Twenty Years of “What’s Your Diagnosis?”

This issue marks 20 years of “What’s Your Diagnosis?” columns in CONSULTANT. We have celebrated with a topic that is dear to the heart (page 633).

What meaning resides in the series as a whole? To me, it embodies deep-seated belief and central practice: the primacy of time spent with the patient, gathering meaningful information and building the relationship that is often the most powerful therapeutic instrument we have. From the second year of medical school I planned to become a good physical examiner. I hungered for patient contact amidst a sterile curriculum. Also, I arrogantly, short-sightedly failed to see how the unpalatable basic science years formed a crucial, deep, and rational foundation for clinical understanding. Thirty-five years on, I have honed my skills. But daily I doubt some findings and interpretations; any clinician who is always sure is a fraud and a fool.

Besides thanking teachers, colleagues in medicine and nursing, patients, and families, I offer sincere appreciation to editorial staff and readers of CONSULTANT for helping me grow whatever strengths I possess. The columns have played a key part: the teacher always (happily) must learn the most. Preparing the 477 columns to date has made me read the physical diagnosis literature ad infinitum. Thinking and reflection have been required. Best of all, the work has enlivened the daily exercise of my bedside skills, stretching me to try out new methods, to discern additional meanings and to accept limits of examination based on data, not on hunch nor on my own personal limitations. Now I (sometimes) perceive findings that earlier crossed my visual field uncomprehended. Revisiting a topic to expand the writeup (the columns in references 1 and 2, for instance) instructs and humbles me: “How did I put out that brief, fuzzy article, given that a mere 15 years later I can do better?”

Patients are unbelievably generous: The men who let us take the extremely upsetting images in references 3 and 4 bestowed more than anyone could be asked. We have avoided others that we felt would be unacceptably horrific, or that might feel unkind no matter how earnest our desire to prepare colleagues for the next patient burdened with an appalling disease. We have also avoided rare conditions that offer a mere medical museum without generalizability whereby they can merit the time spent in the busy life and work of every reader.

Favorite topics? Certainly, the man with acromegaly over the years⁵; he and his kind wife brought in snapshots from across the decades. HIV cases hold a special place in my spirit (those in references 6 through 10, for example) because this illness—even more so in the early years when treatments were few and feeble, and the stigma in society worse than now—so demands our best as both humans and professionals. The most challenging adults to treat include those with advanced HIV disease, and the frail demented elderly: Each has so many complex interactions between problems and between medicines that have to be thought out, hoping not to worsen one problem by attack on another. In both, manifestations of illness often differ from the classical description. We hope the images and columns have helped some readers find any such patients less alien, more familiar, and thus more readily treatable with the armamentarium developed throughout one’s whole antecedent clinical experience.

Previously undescribed physical findings have been a special treat.^11,12 I savor unsolved diagnostic puzzles, such as the oral lesions in an old woman,¹³ and also findings that interact with social issues as in our discussions of World War II veterans in 2008,¹⁴ the column on physical signs in falls,¹⁵ and one on ram’s horn toenails.¹⁶

Examination of human beings is not antiquated or quaint. It is the core of what we do. Neither insurers nor government, though their pursestrings suggest that procedures are the essence of medicine, can define our calling. Expert, thoughtful, focused examination will always build relationships and fulfill both clinician and patient—and any family member in attendance. For this bulwark to stay strong, examinations must not devolve into rote repetition for billing code, nor merely complete a form in the chart. None of us wishes to make the chart our patient, rather than the person it purports to represent.

Does this mean we have to swim upstream against the current? If so, I urge you to share my pride in guerilla action against the broken system of American medicine in 2009. I welcome even being labeled ridiculous and quixotic: without idealism our noble profession would be, in the words of Robert Frost’s poem, “a diminished thing.”¹⁷