Chapter XII: The Lost Skills, the Bad Habits

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The Remarkable Congressional Hearings. The hearings were held in January, 2000, and Ms. D, the fastest woman on earth, the 100 meter-sprint Olympic golden medallist, took the stand. She told a stunning story. "A string of doctors failed to diagnose her disease, despite classic symptoms," reported the press. "It all started in 1988, when she left her first Olympics, too weak to even make the finals." "I was told I was over-training and must take time off. I'd take time off and come back even worse," Ms. H told the congressional committee. "Her heart sped up to a dangerous rate. Her eyes began to bulge ... A huge goiter grew on her neck. She dropped from 125 pounds to 87, and then the doctors suspected eating disorders." (95)

Of course, also in Poland or Rumania it can happen that a doctor, particularly one of those who have entered the practice without solid hospital training, would miss the diagnosis of severe hyperthyroidism (Graves' disease) in a case like this one. It is very unlikely that several doctors would fail to diagnose such a conspicuous condition for several years. Medicine is still old-fashioned in Eastern Europe, as it is--to a degree--in the Mediterranean, and in those countries doctors still look at their patients.

I cannot resign myself to the notion that doctors of the new generation, so much more knowledgeable than we were, so much more skilled in various techniques, should be unable to see what we can see.

The Art of Seeing. For a long time the ability to see at a glance what was wrong with the patient was admired as a clinician's true gift. It has never been considered a universal diagnostic tool; yet in quite a few cases an attentive look cast at the patient could directly lead to the diagnosis of a disease that otherwise would be missed.

There is nothing unique or mysterious in the "gift" of seeing. This was simply the way doctors used to be trained. Looking attentively at the patient, and allowing a flow of thoughts and mental associations to start if we noticed something peculiar, was a working habit which we as medical students used to acquire while learning clinical medicine under the guidance of senior physicians.

An excellent book was published in the 1920's by Dr. Ortner of Vienna, under the title "Strassendiagnose." It was a treatise on diagnosis which a clinician could faultlessly make just crossing people in the street. Indeed, it takes only a glance to notice the bluish-purple "butterfly" on the cheeks of a lady with mitral valve disease; the "haggard look" and protruding eyeballs of a woman with hyperthyroidism; the drooping foot of a patient with peroneal nerve palsy, the coarse facial features and heavy jaw of a man with acromegaly, the brown skin of a person with Addison disease; or the incompletely recovered stroke patient's arm, bent and drawn to his chest, while his leg is making an awkward half-circle at every step (the Wernicke-Mann posture and gait). Extensive chapters on visual diagnosis can still be found in all good textbooks of medicine.

In Lodz, my good assistant Dr. W, an experienced internist, asked me to see one of her patients. The 60 year old lady, whom I had known socially, for several weeks had complained of a finger that badly hurt. "A finger is just a finger," said Dr. W,, "but her complaint is so intense that I am worried about her." I looked at the patient whom I hadn't seen for about a year. The change in her appearance struck me. She was masculinized, had a thin mustache and the shade of a beard, almost a goatee. Even the skin on her cheeks was thickened, grayish, with pores showing, as is only seen in some males. With her shoulder-long hair the patient looked very much like the XVIIth century's portraits of the Polish king Jan Casimir.

By sheer happenstance--these cases are exceedingly rare--I had once in the past seen a female patient looking precisely like this one. I said to Dr. W: "Admit her to the hospital, and first of all take a chest X-ray. …

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