their own private respects. I have diagnosed this disease and others similar to it, and every time I make the right call, I see Carlotta's face once more.

Hand to Hand, Mind to Mind Part of the romance, the appeal of the physical exam-at least for me-comes from the way it's taught. I learned from the individual physicians who instructed me. They, in turn, had learned it from the physicians who taught them, creating a line of transmission that extends backward, like genealogy, to the originator. Emphasizing the personal nature of this transmission, the examination maneuvers or techniques often carry the name of the doctor or sometimes nurse who created them. Spurling's sign, named for an early-twentieth-century American neurosurgeon, describes the maneuver Roy Glenwood Spurling developed to see if a pain in the arm or hand originated in the cervical spine. In this maneuver the head is tilted toward the side with the pain and then the physician presses straight down, compressing the soft discs between the bony vertebrae. If this reproduces the pain, reported Spurling in a paper published in 1944, the pain can be attributed to a pinched nerve in the neck, a useful tool in the days before MRI and still routinely taught as a way to evaluate arm pain.

Tinel's sign was named after a French neurologist, Jules Tinel. He developed the test while caring for World War I soldiers with injuries due to gunshot wounds. Frequently, once the wounds were healed, sensation and strength would still be limited due to damaged nerves to the region. Tinel would tap on the nerve just before it entered the injured extremity. If the patient felt tingling in the damaged area, said Tinel, the nerve was recovering and the soldier could expect to get back some sensation and use. These days, it's commonly taught as a method for diagnosing carpal tunnel syndrome, an overuse injury of the median nerve that causes numbness or tingling in the thumb, first finger, or second finger. If a tap on the wrist reproduces these symptoms, the patient is said to have carpal tunnel syndrome.

Here's the problem. Many of these maneuvers don't work. Spurling's sign is no more predictive of cervical disc disease than flipping a coin. Many people will have pain with this kind of maneuver, but the pain could have many causes: rheumatoid arthritis, osteoarthritis, bone metastases from cancer. And many with a pinched nerve in the neck will have no pain. Still, it keeps getting taught.

Tinel's sign is just as worthless in diagnosing carpal tunnel syndrome. People who have carpal tunnel syndrome may have tingling when the nerve is tapped, but so will people with other problems. And many people with carpal tunnel syndrome won't feel the diagnostic tingling when tapped. So it can't reliably identify either those who have it or rule out those who don't.

The individual components of the physical examination were developed when physicians had few other means of diagnosing problems. Any sign or symptom that was found useful at the time was welcomed into the fold. Unlike modern (and expensive) high-tech tests or medications, there was no requirement for any of these exam techniques to be evaluated. And often, when these techniques were developed, there was no way to tell if the tests were right or not except by surgery or autopsy. As technology improved, so did our ability to test our tests. But we're only beginning to do that. In the meantime, doctors keep teaching them.

A colleague, Dr. Tom Duffy, told me about a test I'd never heard of, and about a patient for whom it made an important difference. Michael Crosby was a young man-healthy and active with no medical problems at all. Michael remembered clearly the moment he became aware that he was ill. It was his second day of teaching. A new job, a new school. He was giving the cla.s.s a quiz and as the students worked he paced between their desks. Their heads were down, pens in hand, eyes moving from the words on the board to their own papers as they worked their way through the first test of the year.

He was a subst.i.tute teacher. And that morning he felt strangely nervous. He could feel his heart pounding in his chest and hear himself breathing in short, deep gasps. He'd trained for five years to get here; done internships in some of the worst neighborhoods in urban upstate New York, and yet this middle-cla.s.s ninth-grade Spanish cla.s.s in rural Connecticut had him scared? His racing heart told him it was true.

But was this fear? All he knew was that it was hard to breathe. Really hard. And suddenly he was terrified. Breathing-the easiest, most natural thing in the world-all at once felt neither easy nor natural. He could feel himself go through the motion of breathing and yet the breath didn't seem to make it to his lungs. He felt sweat beading coolly on his face. His tie felt too tight around his neck. He glanced at the clock. Could he make it to the end of the period? He sat behind the desk at the front of the room and tried to relax.

The bell finally rang. The students dropped their papers onto his desk and clotted at the door. Crosby was right behind them.

The hallway to the school nurse's office seemed to stretch out into the distance. Every step was an effort. "I can't breathe," he croaked, once he finally made it to the tiny medical office. "I feel sick." Pat Howard, the school nurse, led him to a bed. He could hear her asking him questions, trying to get more information, but it was hard to speak. He felt like he was drowning on dry land. She removed his tie, then placed a mask over his mouth and nose. The cool rush of oxygen brought some relief. He remembered being loaded into an ambulance. When he opened his eyes again, he was in the emergency room surrounded by unknown faces.

He was quickly diagnosed with a ma.s.sive pulmonary embolus. A blood clot from somewhere in his body had broken free and been carried through the circulation into the heart, then lodged in his lungs. He was started on blood thinners and admitted to the ICU where he could be monitored closely. As soon as he was stable the doctors turned their attention to the clot itself: where had it come from and why did he have it? They needed to know because another a.s.sault like that could kill him.

Clotting is something our lives depend on. But like so much in the body, context is everything. In the right place, at the right time, a blood clot can save your life by preventing uncontrolled bleeding. In another setting, that same clot can kill. Clots normally form at the site of any injury to a blood vessel. They can also form when blood stops moving; that's why anything that causes prolonged immobility, like traveling or being stuck in bed, increases the risk of a pathological clot. Pregnancy increases your risk. So do certain drugs and hormones. Some people have a genetic abnormality that makes their blood coagulate too readily. Finding the cause of a clot is crucial to estimating the risk of another.

So, his doctors looked: He had no clot in his legs-the most common source of abnormal blood clots. CT scans of his chest, abdomen, and pelvis likewise showed nothing. He hadn't traveled recently, hadn't been sick. He took no medicines and didn't smoke. His doctors sent off studies of his blood to look for any evidence that his blood coagulated too eagerly. Normal. They could find no reason for this otherwise healthy young man to develop a clot. He was discharged from the hospital after two weeks and told that he would have to be on warfarin, a drug that prevents blood from clotting, for the rest of his life. Without it the risk that he would have another clot was just too high.

It's difficult to be a patient with an illness that can't be explained. What made that uncertainty even worse was the new certainty that accompanied it-that he would have to take a blood-thinning medicine forever. He was twenty-three years old, a jock with a sport for every season. The blood-thinning medicine would protect him from another pulmonary embolus but in return he would have to avoid anything that could cause bleeding-including the games he loved.

The patient searched for an alternative and found my friend Tom Duffy, a hematologist at Yale University with a reputation as a great diagnostician. He hoped that Duffy could figure out what caused this devastating pulmonary embolism and possibly get him off the warfarin.

Duffy is a slender, fit man in his sixties with round tortoisesh.e.l.l gla.s.ses, a preference for bow ties, and a precise, studied manner of speaking. He listened to the patient's story and then asked for a few more details: What kind of physical activity had he been doing in the weeks before the clot? He was alternating three days of weightlifting with two days of swimming or running. Had he taken any performance-enhancing drugs? The young man admitted that he had when he was younger but he'd taken nothing for years.

As he listened to the patient, Duffy considered the possibilities. The first set of doctors had done the usual testing, so this was going to be one of the unusual causes of pulmonary embolus. The scans done when he was in the hospital hadn't shown a clot in the vessels of his legs or trunk. A rare blood disease called paroxysmal nocturnal hemoglobinuria can cause blood clots in the liver, the spleen, or beneath the skin. The CT scan wouldn't have shown that. Could he have this rarity? Or could he have a myxoma, a rare type of tumor that grows in heart muscle, which can cause a clot within the heart itself? The physical exam might give some clues if these diseases were involved.

As the patient undressed for the exam, Duffy was struck by the highly developed muscles of his upper body. "He looked like one of those young men in a fitness magazine," he told me later. "It was quite striking." Otherwise his exam was completely normal: there were no extra sounds in his heart suggesting a tumor or anything else obstructing the flow of blood. His abdominal exam revealed no tenderness or enlargement that would suggest a clot hidden there.

Duffy looked at the patient again. He remembered something he'd learned in medical school many years before. He lifted the patient's arm until it was parallel to the floor. Carefully placing a finger over the pulse at the young man's wrist, he moved the arm so that it was pointed just slightly behind the patient. Then he asked the patient to tilt his head up, turn his face away from the elevated arm, and take a deep breath. When he did that, the pulse disappeared. When the patient looked forward again, the pulse returned. He repeated the maneuver. Again, the pulse disappeared when the patient turned his head and took a breath. Immediately Duffy suspected what had caused the clot.

The vessels that carry the blood from the heart to and from the shoulders and arms have to travel underneath the clavicle and above the top of the rib cage-through a very narrow s.p.a.ce. The presence of an extra rib or hypertrophied muscles of the shoulder or neck can make this tight opening even tighter. This problem, known as thoracic outlet syndrome, is most commonly seen in young athletes who use their upper extremities extensively-baseball pitchers or weightlifters-or in workers who use their arms above the level of their shoulders-painters, wallpaper hangers, or teachers who write on a blackboard. For those with this condition, when the arm is elevated, the extra bone or muscle narrows the s.p.a.ce between the two structures and the vessels that travel through them can be blocked. This patient was both a weightlifter and a teacher. He was a perfect setup.

Duffy set about to confirm his diagnosis and rule out any other cause of the clot. The blood work ruled out paroxysmal nocturnal hemoglobinuria. He got an MRI of the heart, which showed no tumor. An MRI taken while the patient lay with his arms above his head and his head turned away-the maneuver he'd done for Dr. Duffy-showed that one of the large veins carrying blood from the arms back to the heart was partially obstructed. Duffy was right. He referred the patient to a surgeon who had experience with this unusual and difficult surgery and the patient had his first rib removed from each side the following summer. The next winter he was able to stop taking the warfarin. That was four years ago. He's been symptom-free ever since.

The value of any test or exam resides in its ability to reliably predict the presence or absence of disease. Many doctors wrote to me, after I published this story, to question the accuracy of the test Tom Duffy had performed, a maneuver known as Adson's test. I searched the published literature, and these doctors were right-there was nothing on it. It simply hadn't been studied. In other words, no one really knows how good the test is.

On the other hand, the test was fast, convenient. It was easy to perform and carried no risk. One of the doctors who wrote to me about the test offered the following perspective: "Whether Adson's maneuver is accurate or not hardly matters. The fact is that Duffy thought of the diagnosis-and if the maneuver promotes that, then it's a good test."

And yet if a particular exam is not reliable, how are doctors to judge the results they get? Can their findings be depended on? If the exam suggests the presence of a specific diagnosis, will it pan out? If, instead, it suggests the patient doesn't have the disease, can we rule it out?

We know how well many of the various technological tests work. For example, it's been shown that an ultrasound is less reliable than a CT scan. And doctors can take that into account when they consider the test results-especially if the findings they get don't support their own diagnostic hunches. But we don't have that kind of data on many of the tests that make up the physical exam. And even for those for which we do have objective testing, the findings are often not taught. The result is that when we perform the physical exam we have no idea how much faith to put into what we find. That uncertainty can lead to the wrong diagnosis. Far more often it leads doctors to ignore or omit the exam and its findings and skip directly to a test that the physician can feel more confident about.

"The real problem," says Dr. Steven McGee, who has collected and reviewed much of the research on the physical exam, "is that there is all this tradition handed down to us and our poor medical students try to learn all of it. Then they find out that some part of it doesn't work and they throw the whole thing out. The truth is that there is a lot in the physical exam that turns out to be not terribly useful. But there are parts that are essential, even lifesaving." McGee is part of a growing movement in research to a.s.sess the utility of various components of the physical exam.

The physical exam isn't perfect, McGee told me, and we are all very much aware of that these days. "Our findings on physical exam feel like shades of gray while test results literally appear in black and white." When we compare our own uncertainty with the confidence we feel when we look at a piece of paper-well, it's no wonder we prefer tests. "But what you don't see on that piece of paper and what we often forget is that these tests in which we have placed our confidence aren't perfect either." Take the chest X-ray. How reliable is that? One of the most basic findings we look for in a chest X-ray is the size of the heart-is it normal or is it large? A straightforward question and a chest X-ray should show that clearly enough. Having said that, if the same X-ray is read by more than one radiologist, how often will they agree about this simple finding?

Statisticians measure agreement using a tool called the kappa statistic. This takes into consideration the fact that sometimes with even random occurrences like flipping a coin, two people will agree or get the same answer merely by chance. To find real agreement rates you have to account for those that occur just by chance. So to use the example of two people flipping a coin, simple chance would have the coins both land on the same side about half the time. If the two coins were in agreement more often or less often, that would be their kappa statistic. You wouldn't expect any more than 50 percent agreement and so the two coin t.o.s.s.e.rs would be expected to have a kappa statistic of zero. On the other hand, if two individuals were looking at either a red card or a blue card and neither was color-blind, you would expect them to agree virtually all the time. Their kappa statistic would approach 100.

So how do radiologists do when determining if a heart is a normal size or larger? Their kappa statistic is 48. In other words, once chance agreement is taken into consideration, there's a good chance the two radiologists will disagree at least some of the time. The same kind of disagreement occurs in other types of radiology-the problems with mammograms have been the most well described. Researchers calculated its kappa statistic as 47. Mammographers agreed with one another about 78 percent of the time. Pathology is another area of notorious disagreements.

Even laboratory testing is far from perfect. Clostridium difficile Clostridium difficile is a bacterium that causes severe diarrhea and requires treatment with antibiotics. Diagnosis is confirmed by detecting a toxin produced by the bacteria in the stool. When the test is positive, you can be certain that the patient has the disease. When the test is negative, however, it's far from clear that the patient doesn't have this infection. Studies show that up to one third of patients who have the infection will still have a negative test. Because it's an important diagnosis to make, routine practice in the hospital is to repeat the test up to three times. Only when all three tests are negative can you be certain that the patient doesn't have this potentially deadly infection. is a bacterium that causes severe diarrhea and requires treatment with antibiotics. Diagnosis is confirmed by detecting a toxin produced by the bacteria in the stool. When the test is positive, you can be certain that the patient has the disease. When the test is negative, however, it's far from clear that the patient doesn't have this infection. Studies show that up to one third of patients who have the infection will still have a negative test. Because it's an important diagnosis to make, routine practice in the hospital is to repeat the test up to three times. Only when all three tests are negative can you be certain that the patient doesn't have this potentially deadly infection.

What we've ended up with, says McGee, is a culture where test results have too much credibility and the good parts of the physical get too little. Neither is good for the patient. And we forget that for many diseases the diagnostic standard is still the physical examination: there is no test better than the physical exam to diagnose Parkinson's disease or Lou Gehrig's disease. Same with many dermatologic diseases. We need to weed out the useless components of the exam. Stop teaching those parts, says McGee. The rest can play an important role in diagnosis. We lose our skills, McGee suggests, at our patients' peril.

David Sackett, a Canadian physician considered the father of evidence-based medicine, has been one of the strongest advocates of a more evidence-based approach to the physical exam. In the 1990s he started working with the Journal of the American Medical a.s.sociation Journal of the American Medical a.s.sociation to develop a series of articles called the Rational Clinical Exam. Each article in the series asks a question: does this patient have (some disease)? The article reviews the parts of the history and the exam and then provides the doctor with a measure of the test's accuracy and precision. The first article focused on ascites-fluid in the abdominal cavity. In the intervening years the series has looked at everything from asthma to appendicitis. It's been enormously successful, devotedly read and cited by physicians long frustrated by the vagaries of the physical exam. to develop a series of articles called the Rational Clinical Exam. Each article in the series asks a question: does this patient have (some disease)? The article reviews the parts of the history and the exam and then provides the doctor with a measure of the test's accuracy and precision. The first article focused on ascites-fluid in the abdominal cavity. In the intervening years the series has looked at everything from asthma to appendicitis. It's been enormously successful, devotedly read and cited by physicians long frustrated by the vagaries of the physical exam.

For example, the gold-standard physical exam to find ascites, I was taught, was the puddle sign. In this exam, you ask the sick patient to get on his hands and knees, as if he were playing horsie with a child. Theoretically the free-flowing ascitic fluid in the abdomen would collect at the lowest part of the belly-the part hanging down. By striking that with your finger you would hear a dull sound if there was fluid there, a tympanic sound if there was only bowel there. It turns out that this embarra.s.sing and uncomfortable test isn't very useful. What was shown to be a more effective test was to check for fluid when the patient was lying on his back. The patient puts his hand on the middle of his abdomen, holding the subcutaneous fat in place, and the doctor taps sharply on one side of the abdomen while feeling the other side. If there's fluid in the abdomen, you'll feel it slosh against the inner wall of the abdomen. If there's only abdominal fat, you will feel no movement.

I went to hear Steven McGee speak at a meeting of the American College of Physicians. The large room was filled to capacity. After the introduction, he walked up to the stage, a small man, trim and owlish, with horn-rimmed gla.s.ses hiding his eyes. He spoke in a quiet baritone about his own approach to making the physical exam worth doing again. Sometimes, the exam will give you all you need to make a diagnosis. Sometimes, he said, it will tell you what the patient doesn't have. You just have to know which parts you can depend on. "Who uses Tinel's test when you're seeing a patient with hand numbness and tingling?" he asked the audience. Hands appeared across the room. Bad news, he told us. Not a good test. Asking the patient to show you where the symptoms occur on the hand is a better test. Those with carpal tunnel are most likely to point to the thumb and first two fingers. Finding decreased sensation on the thumb and first two fingers is a fast and simple technique that may help you make that diagnosis.

His goal, he told his audience, is to help doctors examine patients more confidently and accurately. "Once versed in evidence-based physical diagnosis, clinicians can then settle many important questions at the time and place where they first arise-at the patient's bedside."

When his talk was over I overheard s.n.a.t.c.hes of conversation as the audience left the hall to go to their next lecture. There was excitement, hope, and pa.s.sionate discussions of the accuracy and validity of favored physical exam tests. As I walked through the double doors into the crowded hallway, I fell behind a group of young doctors and overheard their brief conversation on the talk. One tall, dark-haired young doctor nudged his friend with an elbow and said simply, "As if." Then laughed. I didn't see his face, but the meaning was clear: as if this research could change a fait accompli, the death of the physical exam. The others laughed with him. Another in the group said, "Like I'm not going to get the test." It was an abrupt reminder of the conservative nature of doctors. Changing this new status quo would be a challenge.

I thought again of my sister-in-law, Joanie, who'd offered to teach me on her own cancer. The gesture suggested she had far more confidence in the diagnostic potential of the physical exam than just about anyone in that lecture hall. Would she care if these skills were just allowed to die? Would she even notice? Can simply updating our armamentarium of physical exam techniques-eliminating those that don't work, buffing up those that do-be enough to reanimate the corpus of the physical exam? If not, what else might be needed?

CHAPTER SEVEN.

The Heart of the Matter.

I leaned forward in my seat and pressed the cheap plastic earpieces of the stethoscope deeper into my ears. I could hear the normal double knock of the heart at work, but there was another sound there too-one I didn't recognize. It was a quiet scratchy noise-regular, rhythmic, driving-like a percussionist thrumming out a rhythm on a washboard. leaned forward in my seat and pressed the cheap plastic earpieces of the stethoscope deeper into my ears. I could hear the normal double knock of the heart at work, but there was another sound there too-one I didn't recognize. It was a quiet scratchy noise-regular, rhythmic, driving-like a percussionist thrumming out a rhythm on a washboard.

At the business end of the stethoscope I wore about my neck, the end that I would normally place on the patient's chest, the silver-dollar-sized disc was missing. In its place was a small black box made of cheap plastic, about the size of a pack of cigarettes. It was a lightweight radio receiver and the sounds I heard through the earpieces were being broadcast to me.

What is that noise? I should know this.

I sat among a dozen or so other doctors listening intently, trying to identify the cause of these abnormal sounds. All of us, medical school graduates, several years of specialty training and practice under our belts, were here at a cla.s.s taught at the American College of Physicians conference, to relearn one of the fundamentals of the physical-the examination of the heart. I glanced at the woman next to me; her casually curly gray hair framed a brow wrinkled with concentration. She caught my look and smiled sheepishly. Clearly she too was stumped. A younger guy with oversized gla.s.ses stared intently at the floor.

"Who can tell me anything about what we're hearing?" asked Dr. Vivian Obeso, the course leader. She scanned the faces of the dozen or so doctors who sat before her, on the other side of a life-sized mannequin of a young man. His chest was exposed, a sheet covered the rest of him, and his plastic legs were amputated mid-thigh. The missing end of our stethoscopes rested on the upper left side of the mannequin's chest, a couple of inches below the clavicle, demonstrating where the sound we heard would be coming from, had this plastic dummy been a living patient. The tiny cla.s.s sat silent. Despite the age and years of experience of most of the doctors, there was an awkward pause as we hesitated to answer-it was a moment straight out of sixth grade. I knew from my own years of teaching medical residents that it's often hard to tell what that silence means. Is the question too hard? Or too easy? Both provoke the same uneasy hush. I still hadn't recognized the heart sound and suspected that was true of the others as well.

"All right. Don't tell me what you think it is-we'll get to that. Just describe the sound." Obeso tried again. "First, when does it occur? Is it systolic or diastolic?"

A normal heartbeat has two sounds separated by a very short period of what is usually silence-these two beats and the pause between them is known as systole (from the Greek word systole, which means contraction, so named by William Harvey when he first described the circular motion of the blood through the body in the seventeenth century). These are the noises made as the heart squeezes the blood into the lungs (the right side of the heart does this job) and into the general circulation (done by the left side of the heart). This double knock, onomatopoeia'd as lub-dup, is followed by another pause, this one often longer than the first. During the pause between lub-dups blood pours back into the heart, refilling each side before the next contraction. This longer pause is called diastole (from the Greek for drawing apart, because the heart enlarges as it relaxes and fills with blood). Because the activities in these two phases are so different, heart sounds are usually identified by where in this cycle they occur.

"Who can tell me? Systolic or diastolic?" The woman next to me looked up. "It's both," she offered quietly.

"Right. Did everybody hear that? There is both a systolic and a diastolic component."

I listened again. Indeed, the staticky sound came between the lub and dup, but then reappeared in the time between beats.

The teacher continued: "The patient is a young man who comes to the emergency room complaining of chest pain. This is his heart exam. Can you describe the sound?" A young man in the front row looked up. "It's scratchy," he said.

"Exactly right." Obeso nodded. "So what is this? There are three components to this sound. You don't always hear all three, but even just two of them will allow you to make this diagnosis."

Three components? Oh right. I didn't recognize the sound but I do recognize the description. This must be pericarditis.

An inaudible voice from the front row spoke. "Correct," Dr. Obeso said, flashing her remarkably white smile. "This is pericarditis. What you are hearing is a pericardial rub-the result of an inflamed pericardium [the sac in which the heart sits] rubbing against the smooth muscle of the heart. Here's another patient with the same type of rub." We listened again to a different recording, trying to store the noise somewhere in our individual brains so that we'd recognize it, if and when a patient with a heart that sounds like this walks into our offices one day.

The American College of Physicians started these refresher cla.s.ses in clinical skills in 1995 with little more than a library of recommended t.i.tles and a couple of computer terminals. The current lab director, Dr. Patrick Alguire, first began teaching at the lab a couple of years later when the college decided to add a course in performing skin biopsies and suturing-surgical procedures that many internists do infrequently enough to need a refresher. But, says Alguire, it soon became clear that doctors wanted help not just with these unusual procedures but with skills they need to use a whole lot more often.

First they added cla.s.ses in the breast exam and genital exams using patient-instructors to teach these procedures on their own bodies-an innovation already commonplace in medical school. Over the next several years they added cla.s.ses on how to examine different parts of the body: the muscles and joints, the eyes, the thyroid gland.

The diversifying syllabus, says Alguire, was a response to the growing evidence that physicians were entering practice with important gaps in their clinical skills, gaps that would be difficult to fill by simply reading. "We saw from the very first course that there was a huge need for this kind of hands-on learning. When you finish your training you get out into practice and you are suddenly confronted with all the stuff maybe you didn't learn-or didn't learn well enough. It's the stuff you didn't know you didn't know-until you needed it. That's been the driving force behind the center." Perhaps not surprisingly, says Alguire, most of the students at the center are young-doctors in their thirties and forties.

This is the first year the center has offered the heart exam. Alguire had been looking for a way to include it for several years but hadn't found a good method to teach it. And then he saw Harvey-the electronic dummy I had spent my morning with. He thought it would be perfect for the doctors who had requested a.s.sistance with the heart exam. Seven cla.s.ses were offered over the course of the conference that first year. All were filled; most had waiting lists. The word was that the course was worth the wait in line for the chance at an unoccupied seat, that it was an efficient and effective way to brush up on the basic cardiac exam skills.

The life-sized mannequin is capable of simulating a dozen different heart conditions, offering high-quality digital recordings of the sounds of the abnormal heart. It can show the pulses in the arteries of the neck and where, on the chest, the heart beats most forcefully. It reproduces the differences in the sound depending on where on the chest the microphone is placed. All these characteristics are essential clues for the clinical diagnosis of a wide variety of diseases of the heart. And unlike our catch-as-catch-can training in the hospital, this Harvey could teach them all-a kind of one-stop shopping for the heart exam.

Listening is the third and final sense we use routinely in the physical exam. Doctors often listen to the lungs and the gut. We strain to hear the first and last sounds of blood rushing through arteries narrowed by our blood pressure cuffs to look for hypertension. We listen to the vessels of the neck, searching for pathologic blockages in the arteries that carry blood from the heart to the brain, a potential source of strokes. We press our stethoscopes firmly into the belly beside and above the navel to check for sounds of turbulent flow into the kidneys-a cause of high blood pressure resistant to routine antihypertensive medication. But mostly, we use our stethoscopes to listen to the beating of the heart. Detecting deviations from the expected lub-dup is one of the oldest and most valuable tools we have for diagnosing important and sometimes life-threatening diseases of the heart.

In many ways, the heart exam stands as a symbol of the entire physical exam. It's not the most complicated exam-the neurological exam is the probably the most complex. Nor is it the most technically difficult exam-looking at the retina of the eye may get that honor. And it's not the most time-consuming exam-that would probably be the psychiatric exam. But the heart exam was the first examination developed in modern medicine and the one most strongly linked with the physician's role as diagnostician and caregiver.

Moreover, the heart exam is a subtle exercise and requires well-developed skills to detect the nuanced variations from expected heart sounds. A thorough understanding of the anatomy and physiology of the heart and the circulatory system is essential in interpreting these quiet deviations and identifying the lesion they suggest. As such, it has functioned as the proverbial canary in the coal mine, the first alert that physician skill and interest in the physical exam was waning.

Salvatore Mangione chose the heart exam to test in his 1992 study of doctors' skills not only because it was an area in which he had noted waning skills but also because of this position in the pantheon of examination abilities. He describes it as the "tip of the iceberg" of the physical exam-the most apparent component to doctors and patients alike of this much larger practice, this sensual science of the body, the physical exam. Technology is eroding, melting away this ancient, ma.s.sive, and essential part of the way a physician knows the human body.

If and when the physical exam is saved, says Mangione, we will know it when the heart exam is restored to its former preeminence as the signal of a highly skillful, well-trained physician.

A Different Way of Listening On my first day of medical school I was given the short white coat that signified my status as a student of medicine and my first stethoscope. These two symbols of my entrance into medicine were presented in very different manners. The white coat was given in a ceremony on a beautiful September morning in 1992. A sun-drenched hall was filled with rows of folding chairs for me, my ninety-nine new colleagues, and our families. The two deans of Yale Medical School, Gerald Burrow, head of the medical school, and Robert Gifford, the dean of students, stood at the front of the room, welcoming us into the profession. The late morning sun poured through a wall of windows, reflecting off the polished wood floors of the hall, suffusing the room with a fog of light. After a few words of welcome, Dean Gifford explained that the short white coat that we were about to receive indicated our status as medical students; these would be replaced in four years, upon graduation, by a full-length garment that signified our role as full physicians and teachers. Then each of us was called to the front of the hall to receive our own white coat. As we walked up the aisle, a brief bio was read, our first introduction to our peers for the next four years.

My husband squeezed my hand as my own name and credentials were read and I shuffled down the row of chairs to walk up the aisle, put on the crisp white jacket, and took my place among my new colleagues. Pride and excitement shone on everyone's face. When the last name was read, faculty and family joined in giving us a round of applause. It was a magnificent moment.

My first stethoscope had a far more ignominious entry into my life that day. After the ceremony we were sent off to finalize the complex logistics of registration. After filling out and signing a sheaf of forms, we were given our schedules and the key to our mailboxes. They were already overflowing with the typical packets of welcoming materials-sheets listing courses and books, still more forms to fill out for library and ID cards, manuals on policies and procedures, rule books, discount cards for local stores, and advertis.e.m.e.nts for various tools of the trade-and a stethoscope.

The stethoscope itself was one of those advertis.e.m.e.nts-a gift from Eli Lilly. If I received that gift today I would have different feelings about it, but this was before I had really thought much about the meaning of these gifts from the pharmaceutical industry. It came in a slender white box with the name of the manufacturer written in a tasteful script. It had the elegant proportions of a box from a jewelry store. I put everything down and picked up the box. Inside, the stethoscope lay draped on a black cardboard background contoured to keep the precious instrument in place.

Lifting the stethoscope out of the box, I was impressed by its heft. The disc at the end was polished chrome. The name of the drug company was written on the diaphragm-but that first day, I didn't even see it. Shiny gray rubber tubing extended from the disc and split, ending in a length of curved chrome and two gray rubber earpieces. Despite the elegant presentation, it was an ugly industrial object and yet I loved it. To me, it was far more important than the white jacket of the morning service. This was the real evidence of where I was going, the proof that at the end of all this there would be patients and healing-just as close to me as this disc was to these earpieces.

And yet as I think back on this I realize that this was my first clue to the status of the physical exam. The white coat, symbol of authority, knowledge, and progress, was the focus of the official welcome. The stethoscope, the symbol of the physical examination of the body, of our role as caregivers, was an industry-supported trinket-a freebie.

At home after that first day at school, I pulled the stethoscope out again. The silvery arms crossed and reached down as graceful as a dancer in first position. I put the soft rubber pieces to my ears, expecting them to sink into place. They didn't. I pulled the stethoscope off and looked at it once more. I tried again. Still awkward, still uncomfortable in my ears. I flipped the thing around so that the earpieces looked up at me like a leering cross-eyed sailor. I tried again. This time the earpieces fit snugly, the soft rubber adjusting to the contours of my ears so that all other noises were blocked.

I put the silver disc over my heart, head c.o.c.ked, and I listened. I heard-nothing. I stood quietly. Still nothing. Was there something wrong with the stethoscope?

I took a deep breath. That I heard. I breathed again. The sound was clear, like the sound of wind pa.s.sing through a hollow piece of plastic. Then I stood quietly listening, listening. After what seemed forever I felt, rather than heard, a quiet rhythmic pressure against my eardrums. I concentrated on that beat, then finally-somehow-was able to hear the now familiar lub-dup. This instrument required a different way of listening.

This was not going to be as easy as it looked.

On another morning, this one nearly two hundred years earlier in Paris, a young physician with the improbably delicate name of Rene-Theophile-Hyacinthe Laennec was confronted with the problem of examining a plump young woman with chest pain who was suspected of having a diseased heart. The year was 1816. The problem was one of logistics and propriety: how to evaluate the heart of this young woman. The recently developed practice of placing the ear directly on the chest of the patient seemed likely to be ineffective as well as improper. Other techniques of examination, also newly discovered-palpation (feeling the chest for the beat of the heart) and percussion (thumping the chest the way you might a melon)-were attempted but quite useless in this case, reported Laennec, "on account of the great degree of fatness."

"I recalled a well known acoustic phenomenon," Laennec wrote several years later. "If the ear is placed at one end of a log, the tap of a pin can be heard very distinctly at the other end. I imagined that this property of bodies could be applied to the case at hand. I took a paper notebook, made it into a tight roll, one end of which I applied to the precordial area [chest] and putting my ear to the other end, I was just as surprised as I was satisfied to hear the beating of the heart in a manner that was clearer and more distinct than I had ever heard it by the direct application of the ear."

The utility of the device, ultimately called the stethoscope (from the Greek stethos stethos, chest), was immediately apparent to Laennec. It was the first technologic development enabling a "view" into the inner workings of the living body. The device was so successful at transmitting the noises from inside the chest to his ear that Laennec devoted the rest of his career to better understanding the instrument and the body it revealed.

In Laennec's time, diseases were cla.s.sified primarily on the basis of symptoms. An illness was defined by the subjective sensations experienced by patients. Doctors didn't examine patients; they interviewed them. What const.i.tuted a "disease" then was a.s.sembled from a constellation of subjective symptoms and distinguished based on the type of symptoms, the sequence of their presentation, their severity and rhythm. Physical signs-derived from the pulse, touching, and observations of the skin and excreta-were contributory, but of much less importance.

At the turn of the nineteenth century, two new, closely linked ideas emerged that would change medicine forever. First was the growing understanding that disease was caused by the disruption of individual organ function. An Italian physician and teacher of anatomy, Giovanni Battista Morgagni, published a book called On the Seats and Causes of Disease Investigated by Anatomy On the Seats and Causes of Disease Investigated by Anatomy, just a few years before Laennec was born. This revolutionary tome presented detailed drawings of diseased organs and then linked these abnormalities to clinical diseases. The connection between the diseased organs hidden within the body and clinically apparent diseases led to the second new idea: if diseases were caused by organ dysfunction, then they shouldn't be defined by their symptoms-too many diseases presented with the same kinds of symptoms. If the patient couldn't distinguish which organ was involved-and this was and remains true-then doctors had to find some way to identify the source of disease independent of the patient's story. For this they turned to the body itself, to the physical exam.

This new generation of physicians rejected the dependence on the vagaries of the patient's history. They argued that diseases could be cla.s.sified based on changes that could be seen, felt, tasted, smelled, and heard by the doctor-changes that could be detected by an objective observation, independent of the patient's subjective account.

Laennec was a leader in this revolutionary reworking of the fundamental ideas of medicine. He used his new invention to find concrete, objective manifestations of disease. Others before him had developed some techniques that Laennec himself frequently made use of. But it was Laennec who made the greatest contribution to the radical new medicine, not only providing its first tool but making the link between what he was able to see and hear and the hidden dysfunction within the body.

Laennec was in the perfect place to do this too. He was the director of Necker Hospital, a small inst.i.tution on the outskirts of Paris. Because of his position, he was able to follow hospital patients and their examination over the course of an entire hospital stay. All too often he could then correlate what he found on examination with what was revealed at autopsy. Laennec pioneered the way to link the pathologic changes caused by disease within the body to clinical information-the physical exam-collected from outside the body. His work put the physical exam at the forefront of the modern approach to medicine. Using his eyes, his ears, his stethoscope, the doctor became a detective-deducing the pathology within from observations made from without. Using the clues provided by symptoms described by the patient and the signs elicited and observed by the physician, the doctor-detective was able to track down the villain-the morbid processes within the body.

Laennec recorded each patient's physical exam in his daily notes, carefully tracking how the exam changed over time and incorporating these findings into the cases he reported. When the patient died-a common occurrence for those sick enough to go to the hospital-Laennec could identify the cause of the disease and the symptoms that revealed it. Once Laennec had made this link between the findings on physical exam and those at autopsy, he was able to diagnose similar patients in life with a precision rarely seen in previous centuries of physicians. Many of the diseases we now routinely identify by physical exam were first described by Laennec.

For example, Laennec was the first to diagnose emphysema. Others had seen the destructive nature of the disease on autopsy but Laennec linked the symptoms and physical findings to the pathological ent.i.ty. The case involved a thirty-seven-year-old farmer who was admitted to the hospital in 1818 for worsening shortness of breath. Any exertion left him gasping for air. His hands, feet, and s.c.r.o.t.u.m were hugely swollen and tinged with blue-cyanotic from a lack of oxygen. Laennec and his colleagues had seen these symptoms before. It was usually attributed to heart failure, where the heart becomes too weak to keep pumping out the quant.i.ty of blood sent back from the circulation, and fluid backs up-acc.u.mulating in lungs, abdomen, and extremities.