At a recent dinner party here in Tucson, an 80-year-old Chinese woman from Nanjing read the palms of each dinner guest. Her readings were surprisingly accurate and included ages at which individuals had had a serious illness, as well as the number of children that the various women present had delivered in their youth. She predicted with accuracy the age at which one of the men planned to retire and also that he was planning a second career. The guests were amazed, as was I. After the party was over my spouse, a molecular biologist, and I were discussing the remarkable perspicacity of the various palm readings. Because neither of us believe in superstition, fortune tellers, or ghosts, we tried hard to discern how she was able to tell so much about each individual guest’s background and future plans. We decided that what she was actually doing was make shrewd observations of each person present and combining that with a keen sense of intuition, to arrive at her surprisingly accurate pronouncements.
In thinking further about this past evening’s fortune telling event, it occurred to me that experienced clinicians often engage in a thought process that involves the same kind of observation and intuition. When I was a medical student and a resident before the era of sophisticated biomarkers, and ultrasonic, computed tomographic, and magnetic resonance imaging, I was privileged to learn from some of the most extraordinary clinicians present in Boston at that time. These physicians were remarkable in their ability to assemble a series of clinical observations for a specific patient and then combine this information with a sense of clinical intuition, thereby arriving at a diagnosis. Of course, I am not the first person to notice this extraordinary ability. Sir Arthur Conan Doyle, the author of the Sherlock Holmes stories, based his now-legendary character on his personal experience as a medical student at the University of Edinburgh. His professor of surgery, Joseph Bell, was famous at that school for using his remarkable powers of observation and deduction together with a developed sense of clinical intuition to glean a variety of accurate diagnostic and even personal information from patients he examined on the teaching wards of the hospital.1, 2
My experience as a student and young faculty member in Boston never involved anyone quite as perspicacious as Joseph Bell or his literary shadow, Sherlock Holmes, but I did have the opportunity to see some remarkable clinicians use keen powers of observation and intuition during daily clinical teaching rounds.
One patient clearly stands out in my mind. This case involved one of my mentors, Professor Lewis Dexter, one of the pioneer cardiologists of the 20th century. The patient was a 65-year-old man with a long history of hypertension that had been treated only intermittently. The man came to our emergency ward complaining of the sudden onset of marked shortness of breath that followed an episode of sharp and severe chest pain lasting some minutes and then resolving. The patient was clearly in severe heart failure when we first saw him in the Emergency Room. After admission to the hospital floor, we called our attending physician, Dexter, to come and help us with this very ill patient. Before examining the patient, Dexter opined that this might be an example of a ruptured sinus of Valsalva aneurysm into the left ventricle or possibly a dissection of the aorta with either acute aortic insufficiency or formation of a fistula into the right atrium or ventricle with a large left-to-right shunt. When he examined the patient, Dexter called our attention to a continuous murmur that was present along the right sternal border, implying abnormal continuous blood flow from the left side of the circulation into one of the right heart chambers. Subsequently, during angiography, the patient was shown to have had an ascending aortic dissection that had formed a fistulous tract into the right atrium, a very rare entity.
What I found remarkable at that early phase in my career was that Dexter was able to formulate a surprisingly accurate diagnosis based on the patient’s history combined with an expert cardiac examination. When I asked him later how he was able to deduce the patient’s problem so quickly, he told me that he had once heard about a similar patient, and upon hearing our patient’s story, he was reminded of the anecdote that he had heard many years before.
I would love to believe that I have acquired some of Dexter’s skills after many years of clinical experience, but that is very doubtful, especially in this era of rapid computed tomographic, ultrasound, or magnetic resonance imaging performed in the Emergency Department. The anatomic diagnosis is usually made there before the patient is admitted to the hospital. Nevertheless, I think that a strong sense of clinical intuition combined with careful observation of the patient is still important. The article by Verghese et al3 in this issue of The American Journal of Medicine supports this contention. Without careful observation of the patient, combined with a strong ability for deductive clinical reasoning and intuition, serious diagnostic mistakes can occur as documented in this article. I am sure that Verghese would agree that the skills of Professor Joseph Bell as portrayed in the Sherlock Holmes stories and novels are still useful in clinical medicine today.
As always, I welcome responses and reader anecdotes on our The American Journal of Medicine blog at amjmed.org.
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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
This article originally appeared in the December 2015 issue of The American Journal of Medicine.
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