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. I'm afraid we'll see many round shadows. The patient apparently has a masculinizing tumor of the adrenal cortex, and these tumors immediately metastasize to the lungs."
Alas, I was right: the lungs were packed with round secondaries, and the primary tumor was in the adrenal cortex. What was wrong with the patient's finger we never found.
Well, I just happened to have seen one such patient in the past. I also happened to have known this lady before her illness, and was able to notice at once the change in her appearance. Impressive as my diagnosis was, it did not allow much generalization.
Diagnosing thyroid disease is more instructive. In Denmark, while working at the department of cardiology in Aalborg, I was surprised seeing how my colleagues were using the thyroxin test (the more refined test for thyroid-stimulating hormone was not yet in use at that time). Thyroxin is the hormone of the thyroid gland; low blood levels of thyroxin indicate hypothyroidism, insufficient function of the thyroid, while high levels are typical of hyperthyroidism. Well, the doctors at the department ordered thyroxin test when I wouldn't; and they didn't ask for thyroxin levels when I did. The difference between us in using this test--that is, in considering the possibility of thyroid disease--was so striking that I thought it should be researched. There had never been such a difference between my diagnostic queries and those of other members of the team in Lodz!
I pulled from the lab register all 96 thyroxin tests ordered by our department in 1971. What I found was an even more pronounced difference than I had expected. That year, I ordered four thyroxin tests. All four were abnormal: two showed hyperthyroidism (overactive thyroid gland, Graves' disease), and the other two indicated hypothyroidism. The department's other five doctors ordered 92 thyroxin tests. All these, with no exception, showed normal levels of the hormone. In other words, the doctors ordered 92 thyroxin tests that weren't really needed.
I then asked each of the five doctors separately what their reasons were for ordering a thyroxin test. Every one of them answered that he ordered the test because the patients had heart problems, and hyperthyroidism (nobody mentioned hypothyroidism) was one of the possible causes of cardiac complaints.
None of the doctors said that he ordered the test because the patient looked like having thyroid disease. I, on the other hand, ordered the thyroxin test only when something I saw directed my attention to a disease of the thyroid. A goiter can be present or absent, but bulging eyes, or the whites of the eyes showing above the irises and giving a lady's face a "frightened" look, the swift pulsation of the arteries, the smooth, warm skin, the somewhat excessive movements of arms and of the whole body, the fine tremor of hands point to an overactive thyroid. Sometimes, in an elderly gentleman, just the somewhat shining eyes and, on auscultation, a too loud first heart sound draw my attention.
I also ask for a thyroxin test when a patient's "tired look," swollen eyelids, dry skin, rough and darkened at the knees and elbows, or a lady's deep voice, alert me to the possibility of hypothyroidism.
The results of the 96 thyroxin tests showed that this "Polish approach" was efficient while that of my "modern" colleagues was a waste of time, money, and patients' blood.
Even in Holland, where many doctors' clinical training is still very good, errors now occur due to the modern fashion of not looking at the patients. Leaving for a vacation, my excellent young associate in Den Bosch asked me to see at least once during her absence a patient she was worried about. The 50 year old lady was referred to the cardiologist because the blood test showed an elevated creatine phosphokinase (CPK). Inordinate amounts of this enzyme are released from the heart muscle in cases of myocardial infarction. The patient's CPK, however, was of a different kind, not the MB fraction originating from the heart, but the MM from the body's other muscles. A very thorough examination failed to reveal the cause. There was a thick file full of results of various tests.
The patient complained of tiredness, and in the last two months, moderately swollen legs. She was so tired that she had difficulty with climbing stairs. I looked at her. She did not look ill, but was rather pale and had slightly swollen eyelids. This gave the direction to my further questioning. Yes, she did sometimes perspire (this did not support my hypothesis). Yes, she was sensitive to cold, "but it has been so all her life." Yes, she has gained weight. Her voice was a deep alto, but not the typical bass. Her pulse rate was about 60, the skin was dry and rather rough and slightly darkened at the elbows and knees. I sent the patient to the lab for a thyroxin test. It was very low. By the way: this explained the high CPK levels in the patient's blood: in hypothyroidism the CPK MM fraction is raised due to the muscular waste.
While writing the letter to the internist I could not refrain from making a nasty remark. "Dear Nico--I wrote--will you please take this patient over for treatment of her hypothyroidism. I enclose the result of thyroxin test. I also enclose the results of 52 tests that Frieda had ordered."
This was a case of hypothyroidism which manifested itself in a discreet way, but another time I came across a patient with a most conspicuous myxedema (extremely severe hypothyroidism) that a doctor, lost in details, and busy with treating each symptom separately, managed to miss. We admitted the lady to the coronary care unit in Den Bosch with an acute myocardial infarction. She had it; but she also had another serious problem. She had previously been sick for two years, and assiduously treated by her doctor for several ailments. The family physician treated her with a diuretic for her swollen legs, with iron pills for her anemia, with symvastatin for high cholesterol, and...