Every Patient Tells A Story Part 5

As I entered the cool soft light of the museum's atrium, a dozen first-year students were standing around in small groups, waiting to enter the conference room to find out what they were doing in this unusual setting. Braverman, a round-faced man with a comb-over and an impish smile, sat at the head of a long table of l.u.s.trous dark wood like a folksy CEO of some big corporation. Their job that afternoon, he told them, was to look at the pictures they were a.s.signed to and then just describe them. Not too hard, right? He looked around hopefully. A few students sitting near him smiled and nodded enthusiastically. The rest of the table was a harder sell. "It's always like that," Braverman told me as we followed the students up the stairs to the third floor, where most of the nineteenth-century paintings he liked to use were on exhibit. "A handful of students either get it right away or are just habitually enthusiastic. The rest of the students here need to be convinced. But, you watch, by the end of the afternoon, I'll have some converts. Wait and see."

Once stationed at their a.s.signed pictures the students reviewed the rest of the rules. They were not to read the little labels next to the paintings. They'd have ten minutes to look at the pictures and then together the cla.s.s would discuss the images, one by one. Each of the pictures would have a story to tell. It was the student's job to figure out what that story was and relate it to the rest of the group, using only concrete descriptive terms. If you think a character looks sad, he told them, figure out what you are seeing that makes you think that and describe it. If you think that the picture suggests a certain place or cla.s.s, describe the details that lead you to that conclusion.

A tall young man with a sweet face and a prominent Adam's apple peered at the image of a slender man whose upper torso was hanging limply over the side of a bed, his right hand touching the floor. His eyes were closed. Was he asleep? asked Braverman.

"No," he announced decisively to his fellow medical students gathered around the scene. "He could be drunk-he has a bottle in his hand-but he's not asleep. I think he's dead." "How do you know that?" asked Braverman. "His coloring-it's not right. He looks green," he answered thoughtfully. "And there's death all around him." He described the sad scene. The young man lies in a small, unadorned garret apartment. An indifferent landscape of rooftops dark in the changing light of a setting sun is silhouetted outside the narrow dirt-encrusted windows. Petals of a dying rose ornament the windowsill, their color gray in the fading light. Shreds of torn papers are strewn across the floor. "I think he's taken his own life," he concluded triumphantly.

"Excellent," agreed Braverman. Linda Friedlaender, curator of education, spoke briefly about the painting (The Death of Chatterton, Henry Wallis's rendition of the suicide of the seventeen-year-old poet of the eighteenth century, Thomas Chatterton) and then they moved on to the next painting.

After the cla.s.s, Braverman and I talked over coffee about his innovative teaching technique. "Astute observational skills are usually acquired only after several years of being in medical practice," Dr. Braverman said. "Suddenly, all of the acc.u.mulated experience leads doctors to see things they have not been taught before. They become terrific observers-eventually. With this course, I hope to jump-start these special diagnostic skills right from the beginning." Even though they're looking at paintings, not patients, what they learn here can be applied to medicine, Braverman a.s.serted.

He knows this because he tested it. For two years Braverman had partic.i.p.ants write a description of what they saw in a dozen photographs picturing individuals with visible abnormalities. After the cla.s.s they were given a different set of photographs with the same instructions. Tests were scored based on the description of specific aspects of the photographed abnormalities. Correctly identifying the disease or condition did not affect the score; identifying and describing the visual data was all that counted. Before-and-after test scores were compared, and students improved by an average of 56 percent after spending this afternoon in the museum.

To ensure that this was not simply due to better test-taking skills the second time around, the same two-part test was given to a group of students before and after a lecture on physical examination. These students also improved-you don't get to medical school if you can't learn how to take a test-but not nearly as much.

Even before I heard about this study, I knew from personal experience that these skills could be taught. I was in my third or fourth year of medical school when I suddenly started seeing people with abnormalities everywhere. It was as if I had suddenly been transported into a world populated with the ill, the injured, the aberrant. Of course they were there all along-why hadn't I seen them? Certainly knowledge plays a role. When you learn a new word or name, it suddenly seems to be everywhere.

But it's more than that. We are trained from a very early age to avert our eyes from abnormalities. Children are fascinated by people whose appearance differs from what they've come to expect. And we teach them to ignore that interest. My daughter, Tarpley, once asked a cas.h.i.+er if she was a man or a woman. My husband flushed with shame for the discomfort it caused the homely, hirsute woman. He apologized but recognized that the damage was done. Afterward he explained to our daughter just how much that kind of comment must have hurt the woman. She doesn't ask those kinds of questions anymore. She's learned not to stare.

Medical school forces you to undo that training. You mustn't avert your eyes from abnormality. You need to seek it out. You need to figure it out. And it doesn't just turn off when you leave your office. I frequently (quietly, I hope) point out to my husband pathology that I see on the street-the rolling gait of a man with an above-the-knee prosthesis; the strange gray-toned tan of a man with iron overload syndrome, known as hemochromatosis, the schizophrenic woman's restless lips and mouth, a long-term side effect of many antipsychotics. I now live in a world filled with abnormality. It's fascinating.

How is it possible to see something without noticing it? Dr. Marvin Chun, a professor in the Visual Cognitive Neuroscience Lab at Yale, has devoted his career to trying to answer that question. When I visited him on a warm fall afternoon, he invited me to view a video already quite famous in his field of vision and attention. On a monitor I saw six adults standing in the midst of some strange game, their actions frozen by technology. There appeared to be two teams-one dressed in white, one in black. Each team had a basketball. Strangely, they weren't on a court but in the corridor of an unidentified office building. Closed elevator doors were clearly visible in the background.

My task, once the video started, was to watch the white team and keep track of how many times the ball was pa.s.sed between players-keeping separate counts of when it was pa.s.sed overhead and when it was bounced from person to person. The image started to move and I kept my eyes glued to the white team's basketball as it was pa.s.sed silently among the moving ma.s.s of black and white bodies. I got up to six overhead pa.s.ses and one bounce pa.s.s and I lost track. Determined not to give up, I kept going until the thirty-second video was complete.

Eleven overhead pa.s.ses and two bounce pa.s.ses? I ventured. I told Chun that I got a little confused in the middle. Despite that, I'd done a good job, he told me. I missed only one overhead pa.s.s. Then he asked, "Did you see anything unusual in the video?" Other than the unusual setting for the game, no, I saw nothing at all out of the ordinary.

"Did you see a gorilla in the video?"

A gorilla? No, I had definitely not seen a gorilla.

"I'm going to show you the video again, and this time, no counting, just look at the game." He restarted the video. The white and black teams sprang back into action. Eighteen seconds into the game-around the time I lost my concentration-I saw someone (a woman, I find out later) in a gorilla suit enter the hallway court on the right. She strolled casually to the middle of the frame, beat her chest like a cartoon gorilla from a children's TV show, then calmly exited out of the left side of the picture. Her on-camera business lasted eight seconds and I hadn't seen her at all.

If you had asked me if I thought that I could miss a gorilla-or even a woman in a gorilla suit-strolling through the picture, I would have agreed that it was impossible to overlook such an extraordinary event. And yet I did. So did more than half of those who were given the same task by Daniel J. Simons in his lab at the University of Illinois at Urbana-Champaign. How is that possible?

We have tremendous faith in our ability to see what is in front of our eyes. And yet the world provides us with millions of examples that this is not the case. How often have you been unsuccessful in looking for an object and recruited the help of someone who finds it immediately right in front of you? Or had the embarra.s.sing encounter with a friend who confronts you angrily after you "ignored" his wave the night before while scanning for an open seat in a crowded movie theater? According to the Federal Highway Administration, there are over six million car accidents every year. In many of these crashes, drivers claim that they had looked where they were going and simply hadn't seen the object with which they collided-evidence that people are regularly capable of not seeing what's in front of their eyes, what Sherlock Holmes might have called seeing without noticing.

Researchers call this phenomenon "inattention blindness" because we often fail to notice an object or event simply because we are preoccupied with an attentionally demanding task. Our surprise when experiencing this very common event derives from a fundamental misunderstanding of how the brain works. We think of our eyes like movie cameras, capturing all that is before us as we choose what to focus on at the moment. We might not be paying attention to everything, but we a.s.sume, first, that we will be able to recognize any important event that occurs and, second, that, if necessary, we can always rewind the movie and play it back in the theater of the mind. What we missed the first go-round would be noticed when we remembered the event.

Of course, that's not how it works. When asked about the gorilla in the basketball game, I had no memory of the beast. I searched my memory but I didn't remember him because I didn't see him. My attention was directed elsewhere.

There are qualities that make an object more likely to be seen. Chun tells me that if a naked man or woman had walked into the frame instead of a gorilla, the chance that I would notice the unexpected image would be much higher. Or if the gorilla had been b.l.o.o.d.y, or if he had moved or acted like a gorilla, I would have been more likely to see him. That's because there are some fundamental images that the mind recognizes as important.

So what's going on here? Clearly the information is traveling through the eyes to the retina. And a functional MRI-one that reveals which areas of the brain are working in any given task-shows that the neurological signaling is getting the information to the right part of the brain-so you're definitely seeing it. But before this image can enter your awareness, another part of the brain jumps in to try to decide if this information is worthy of attention. And that judgment all depends on what you're looking for.

As it turns out, most of the time we see what we want to see, what we expect to see. Our ability to see objects or events that are unexpected and dissimilar to those that we are looking for is extremely limited.

To go back to the experiment with the ballplayers and the gorilla, my task was to follow the white-clad players and keep track of how often they threw the ball. Most viewers given that task fail to notice the gorilla. In the same experiment, subjects instructed instead to follow the ballplayers wearing black did see the gorilla. Because the gorilla was also black, it was closer to what they were looking for and so the image was able to get past the brain's gatekeepers and be noticed.

What happens to the visual information that enters the brain but doesn't get the attention of the subject's consciousness? Is it stored there, waiting for a second chance, like a delicious detail in a rerun episode of The Simpsons The Simpsons? Most research suggests not. If the sight doesn't capture one's attention initially, it's gone forever.

Based on research like this, Chun and many other researchers in this area now believe that the expectations of the viewer are the primary shapers of what is seen, and that the unexpected will often be missed. We become better seers when we have better expectations. When you are given a specific task-follow the ball as it's pa.s.sed between members of the white team-you can predict what the expectations might be, and that observers are unlikely to see the pa.s.sing gorilla because it's not in their set of expectations.

What about in situations where you are looking but the task is more complex-the way it is in real life, or in the hospital taking care of patients? If their theory is true, what you see and what you don't see will be shaped by what your experiences have led you to expect. Perhaps Osler was mistaken when he said that more diagnoses were missed because of not seeing than not knowing. Perhaps not knowing is what caused not seeing. Certainly that played a role in the case of Michael Kowalski.

Great Expectations Michael Kowalski was not a man who was easily frightened. And he could count on one hand the number of times he'd cried as an adult. But when Dr. Keith Stoppard entered the room, he heard m.u.f.fled, ragged breathing and, as his eyes adjusted to the dim light, he could see the ma.s.sive man lying huddled in the bed. As unlikely as it seemed, Michael Kowalski, a fifty-two-year-old former college boxer, ex-army man, father of a marine, and all-around tough guy, was crying like a baby.

His wife, Maureen, a redheaded Valkyrie, stood by her husband's bed. Her face was darkened with freckles and lined by fatigue as she tenderly placed a cool, wet cloth on her husband's forehead. His short salt-and-pepper hair and unwaxed handlebar mustache lay plastered to his skin, and his round face was flushed and gleaming with the combination of sweat and tears. "Doc, I'm scared," he said, his raspy voice nearly a whisper. "Can't you tell me what's wrong?" The woman squeezed her husband's hand in silent rea.s.surance.

Stoppard, a third-year resident, didn't know what to say. He was worried. Mr. Kowalski had been in the hospital for three days and Stoppard was no closer to figuring out what was making him so sick than he had been on the day the patient had been admitted.

On that first day, this had seemed like a pretty straightforward admission: a middle-aged outdoorsman sent in by his regular doctor for what looked like Lyme meningitis. Stoppard had spoken to the patient's doctor earlier that day and the case had seemed easy enough-get the lumbar puncture to confirm the diagnosis, then start intravenous antibiotics and watch him get better. But since then nothing had gone as he'd expected, and now he wasn't sure what to think or what to expect.

It was nearly midnight when Stoppard saw Kowalski in the emergency room that first night. The patient told him he'd started feeling sick about a week earlier. At first, he'd figured it was just the flu. He'd felt tired, his body stiff and achy. "I was like an old man-I could barely get around," he told the doctor in his low growl. But after two or three days of feeling lousy, he developed a strange, patterned fever. "You could set your watch by these fevers," he explained. "Around four every afternoon I'd get real cold. I'd be s.h.i.+vering like mad. I'd load on the blankets but nothing I could do warmed me up. Then suddenly I'd be hot as h.e.l.l. Sweaty. It was crazy." His fevers would get up to 103104 every night, his wife, a nurse, added. By four in the morning he'd wake up drenched in sweat and have to change pajamas. By dawn, the fevers would subside-only to have the whole pattern repeat itself that afternoon.

Besides the fever, he told the resident, his neck felt stiff and painful, his head pounded, and a cough had left his throat raw. The joints in his legs, arms, and hands felt tight and sore. It was hard to move, to even get out of bed. Finally he went to see his regular doctor, Dr. Dennis Huebner. After hearing the story and examining him, Huebner figured it was probably just a virus but decided to send off blood to test for Lyme to be safe. He knew the patient was at risk for the disease. Kowalski was an avid outdoorsman, spending as many weekends as he could hunting and fis.h.i.+ng just outside Old Lyme, Connecticut, where the disease was endemic.

The patient had pulled off many ticks over the years, he acknowledged. But, he added, none lately; he'd been too busy to get out to the woods the past few months. Still, Huebner considered Lyme one of the diseases you just don't want to miss. If you get it early you can blast it with a week of antibiotics and it's gone. Miss it and the patient may need months of care. Huebner told the patient it was probably just something going around and he should call if the fevers persisted. He'd let him know if the Lyme test came back positive.

That night the fever came, right on time, and the next day the patient called Huebner, who reluctantly started the patient on doxycycline. "He told me it was probably a virus," the patient reported, "but I felt like I was sick enough to need antibiotics. And he was okay with that. I took the pills, but the fever just kept coming. After a couple of days, the doc says to me: 'Look, you're not getting better. You gotta go to the hospital.'"

The patient considered himself a pretty healthy guy. He'd done his time in the army "in the last war" (Vietnam), and now drove a truck for a local company. He had high blood pressure and his cholesterol was "worse than the doc says it should be," but he took his medicines regularly and had felt well "until this c.r.a.p started up." On exam, in the emergency room, he had a fever of 103 and his heart was beating rapidly. The muscles of his neck were painful to the touch, but he could move his head freely. Just below his jaw he had several enlarged, painful lymph nodes. The joints in his hands and his knees were markedly tender but not red or swollen. Blood work sent by the ER showed an elevated white blood cell count and mildly abnormal liver enzymes.

The fever, painful neck, and pounding headache certainly pointed toward meningitis-a serious, potentially fatal infection. And untreated Lyme disease can progress to the brain, causing meningitis. But it wasn't a perfect fit: as awful as this guy felt, he wasn't as sick as the patients Stoppard had seen in the past with meningitis. With a fever this high, those patients were often too sick to talk. Despite the high fever, this patient was at times irritable, at other times funny, but very much awake and alert. The liver abnormalities weren't typical either. Well, maybe it was a viral meningitis-its course is much less severe than its bacterial counterpart and sometimes could drive up liver enzymes. In any case, they'd need to do a lumbar puncture. That would tell them if this was a meningitis and, if so, what was causing it.

But when Stoppard recommended this procedure, the patient blew up. He was already sick, already in pain, and now these doctors he'd never met before wanted to stick a needle in his back? No way. He would have to talk to his doctor. The patient's wife tried to persuade him but he was adamant: no procedures until he cleared it with his doctor-period. Huebner's partner was on call that night-would he speak with him? The patient sat up in the ER gurney and glared fiercely at the young resident: he would speak to his doctor and no one else. Defeated, Stoppard added high-dose intravenous antibiotics to the doxycycline he was already taking and waited anxiously for the morning and the certainty of the lumbar puncture.

Stoppard reached the doctor the first thing the next morning and he immediately called the patient. He needed this procedure, Huebner told him. They had to know if this was meningitis. The patient agreed, reluctantly, and the uncomfortable test was done. The results came back almost immediately-they were normal. There was no evidence of an infection in his brain. The Lyme test sent by the doctor days before came back that morning as well-it was also normal. He didn't have meningitis; he didn't have Lyme disease. They were back at square one.

One technique doctors use to make a diagnosis is to group symptoms, physical exam findings, and lab data and identify which are the most important and use them to try to find a recognizable pattern. This patient had many symptoms, but which were most important? Stoppard felt that the fever was key-it was extremely high and had this very distinct pattern. He wasn't so sure about the rest of them. But the fever, in combination with the enlarged lymph nodes and the elevated white blood cell count, clearly pointed to an infection. So where was this infection? What had they missed? Kowalski was on two strong antibiotics-but were they the right ones? At this point the team had no way of knowing. All they could do was keep looking.

In the emergency room they had drawn blood to try to grow the infecting bacteria, but so far they had shown nothing. They would need to be repeated whenever the patient spiked a fever-the time when the infectious agent was most likely to be found. A chest X-ray also done in the ER was normal but Stoppard ordered a second one-Kowalski had a fever, an elevated white blood cell count, and a cough-sometimes pneumonia can take a while to show up on an X-ray. He ordered tests to look for an infection in the patient's kidneys, his liver, his gallbladder. They revealed nothing.

On the other hand, Kowalski seemed to be getting better: he still had fevers every night, but they were 100101-much lower than they had been at home or in the ER. And during the day, when the medical team made their rounds, Kowalski looked tired but said he felt okay-no headache, no body aches. Whatever he had, Stoppard was relieved to see that it was responding to the antibiotics.

Or so he'd thought until this afternoon, when the patient's temperature spiked to 104, and the doctor had found him weeping in the darkened room. "Tell me I'm not going to die," he pleaded with the young doctor. "Please help me." He covered his head with the sheet and his shoulders heaved like a child's.

In that darkened hospital room, confronted with the patient weeping beneath his sheets, his wife white-faced with worry, Stoppard was overwhelmed. What if he couldn't figure this out? The day before, Dr. Huebner had suggested that they send the patient to the big university hospital thirty miles away, but the resident had disagreed. He thought they'd find the answer. But right at that moment he was worried he had been wrong. To see this tough guy reduced to tears seemed a reproach of his skills, of his doctoring, of his judgment in keeping him here at this small community hospital far from the fellows and subspecialists at Yale.

Stoppard, now a nephrology fellow at the University of Pennsylvania, remembers that moment well. "I didn't think he was going to die. But I couldn't promise that. And I couldn't lie to him, of course. But I wanted him to know that we were working as hard as we could to figure it out. And I felt pretty sure we would."

He outlined the plan that he'd worked out with the infectious disease specialist brought onto the case. Infection was still the most likely cause of the fever, he told the patient and his wife; they just had to find it. A CT scan of the abdomen and pelvis and an MRI of the brain would show if there were infections hidden there. An ultrasound of his heart would help them look for unusual infections in the valves-infections that can take weeks to grow in cultures. None of these infections is common, Stoppard explained, but neither was a fever that didn't respond to a week of antibiotics.

And, while infection is the most common cause of fever, he continued, it's not the only one, by any means. Blood clots can produce fevers; so can some cancers. Finally, diseases of the connective tissues of the body-the joints, blood vessels, and muscles-can cause fevers and body aches. They would run some specialized blood tests to look for these diseases. Something was sure to show up, Stoppard a.s.sured his patient.

The cool air of the hallway hit his face when Stoppard finally left the room, and he realized he was almost as sweaty as the patient. He wrote the orders he'd told them about and waited for something to turn up.

But nothing did. The tests were done over the next two days as the fever kept its nightly schedule. The scans of the brain and body were normal-no clots, no infections, no other enlarged lymph nodes. The ultrasound of the heart was unremarkable. The blood cultures remained negative. Tests of his liver, which had been abnormal on his admission, remained abnormal, but hadn't worsened. One test stood out: the sedimentation rate. This is a very old test, and looks at how fast red blood cells sink to the bottom of a tiny capillary tube-a reflection of the amount of inflammation in the body. In this patient it was dramatically elevated. However, the test isn't very specific about what is causing the inflammation-it's one of the reasons it's not used very often. It could be an infection but it could also be cancer or one of the diseases of the connective tissues. They hadn't found any evidence of a cancer, and blood tests for lupus and rheumatoid arthritis-the two most common connective tissue disorders-were normal.

The resident was uncertain what to do next. Huebner once again brought up the possibility of transferring the patient to Yale. Kowalski had been in the hospital for almost a week, and they were still in the dark. Stoppard discussed the case with his colleagues and older, wiser physicians. Most of the tests they suggested had already been done. Then he spoke with Dr. Alfred Berger. A youthful man with a broad Irish face and easy laugh, he was new to the faculty but had already become a favorite with the residents. After Stoppard went through the complicated story, Berger asked only one question: "Does the patient have a rash?" No, they hadn't seen one, Stoppard answered. But why had he asked that? Berger smiled. It's all about patterns, he told the resident. The triad of persistent fever, joint pain, and a rash is the cla.s.sic presentation of adult onset Still's disease, an unusual and poorly understood disease of the connective tissue.

Still's was first described in children, and in pediatrics it's now known as systemic juvenile rheumatoid arthritis. Young adults are the usual targets. There is no way to test for it. It is a diagnosis of exclusion-in other words, before you diagnose Still's you have to rule out everything else it could be. "If that's what it is, it's a great diagnosis. It's rare and it's cool," he exclaimed enthusiastically. "Plus you've definitely got to know this one for the boards" (the tests you have to take in order to get licensed), the young teacher added as an afterthought.

In Still's, a rash is usually seen on the trunk and arms and is often only visible when the patient is febrile. Neither the patient nor his wife had said anything about a rash. Stoppard's team was on call that night so they would be able to look for the rash once the fever appeared.

They got that chance in just a couple of hours. Late that afternoon Stoppard got a call from the medical student on the team. "The rash, the rash-he's got it!" she shouted excitedly. The medical student had told the patient and his wife to be on the lookout for a rash that afternoon. When she'd come to the room to check on him, Kowalski gave her a big smile, then said gruffly, "Hey, Doc, wanna see a nice a.s.s?" He'd turned and dropped his pants to show a rash across his backside.

The resident hurried to the room. The rash was made up of painless, slightly raised, irregular patches of an unusual shade of pink; in textbooks, it's often described as salmon-colored. The patient was started on prednisone, the usual treatment for Still's, and his response was a near instantaneous confirmation of the diagnosis. When he was given the first dose of medicine, his fever was 102.7 and the rash glowed. One hour later, both had completely disappeared.

The next morning the patient was up and dressed when Stoppard brought the team on rounds. His hair was combed, his mustache was waxed, and the car keys were on the bedside table. He was, he told them as soon as they walked in the door, ready to go home now. The fatigue, the muscle pains, the sore throat were completely gone. They wanted to keep him one more day-just to be sure-but the patient wouldn't hear of it. "Aren't you sick of me yet? Because I sure as h.e.l.l am sick of you guys." Reluctantly, he agreed to stay until late afternoon, when the fever usually started, and when it didn't arrive he and his wife went home.

Why wasn't the rash obvious until that evening? Was that the first day he'd had it? In reviewing the chart, I saw that the attending had noted a rash several days earlier. At the time Huebner had attributed it to a simple skin infection and no one else had commented on it. And when asked, none of the team members recalled seeing the rash at all. It was outside their set of expectations. They simply didn't see it. Knowing what to look for makes it far more likely that you will find it.

The patient took prednisone for six months. He followed up with a rheumatologist who was familiar with the disease. She warned him that the disease recurs. It's been a couple of years and the disease reappears occasionally. "I like the house cold when I sleep-always have-but when I wake up and my pillow is sweaty I know the Still's is on the warpath," says Kowalski. "But I don't let it slow me down." He takes a week's worth of prednisone and again the symptoms disappear as quickly and mysteriously as they had that first time. He has to take it easy for a day or two, but knowing the diagnosis, understanding the course of the disease and what to expect, allows him to tolerate the symptoms with equanimity. The fear, the not knowing that made the fever so intolerable in the hospital, is gone. What's left is just the discomfort. "I never even heard of that disease before I got it," Kowalski told me, then added: "To tell you the truth, I don't think my doctor had either."

It's a truism in medicine that difficult diagnoses are most likely to be made by the most or least experienced doctors. The most senior have a broad set of experiences that allows them to consider many different possibilities. Because they are open to a wide variety of observations, fewer pertinent findings are filtered out. What about the novice? They have no expectations and there is some evidence that this lack of preset experience-based biases allows them to look more carefully at the entire picture.

Dr. Marvin Chun points to an experiment conducted by his lab a couple of years ago. Partic.i.p.ants in the study were shown two pictures; they were identical except that in one picture, a single element had been changed. The partic.i.p.ants were shown one of two pairs of pictures. In one set the object that had been changed was central to the image. This picture showed a large room in which three people dressed in laboratory clothing are standing before a background of complicated machinery. In the first image, two support arms located just behind the people are painted bright yellow; in the next image that's changed-they're orange.

The second couplet featured a group of hot air balloons in the shape of farm animals. Well above them at the top of the photograph hovers a large hot air balloon with a clown's face painted on the side. A large, vibrant pink dot is visible on the clown's cheek. In the distance a second hot air balloon can be seen. A bright pink scarf flutters from the surface of the balloon. In the second image of that series, the hot pink spot and scarf disappear.

The researchers' hypothesis was that most viewers would notice the changes in the image of the laboratory immediately because the object that changes color was located right behind the people at the center of the image. The change in the second set of pictures, they thought, would be harder to see because the change was peripheral. They were right. Subjects needed much more time to identify the peripheral change. Experience has taught us that important information in a photograph is princ.i.p.ally found in the center, so that's where we look first.

The researchers took the experiment one step further. What if the picture defied our usual expectations? Would that change how quickly we were able to find the difference in the two images? To answer this question researchers showed another group of subjects the same pictures with one difference: this time the pictures were upside-down. In this experiment the subjects would have no experience in the new inverted world, no experience-based biases, and in this setting, Chun hypothesized, the change that was peripheral to the action would be just as obvious to the viewer as the change that was central to the content of the picture. In fact, that was the case. With the upside-down pictures it took about the same amount of time to identify either of the changes.

So the novice has no expectations, the expert has many expectations. Both states facilitate close observation. Where does that leave doctors (like me) in the middle-after our neophyte days but while still on the road to expertise?

This is an area of great interest to Chun and other researchers, and it's a hot topic in error reduction research. "I don't know that we've found much that's useful yet," admits Chun. "I think the most important thing we've learned is that the control of this is primarily in the brain of the viewer." He believes that drivers-and even doctors-need to be taught to direct their attention more broadly. When we focus too narrowly we will certainly miss something. "It's all there for the taking. We just have to learn how to see it."

After a morning spent with patients at his office in Montefiore, Dr. Stanley Wainapel settled back in his chair and loosened his tie. "People often ask me how I'm able to do the physical exam without my vision. Actually, for me, that's the easiest part. If you go to hear a heart murmur, what's the first thing you do? You close your eyes. You don't want anything else to interfere with your ability to hear. And if you thought you just felt a liver edge you close your eyes to feel it." I found myself nodding in agreement-once again forgetting he couldn't see me.

He paused, thoughtfully adjusting his gla.s.ses. One of the lenses suddenly burst out of the frame. I jumped up and offered to help him find it but before I'd even finished my sentence he'd found the lens and put lens and gla.s.ses into his breast pocket.

"My patients learn pretty quickly that I don't see much, but here's the strange part." He leaned forward and looked me squarely in the face. "They still bring in their MRIs; they still want me to look at their X-rays. Why do they do that? They know I can't see them." I considered this paradox-why bring pictures to a man you know is blind? "They don't want me to see them. They don't care about that," Wainapel explains. "They want me to help them see what's going on. They want me to help them understand. That's really my job. Same as any doctor."

CHAPTER SIX.

The Healing Touch.

The healing power of touch has long been part of Western culture. The prophet Elisha was said to have brought the dead to life with a simple touch. Jesus laid his hands on a leper and he was cured. His disciples were also granted this power to heal. Christian saints often performed miracles of healing by touch. And since Western monarchies were granted their power by divine right, many kings claimed this power as well. Until the eighteenth century, a single touch from the monarchs of England, Germany, or France was thought to be able to cure scrofula, a chronic infection of the skin-a therapy just as effective but far less painful than other available cures.

The use of the touch in medical diagnosis has had a spottier history. Hippocrates relished and eagerly employed the data provided by the senses. He wrote, "It is the business of the physician to know in the first place things ... most important, most easily known, which are to be perceived by the sight, touch, hearing, the nose and the tongue." And texture, temperature, and contour were often provided in the description of patients and their diseases in his works. That approach to medicine was followed only intermittently until the Renaissance, and not until the Enlightenment was it fully re-embraced by physicians who sought to use the concrete data provided by the body to make medicine a true science in an age of scientific achievement. Ultimately it is the same quest for the precision and accuracy of a true science that has practically destroyed the physical exam. The doctor's touch seems primitive and uncertain when compared to what we can find out through the marvels of technology.

That's the perception, but is it true? There's mounting evidence that the hand of the doctor provides information that can't be gained from the cool eye cast by its technological replacements. Take, for example, the issue of screening for breast cancer. What can an exam pick up that can't be discerned by a machine? The machines in question-mammography, ultrasound, magnetic imaging-play a powerful role in the detection of breast cancers. But so does touch. Most breast cancers-well over 70 percent-are detected by women who feel a lump in their breast. Mammograms account for another 20 percent-clearly an important tool in the detection of this common disease. Yet studies suggest that the breast exams performed by a physician account for another 5 percent of breast cancers detected-given the number of breast cancers in this country, that comes out to ten thousand cancers picked up on exam every year, making touch a surprisingly powerful tool as well.

The a.s.sessment of abdominal pain-one of the most common and problematic emergency room complaints-is another example where the physical exam may work better than even the best technology. Every year over three million patients come to an ER somewhere in the country complaining of pain in the belly. A quarter million of those patients end up in an operating room, having their appendix taken out. Most of the time, it's a good call-the surgeon will remove a diseased organ. But on average 20 percent of those who take that trip to the OR will have what the surgeons call a negative appendix-that is, an appendix that is completely normal. For women the rate of unnecessary appendectomies can be twice that, up to 45 percent in some studies. And these statistics have been unchanged for decades.

For many years this was considered an acceptable rate. Overall it was clear that early intervention was the safest way to deal with this potentially fatal disease and that the benefit of rus.h.i.+ng patients with suspected appendicitis to the OR outweighed the potential harm of the unnecessary surgery.

Twenty years ago, Alfredo Alvarado, an emergency room physician in Florida, developed a method of separating patients who may have appendicitis from those whose pain probably comes from something else. Using the Alvarado score, doctors can then identify those with likely appendicitis, who can be taken directly to the operating room, from those with possible appendicitis, who should be watched. Alvarado considered three components in developing his score: three symptoms-nausea, anorexia, and abdominal pain that migrates to the right lower quadrant; three physical exam findings-fever, tenderness over the right lower quadrant, and the presence of what is known as "rebound tenderness," where the sudden release of pressure on the abdomen is more painful than the pressure itself; and a single test showing the number and type of white cells in the blood. Each factor present carries one or two points for a maximum score of 10. Those patients with scores of 7 or more probably have appendicitis and can go straight to the operating room. No further testing is needed. Those with scores of 4 and under probably don't have appendicitis at all and should be evaluated for other causes of abdominal pain. In studies, this system has been shown to reduce the rate of unnecessary appendectomies to less than 5 percent.

The score is useful for those at the extremes-patients with a score of 4 or less and those with a score of 7 or more. But what do you do with those in the middle? Those who have signs and symptoms that suggest appendicitis but whose scores don't put them in the definite category? That's when technology comes in handy. CT scans can correctly distinguish between those who need surgery and those who don't almost 100 percent of the time. Using both the Alvarado score and CT scans in cases when the diagnosis is unclear has been shown to be very effective and reduces the rate of negative appendectomies to nearly 1 percent.

If the CT scan is so good at showing who needs to go to surgery, why not use it all the time? Why not take all patients with possible appendicitis pain straight to the CT scanner? In fact, that is what has happened. CT scans are routinely used to evaluate virtually all patients with abdominal pain. But a recent study suggests that this may not be the best strategy. Herbert Chen and others at the University of Wisconsin looked at the records of 411 patients diagnosed with appendicitis. Two thirds had a CT scan before going to the OR. In the other third, the decision to take the patient to surgery was made based on the history, physical exam, and laboratory findings. What they found was that those who had the CT scan had a much higher rate of complications than those who went straight to the operating room. And the rate of perforations was twice as high in those who had the test. Why? The authors speculate that it was the slower time to the OR. The third that didn't have the CT scan went to the OR within the first five hours of their arrival in the ER, while those who got the CT scan had to wait almost twice as long for surgery.

Despite the research, this is still a remarkably hard sell. In my community hospital Dr. Jeff Sedlack is in charge of teaching general surgery residents. For years he lamented the fact that his trainees took virtually all patients with abdominal pain straight to the CT scanner, skipping the exam completely. He got tired of complaining, so eventually he decided to try something new. He set up a compet.i.tion. Surgical residents would get one point for every patient with a suspected appendicitis that they examined and calculated an Alvarado score for. Patients who had a CT scan before being seen by the resident were disqualified. The trainee with the most points would win a small prize.

The residents took the compet.i.tion seriously. One second-year resident got a bonus when he was able to persuade the ER doctor that the patient had a clear diagnosis of appendicitis without the expensive test. Instead of taking the patient to the CT scanner, the surgeons took him to the OR, where a pus-filled appendix was quickly removed. The compet.i.tion was a tremendous success. The rate of CT scans went down, complications went down, and as an additional benefit, says Sedlack, the residents' exam skills improved dramatically. The next year the compet.i.tion was brought back-by popular demand.

The presence of abdominal pain and tenderness can be extremely useful in making a diagnosis. Sometimes the inverse is also true: seeing a person in pain when that pain cannot be elicited by touching can also be informative.

The Dog That Didn't Bark It was July 1, my first month admitting patients as a resident. As an intern I had a resident at my side supervising my every move. Now I was the night float resident-taking admissions after the on-call team had reached their quota of daily admissions. My presence allowed them at least the possibility of sleep. It was exhilarating and a little scary being on my own this way. I knew there was always someone with more experience around-should I need them. Still, I was nervous.

I got my first call from the ER at around two a.m. A woman had been brought in from a nursing home by ambulance. Over the clatter of a busy ER the doctor spoke in the coa.r.s.e, cryptic patois of medicine.

"We got a sick, demented eighty-seven-year-old female, name of Carlotta Davis. Sent from an ECF [extended care facility, or nursing home] with acute change in mental status. She's got a history of hypertension, CAD [heart disease], and a three-vessel CABG [heart bypa.s.s surgery] twenty years ago. She was out of it when they came to tuck her in, so they sent her over. Nothing on exam except a borderline low BP [blood pressure]. Labs showed a white count of sixteen [that's high] and a dirty [infected] urine. We sent her up on IV Cipro [an antibiotic] and a liter of saline [for the low blood pressure]. We're getting slammed down here so I gotta go." And the line was quiet again.

Here's rule one you learn as a house officer-never just accept the emergency room's diagnosis. It's their job to determine if a patient is sick enough to be hospitalized. They like to give a patient a diagnosis because the paperwork asks for one and they often have a good idea of the problem. But they don't have the time or the resources to determine the diagnosis for any but the most obvious cases. Rule two: if the ER says someone is sick, go see them right away. They know what sick is.

"Mrs. Davis," I said softly as I entered the darkened room. I heard a long, deep moan. I turned up the light to reveal a tiny woman engulfed by pillows and blankets, moving restlessly in the bed. I crossed the room to the bedside and introduced myself. The patient lay with her eyes squeezed shut, s.h.i.+fting from side to side as if looking for a comfortable position. Her legs whispered to me as they slid back and forth continuously across the rough white sheets.

"Carlotta?" I tried again. No answer. I touched the thin skin of her wrists. She was warm and her pulse rapid but barely palpable. Her blood pressure was low-same as it had been in the ER.

"Can you open your eyes, Mrs. Davis?" Again she didn't answer. If anything, she squeezed her lids even tighter, as if opening them would make the unbearable even more so. Just the moan and the near constant motion on the bed. Was it pain that was causing this movement, or delirium? Could be either. I listened to her heart, then slid my stethoscope beneath her bony back to listen to her lungs. I pulled back the covers and hospital gown to reveal an unexpectedly rounded stomach. Why wasn't her stomach as thin and as flat as the rest of her tiny slender frame? I rested my stethoscope on the mound lightly. Silence. I forced myself to listen for a full minute. Normally the gut is always making noise. Not this gut.

The emergency room doctors found that she had a urinary tract infection and were concerned it had spread to her blood. They'd already started her on intravenous antibiotics. It was a common cause for hospitalization among the elderly and frail. And sometimes a severe illness can cause the gastrointestinal tract to shut down temporarily. Was that what was going on or was there something else? I carefully examined her abdomen. I felt no ma.s.ses-no tenderness, either. She never flinched, never reacted to even the deepest touch. She was clearly in pain, but what I was doing didn't seem to affect it.

I pressed my fingers firmly down over her bladder. She had an infection here-was this the source of her pain? No reaction. I squeezed and thumped her flanks where the kidneys were hidden. Was the infection there too? No change in her restless movement. I finished my exam, carefully looking for any other potential sources of discomfort. No bedsores; no swollen, painful joints; no redness anywhere. Nothing that would account for the terrible restlessness and the haunting moans that escaped her lips every few minutes.

I had cared for many patients with urosepsis but none of them had looked like this. I ordered a small dose of morphine. We're taught not to treat pain until we know where it's coming from but I wanted to see if it gave her relief-if her distress was from some unfound source of pain. The morphine stopped the restless movement, but the moaning continued. I still didn't know whether it was pain or delirium.

According to the aides at the nursing home, the patient had complained of abdominal pain earlier that day. She may have had an infection in her urine but she didn't seem to have any pain in her bladder or kidney. What else could it be? In this age group cancer was likely. Did she have a colon cancer that was obstructing her bowels? Her stomach was soft, easy to examine, and I hadn't felt any of the firm linear ma.s.ses that suggest stool trapped in the colon. A gallstone could cause fever and an elevated white blood cell count, but I would expect that to cause pain when I palpated her right side. There was none. Same with appendicitis, kidney stones, pancreat.i.tis, a perforated viscus-all caused tremendous pain but those pains were usually localizable. I couldn't think of anything that could cause a pain this intense that couldn't be made worse with pressing.

And her blood pressure was still too low. I ordered another liter of normal saline. In the very ill, inadequate fluid in the bloodstream due to not eating or drinking or to excessive sweating can cause blood pressure to drop. Replacing that fluid will often restore a normal blood pressure. If her blood pressure didn't come up with this fluid, she'd have to go to the intensive care unit to get medicines to restore it.

I sought out Dr. Cynthia Brown, the third-year resident on call in the ICU. Cynthia was a lively, down-to-earth redhead who had been a physical therapist before going to medical school. Older than most of the residents, and like me, a southerner, she and I had bonded almost instantly. I found her at the nurses' station drinking hot tea and reviewing charts. She hadn't been to bed yet but looked remarkably awake and cheerful. She greeted me enthusiastically. I briefly laid out the case, running through my differential and my misgivings.

"There's something more going on but I can't figure out what. And I'm not even sure where to start. Do I send her down for a CT scan? And what of? If I don't get her blood pressure up, she's coming to you anyway."

Cynthia thought for a moment.

"She has heart disease?" she asked.