Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Where Have All the Good Cases Gone? Peter H. Berczeller To cite this article: Peter H. Berczeller (1992) Where Have All the Good Cases Gone?, Hospital Practice, 27:11, 28-31, DOI: 10.1080/21548331.1992.11705519 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705519
Published online: 17 May 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Saskatchewan Library]
Date: 11 June 2016, At: 16:23
Peterli.Berczeller------------------------~
Where Have All the Good Cases Gone?
Downloaded by [University of Saskatchewan Library] at 16:23 11 June 2016
For an internist, that now fossilized "diagnostician" of yesteryear, a good case now and then is as essential as a bone for a particularly disconsolate dog. Whereas abstruse diagnostic and therapeutic puzzles used to be presented to us as if on an assembly line, we now jump on the occasional unsolved mystery with a hunger that betrays our intellectual deprivation. Experienced clinicians have learned, after overdiagnosing unusual entities when they were younger, that most of what they see falls into the category of mainstream disease. Diabetes, respiratory ailments, and arteriosclerosis, for example, take up much of our time, as well they might in view oftheir prevalence in our patient population. Unusual illnesses are by definition infrequent. Yet what has always distinguished internists from other physicians is their willingness or, even better, their sense of obligationalways to consider the unusual masquerading behind the prosaic presentation of a frequently seen disease. In order to be able to accomplish this, we must first of all be aware of the rare pathologic entity. We must also hear about it or read about it now and then so that it does not evaporate from our consciousness. And to have been up close to the rare beast. to have smelled it and looked into its eyes, makes it very unlikely that we will ever forget it. But is an unusual case a good case? And are there good cases and very good ones? The distinctions reflect an interesting paradox about the nature of the medical personality. To begin with, it must be understood that not every unusual entity that is diagnosed is necessarily a good case. The determining factor is the way in which the physician arrives at the diagnosis. If. for example, a diagnosis of medullary carcinoma of the thyroid is made in a person with a known family history of this tumor, this would only qualify as an interesting event. But if the same diagnosis is made in the absence of a family history and on the basis of a thyroid Dr. Berczeller is Professor of Clinical Medicine, New York University School of Medicine.
28
Hospital Practice November 15. 1992
mass and symptoms suggestive of pheochromocytoma (leading one to suspect one of the multiple endocrine neoplasia syndromes), then certainly this would qualify as a good case. In other words, knowledge and ingenuity were required to put together several disparate facts. That sudden flash of recognition that many of us have experienced in our medical lifetimes, and that is so memorable many years later, defmes the "goodness" of the case. So what is the difference between a good and a very good case? The determining factor is the vanity that we physicians all possess in varying degrees. And the paradox is that it's a good thing we do possess it, because if it is present at therapeutic levels. it can be a stimulus to good patient care. Concern about self-image can bring out a kind of competitiveness with oneself and with others. The doctor's search for excellence, even if it exists for the salving of his ego. benefits the patient. Vanity, because of its deepseated nature. is a very reliable quality in this context. It beats, by far, other, more fluctuating stimuli to professional competence, such as political ambition or vague notions of altruism. Thus, a good case is simply one that was handled adroitly by someone else, whereas a very good case is the same thing handled by me. Then what is a great case? I suggest it is one that fulfllls all the medical and personal criteria of a very good case but that is refracted through the prism of time. In this way, the customary sharp edges and blind alleys of yesterday's diagnostic process are modulated by memory while the acuity of the diagnostician is heightened by hindsight. This brings us back our lament over the increasing rarity of unforgettable clinical events. In the 1960s and 1970s, roughly the first half of my years in practice, I had (or so it appears to me now) an unusual number of very good cases. I am tempted to call some of them great, but I must admit that several were actually only good, since a friendly consultant or resident was needed to steer me right. During that time I saw a Wilson's disease as (continues)
Downloaded by [University of Saskatchewan Library] at 16:23 11 June 2016
Peter H. Berczeller
rconttnuedJ----------------,
well as agastric carcinoid. What's more, I had a patient with Gaucher's disease and another with nail-patella syndrome. Acute intermittent porphyria, Wegener's granulomatosis, systemic mastocytosis, and a glucagonoma syndrome round out this particular list. In contrast. during the past 10 or 15 years, the number of cases of this caliber has diminished significantly for me. Reassured by my colleagues that they were noting the same trend, I have sought possible explanations. First of all, are internists seeing fewer good cases because they are being shunted elsewhere? In other words. are medical subspecialists or other specialists seeing them? Certainly, dermatologists, for example. can work up a flushing disorder nowadays and then, depending on the specific etiology, treat or refer to the appropriate subspecialist or surgeon. Likewise, a patient with diarrhea and arthritis may be referred directly to a rheumatologist or gastroenterologist who will diagnose Whipple's disease without the historically correlative function of the general internist. Despite all this, I suspect that the explanation lies elsewhere. The sophistication of internal medicine (general and subspeciality alike) has spread far beyond its borders. Other specialties can now thoroughly investigate their "own" entities-that is, those conditions in which there is an overlap of their fields and internal medicine. A neurologist can perfectly well work up a patient with severe temporal headache. fever, and diffuse body aches. Similarly. it is within a dermatologist's repertoire to order a glucagon level on a patient with a diffuse crusting eruption, oral manifestations, and wasting. In the past. patients like those were sent to internists. Today, largely because we have diffused our knowledge to other fields so well, we are less necessary for the diagnostic process. But the most important reason for what is evidently not just a perceived but an actual diminution of the intellectual challenge tendered to internists by clinical puzzles is the increasing automation of diagnosis. By this I do not allude
to that bugaboo (at least for some of us) of computer-generated diagnosis but rather to multiphasic laboratory testing and screening by means of technically elaborate radiologic procedures such as MRI, CT. and ultrasonography. For example, hyperparathyroidism, which used to be exotic, was considered in cases of unremitting ulcer symptoms or unusual psychiatric manifestations. Usually. after much discussion, a serum calcium was drawn, and there was much excitement if it turned out to be elevated. Now, with multiphasic laboratory screening. hyperparathyroidism has been found to be much more prevalent than before. Many patients are asymptomatic, and there is no clear-cut answer as to what to do with them. The diagnosis is, in a sense, made for physicians before they or the patients are ready for it. But what is most important in the context of this essay is that the criteria for a good case are not met, and we doctors are the poorer for it. Similarly, I am reminded of my one and only patient with an atrial myxoma. I wish I could claim that I made the "pickup" on the basis of, let us say, the appearance of a murmur compatible with mitral stenosis but in the absence of atrial fibrillation in an elderly patient or the auscultation of a "tumor plop." The truth is, though. that the myxoma was seen incidentally on an echocardiogram that was routinely performed for a possible transient ischemic attack. Not a "good" case. I do not mean to be unreasonably nostalgic. Patients and their illnesses are not here just to entertain us doctors. Our real mission is, of course, to find pathology and to do our best to counteract it. But I worry about the nimbleness of our minds. If we were brought up in medicine expecting not to be spoon-fed but to correlate knowledge with imagination, and if diagnosis is made too easy for us, where will we get our essential intellectual exercise? Quite possibly, our much-prized ingenuity and originality of thought will turn out to be victims of medical progress. It would indeed be cruel to gain and lose so much at the same time.
Hospital Practice November 15. 1992
31
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Where Have All the Good Cases Gone? Peter H. Berczeller To cite this article: Peter H. Berczeller (1992) Where Have All the Good Cases Gone?, Hospital Practice, 27:11, 28-31, DOI: 10.1080/21548331.1992.11705519 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705519
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Saskatchewan Library]
Date: 11 June 2016, At: 16:23
Peterli.Berczeller------------------------~
Where Have All the Good Cases Gone?
Downloaded by [University of Saskatchewan Library] at 16:23 11 June 2016
For an internist, that now fossilized "diagnostician" of yesteryear, a good case now and then is as essential as a bone for a particularly disconsolate dog. Whereas abstruse diagnostic and therapeutic puzzles used to be presented to us as if on an assembly line, we now jump on the occasional unsolved mystery with a hunger that betrays our intellectual deprivation. Experienced clinicians have learned, after overdiagnosing unusual entities when they were younger, that most of what they see falls into the category of mainstream disease. Diabetes, respiratory ailments, and arteriosclerosis, for example, take up much of our time, as well they might in view oftheir prevalence in our patient population. Unusual illnesses are by definition infrequent. Yet what has always distinguished internists from other physicians is their willingness or, even better, their sense of obligationalways to consider the unusual masquerading behind the prosaic presentation of a frequently seen disease. In order to be able to accomplish this, we must first of all be aware of the rare pathologic entity. We must also hear about it or read about it now and then so that it does not evaporate from our consciousness. And to have been up close to the rare beast. to have smelled it and looked into its eyes, makes it very unlikely that we will ever forget it. But is an unusual case a good case? And are there good cases and very good ones? The distinctions reflect an interesting paradox about the nature of the medical personality. To begin with, it must be understood that not every unusual entity that is diagnosed is necessarily a good case. The determining factor is the way in which the physician arrives at the diagnosis. If. for example, a diagnosis of medullary carcinoma of the thyroid is made in a person with a known family history of this tumor, this would only qualify as an interesting event. But if the same diagnosis is made in the absence of a family history and on the basis of a thyroid Dr. Berczeller is Professor of Clinical Medicine, New York University School of Medicine.
28
Hospital Practice November 15. 1992
mass and symptoms suggestive of pheochromocytoma (leading one to suspect one of the multiple endocrine neoplasia syndromes), then certainly this would qualify as a good case. In other words, knowledge and ingenuity were required to put together several disparate facts. That sudden flash of recognition that many of us have experienced in our medical lifetimes, and that is so memorable many years later, defmes the "goodness" of the case. So what is the difference between a good and a very good case? The determining factor is the vanity that we physicians all possess in varying degrees. And the paradox is that it's a good thing we do possess it, because if it is present at therapeutic levels. it can be a stimulus to good patient care. Concern about self-image can bring out a kind of competitiveness with oneself and with others. The doctor's search for excellence, even if it exists for the salving of his ego. benefits the patient. Vanity, because of its deepseated nature. is a very reliable quality in this context. It beats, by far, other, more fluctuating stimuli to professional competence, such as political ambition or vague notions of altruism. Thus, a good case is simply one that was handled adroitly by someone else, whereas a very good case is the same thing handled by me. Then what is a great case? I suggest it is one that fulfllls all the medical and personal criteria of a very good case but that is refracted through the prism of time. In this way, the customary sharp edges and blind alleys of yesterday's diagnostic process are modulated by memory while the acuity of the diagnostician is heightened by hindsight. This brings us back our lament over the increasing rarity of unforgettable clinical events. In the 1960s and 1970s, roughly the first half of my years in practice, I had (or so it appears to me now) an unusual number of very good cases. I am tempted to call some of them great, but I must admit that several were actually only good, since a friendly consultant or resident was needed to steer me right. During that time I saw a Wilson's disease as (continues)
Downloaded by [University of Saskatchewan Library] at 16:23 11 June 2016
Peter H. Berczeller
rconttnuedJ----------------,
well as agastric carcinoid. What's more, I had a patient with Gaucher's disease and another with nail-patella syndrome. Acute intermittent porphyria, Wegener's granulomatosis, systemic mastocytosis, and a glucagonoma syndrome round out this particular list. In contrast. during the past 10 or 15 years, the number of cases of this caliber has diminished significantly for me. Reassured by my colleagues that they were noting the same trend, I have sought possible explanations. First of all, are internists seeing fewer good cases because they are being shunted elsewhere? In other words. are medical subspecialists or other specialists seeing them? Certainly, dermatologists, for example. can work up a flushing disorder nowadays and then, depending on the specific etiology, treat or refer to the appropriate subspecialist or surgeon. Likewise, a patient with diarrhea and arthritis may be referred directly to a rheumatologist or gastroenterologist who will diagnose Whipple's disease without the historically correlative function of the general internist. Despite all this, I suspect that the explanation lies elsewhere. The sophistication of internal medicine (general and subspeciality alike) has spread far beyond its borders. Other specialties can now thoroughly investigate their "own" entities-that is, those conditions in which there is an overlap of their fields and internal medicine. A neurologist can perfectly well work up a patient with severe temporal headache. fever, and diffuse body aches. Similarly. it is within a dermatologist's repertoire to order a glucagon level on a patient with a diffuse crusting eruption, oral manifestations, and wasting. In the past. patients like those were sent to internists. Today, largely because we have diffused our knowledge to other fields so well, we are less necessary for the diagnostic process. But the most important reason for what is evidently not just a perceived but an actual diminution of the intellectual challenge tendered to internists by clinical puzzles is the increasing automation of diagnosis. By this I do not allude
to that bugaboo (at least for some of us) of computer-generated diagnosis but rather to multiphasic laboratory testing and screening by means of technically elaborate radiologic procedures such as MRI, CT. and ultrasonography. For example, hyperparathyroidism, which used to be exotic, was considered in cases of unremitting ulcer symptoms or unusual psychiatric manifestations. Usually. after much discussion, a serum calcium was drawn, and there was much excitement if it turned out to be elevated. Now, with multiphasic laboratory screening. hyperparathyroidism has been found to be much more prevalent than before. Many patients are asymptomatic, and there is no clear-cut answer as to what to do with them. The diagnosis is, in a sense, made for physicians before they or the patients are ready for it. But what is most important in the context of this essay is that the criteria for a good case are not met, and we doctors are the poorer for it. Similarly, I am reminded of my one and only patient with an atrial myxoma. I wish I could claim that I made the "pickup" on the basis of, let us say, the appearance of a murmur compatible with mitral stenosis but in the absence of atrial fibrillation in an elderly patient or the auscultation of a "tumor plop." The truth is, though. that the myxoma was seen incidentally on an echocardiogram that was routinely performed for a possible transient ischemic attack. Not a "good" case. I do not mean to be unreasonably nostalgic. Patients and their illnesses are not here just to entertain us doctors. Our real mission is, of course, to find pathology and to do our best to counteract it. But I worry about the nimbleness of our minds. If we were brought up in medicine expecting not to be spoon-fed but to correlate knowledge with imagination, and if diagnosis is made too easy for us, where will we get our essential intellectual exercise? Quite possibly, our much-prized ingenuity and originality of thought will turn out to be victims of medical progress. It would indeed be cruel to gain and lose so much at the same time.
Hospital Practice November 15. 1992
31
