Rejected by the New England Journal of Medicine in February 2010.

To the Editor:

Medical educators I’ve known have often cited the case histories in the Journal’s CPCs as model presentations of clinical information.

Unfortunately, case 2-2010 jeopardizes this reputation by saying the patient experienced “an episode of pain in his left arm … that radiated to his heart” (1).

Medical trainees should not emulate this statement, for three reasons:

First, it is not believable. The complex innervation of thoracic structures prevents localization of pain to any internal organ.

Second, it is ambiguous. Many patients believe pain near the left breast is “heart pain” (2), whereas physicians generally associate retrosternal discomfort with cardiac ischemia.

Third, even if this statement were a direct quote from the patient, it violates the precept to “question [the patient] until sufficient details are obtained to categorize the symptom in medical terms” (3).

No institution of medical education can rest on its laurels. I hope The Journal will re-dedicate itself to maintaining its pre-eminence in this vital field.

(1) Isselbacher EM, Kligerman SJ, Lam KM, Hurtado RM. Case records of the Massachusetts General Hospital. Case 2-2010. A 47-year-old man with abdominal and flank pain. N Engl J Med. 2010 Jan 21;362(3):254-62.   PubMed 20089976

(2) Wood P. Diseases of the Heart and Circulation. 2nd ed. London: Eyre and Spottiswoode, 1956. Page 4.

(3) DeGowin RL. DeGowin & DeGowin's Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987. Page 24.

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Published on January 29, 2018