An Old-Fashioned Diagnostic Technique

Today’s New York Times Sunday Magazine (February 25, 2007) carries the case study of a 23-year-old teacher who developed a massive blood clot in the lung (pulmonary embolism) that landed him in the ICU for several days. Although his physicians were able to make the diagnosis easily through the use of scans, the source of the clot eluded them.

At some point the patient consulted Dr. Thomas Duffy, a sixty-something hematologist at Yale University School of Medicine known for his diagnostic abilities. Dr. Duffy asked the patient to perform a simple maneuver with his arm that pointed him to the correct diagnosis of thoracic outlet syndrome, the condition that led to the source of the clot.

Dr. Lisa Sanders, the internist who writes these periodic columns for the New York Times Sunday Magazine, admits that she “had never heard of the old-fashioned arm maneuver. This and other physical-exam techniques,” she writes, “are part of a disappearing tradition in medicine—replaced more or (in this case) less successfully with a variety of high-tech imaging techniques.”

Dr. Sanders comments: “Had a doctor not done this simple test, the patient’s abnormality may not have been picked up, and he would have been stuck taking medicine he didn’t need (for the rest of his life) and missing out on the sports he loved.”

It is indeed sad commentary that our medical education system no longer emphasizes such techniques in physical diagnosis. Instead, physicians-in-training are taught to rely on more sophisticated imaging and laboratory studies—always considerably more expensive and not necessarily productive.

Thirty years ago, as a Physician Assistant student at Hahnemann Medical College and Hospital, I remember being taught the maneuver Dr. Duffy employed with this patient in my physical diagnosis class. I consulted my copy of Methods of Clinical Examination: A Physiologic Approach (Judge and Zuidema. Boston: Little, Brown and Company, 3rd Ed., 1974), where a description of the Adson maneuver appears on page 292:

“Palpate the radial pulse on the side to be tested. Instruct the patient to extend the neck and turn the chin to the side to be tested. The transient disappearance of the radial pulse during inspiration signifies temporary occlusion of the subclavian artery as the anterior scalene muscle is tensed (by extension of the neck and rotation of the skull) while the ‘floor’ of the thoracic outlet rises during inspiration.…These signs may be intensified as the shoulder is abducted and externally rotated.”

I was gratified to find that in my book I had underlined the text.

In their preface, authors Richard Judge, M.D., and George Zuidema, M.D., note that “the practicing physician may find a few pearls buried within these pages; for the art of medicine is seldom if ever mastered, even by the expert.”

Teaching Law, Teaching Medicine

In her guest column in today’s New York Times, A Skull Full of Mush (February 20, 2007), University of Wisconsin law professor Ann Althouse opines that the teaching of “law should connect to the real world.”

“The cases we read for class are always based on factual disputes that arose in real life,” Althouse writes. “I’ve spent the last two weeks teaching cases on standing doctrine, which prevents the courts from articulating the law in the abstract and ties the judicial power to resolving concrete controversies between genuine adversaries. If it’s not real enough, it’s not a case.”

In Althouse’s opinion, law professors show the greatest respect for their students if they “teach them what they came to learn: how to think like lawyers.”

Historically, clinical medicine has always been taught at the bedside, through the cases of individual patients. Sir William Osler thought that the art of medical practice could not be learned otherwise.

In my opinion, reading case studies through illness narratives greatly enhances the student’s intellectual grasp of the patient’s condition—from presenting signs and symptoms to differential diagnoses and response to treatments. If we complement our bedside teaching with the illness narrative, we teach students of medicine what they came to learn: how to think like clinicians.

Orderly Disorder

A model of the human brain sits on the shelf in my office at home, a plastic testament to the well-ordered anatomy inside the human skull. Cerebrum, cerebellum, medulla oblongata; telencephalon, metencephalon, myelencephalon—the litany of consciousness, the seat of the soul.

Neuroanatomists can pinpoint those areas of the brain responsible for controlling the movements in our limbs, the muscles of our mouths and, most recently, facial recognition. They have mapped the visual and auditory pathways, and defined the speech and language centers. We now know that the seat of emotion lies within the limbic system, orchestrated through the amygdala. Yet despite our anatomical expertise, we still have not succeeded in determining just how and where individual bits of knowledge are stored.

A casual visitor to my home office would have little idea where specific pieces of informational data are kept. There’s the filing cabinet—certainly a good place to start—that houses folders containing important documents such as birth certificates, insurance policies and bank statements. Then there’s the computer, with its massive hard drive—certainly data stored there, albeit password protected, is in some semblance of order, enabling easy retrieval.

Beyond that, the file system seems somewhat scattered. Stacks of envelopes appear on top of the printer and at various places on my desk. Cubbyholes and pasteboard boxes house magazine articles and old newspaper clippings; photographs rest in one of the desk drawers, on top of my bureau and in several shoeboxes on the floor.

Road atlases and maps cover the top shelves of the book cases. I started stacking books in piles on the floor when I ran out of space on the shelves years ago. To the untrained eye, all appears in disarray; yet when I need to retrieve a crucial piece of data, I generally know exactly where to look—most times I’m successful on the first try.

In my office as in the human brain, there is an orderly disorder. The arrangement works fine, until my wife decides to clean, relocating piles of papers in the process. Afterwards, it’s as though I’d had a minor stroke: I find myself hopelessly lost in attempts to navigate through what were once familiar waters. Like those afflicted with senile dementia, it takes some time for me to get my bearings again, some time for the silt to settle out.

My Valentine Dilemma

My Valentine Dilemma
By
Brian T. Maurer

Fourteen lines allotted here to write
A verse composed of words to win her heart:
Iambic prose that reads so well by sight,
Though love is blind, the Bard says, from the start.
Shall I compare thee to a summer’s day?
I think not—no, it’s been tried before.
What then? Im wunderschoenen Monat May?
All seem to me to be a seasoned chore.
Perhaps a tresspass sweetly urged would do,
But trusses pass the point of my desire.
Are such Wilde words worth well the woo?
From such a passioned stance I will retire.
This year I fear she’ll have to be content
With Whitman’s bite-sized chocolate sentiment.

A Separate Peace

Like a recurring childhood nightmare, John Knowles’ novel, A Separate Peace, continues to haunt me decades after I read it for the first time as a teenager. Set on the campus of a New England prep school during the Second World War, the narrative chronicles the relationship between two students: Gene, a quiet and pensive boy, and Phineas, his more pragmatic and athletic roommate. “Always say your prayers,” Phineas advises, “just in case there is a god.” Though distant, the ever-present war saturates the novel, its influence palpable on every page. In a moment of vulnerability, without fully comprehending his actions, Gene’s sudden lurch on an overhead tree branch indirectly brings about Phineas’ fall from grace and subsequent death.

Like the lives of Knowles’ characters, my day to day existence has become saturated with our current war. Though distant, the conflict creeps into my bed at night and waits patiently, exerting its presence as I open my eyes from a restless sleep. The war is always with me: when I lie down, when I wake up, when I go about my daily business. There is no getting away from it. I scan the daily newspaper headlines, and there it is in black and white; I turn on the car radio during my morning commute, and the latest bulletins blast my ears.

Only the daily number of casualties changes: those killed in skirmishes or by suicide bombers, those maimed by roadside IEDs. Sometimes a named journalist or high-level diplomat is kidnapped or murdered. Mostly the numbers remain anonymous, linked only to a time and place; and the names of the places resurface constantly, like carved horses on a carousel turning steadily in time to the piping of the deafening calliope.

Here at home, life goes on as usual. I arise, drive to the gym for my morning workout; shower up, grab a cup of coffee on my way to work; see my patients, and then pack it in at the end of an exhausting day; return home late to take my dinner alone in silence, while my wife sits in front of the TV, watching the evening news broadcast on the war.

The debate rages on: what can be done to remedy the situation? A troop surge? Immediate withdrawal? A timed exit strategy? Dig in for the long term? There are no good answers, it seems. As the saying goes, when we’re up to our derrières in alligators, it’s difficult to remember that the primary objective was to drain the swamp.

At this point, I’m desperate for a separate peace. But only the words of the Bard reverberate inside my head: “To sleep, perchance to dream—ay, there’s the rub.”

PAAV Author to speak at 20th Annual Charter Oak Conference

Author Brian T. Maurer is slated to speak at the 20th Annual Charter Oak Conference, to be held this year at the Hotel Viking in Newport, Rhode Island, March 26 – 30, 2007.

Maurer, a practicing Physician Assistant, will deliver a talk entitled “Something of Value: Patients Are a Virtue” at the Connecticut Association of Physician Assistants annual meeting at noon on Tuesday, March 27, 2007.

Maurer’s presentation will include insights from his 28 years of practice in pediatric medicine, crafted in his recently-released book, Patients Are a Virtue.

“Psychologists tell us that it is quite natural for us as human beings to pause periodically to take stock of our lives, to survey the road we have traveled, perhaps in part to peer around the next curve to learn what lies ahead. It is our nature to attempt to bring some order to the chaos of life—to make sense of where we have come, and to see where we are going.

“One morning several years back, I awoke to find that I had achieved the dubious honor of counting myself half a century old. These days I find myself thinking about my chosen career path, revisiting the reasons I had desired a life of medical practice, and rehashing the ups and downs of my professional training and years of service.

“We learn the practice of medicine through the complex process of integrating knowledge and skills with wisdom and insight in our interaction with the patient. Although the medical record forms a composite history of the patient’s illness; for the clinician, it may be the illness narrative that ultimately imparts some degree of healing to both practitioner and patient alike.”

“Notes from a Healer”—The Shirt Off Your Back

For those interested in glimpsing a slice of daily pediatric practice in chilly New England, you can read the second installment of my “Notes from a Healer” column, “The Shirt Off Your Back”, in The Yale Journal for Humanities in Medicine.

In case you missed it, you can still peruse the premier piece, “Rumblings in the Distance”, that appeared last month.

The Yale Journal for Humanities in Medicine acts as an online clearinghouse for manuscripts treating the humanities and medicine.