Rejected by JAMA in 2007.

To the Editor:

The history and physical examination of the patient with ischemic cardiomyopathy that was presented in the May 2 Clinical Crossroads column (*) fell short.

First, reporting patterns of “chest pain” in a patient with ischemic heart disease invites errors in history taking because ischemic chest discomfort is often not painful, but “squeezing,” “heavy,” etc.

Second, reporting jugular venous pressure on the basis of venous distention is crude and, unless the patient’s posture is provided, useless.

Third, reporting that a patient’s “pulses were intact,” leaving the arteries anonymous and the pulse-amplitude unspecified, communicates little.

Finally, a typographical error describing the patient’s “normal S1 and S1” [sic] reinforces the inattention given to the case description.

All professions have their slang and verbal short-cuts, but these temptations to substitute reflex for reflection should be resisted.

(*) Zimetbaum PJ. A 59-year-old man considering implantation of a cardiac defibrillator. JAMA. 2007; 297: 1909-1916.

Possibly rejected by the New England Journal of Medicine in 2006.
It's also possible that good sense got the upper hand and that I never submitted it.

In fruitlessly seeking a physical cause for lifelong severe obesity in a 15 year old girl (Case 31-2006), the diagnostic evaluation abruptly ended with a sentence unusual in a Case Record: “Symptoms of the most common, well-defined obesity syndromes [3 are named] were absent.”

Such a statment suggests diagnostic surrender. Should physicians entertain only common, well-defined syndromes? Or limit differential diagnoses to three conditions? Or ignore signs? Or require textbook symptoms before testing for syndromes? Is not obesity a symptom of obesity syndromes? Were not the patient’s striae, hypertension, and obesity sufficient to consider Cushing syndrome? And should not the symptoms and signs of obesity syndromes be included as pertinent negatives in the case presentation?

With all these considerations unaddressed, perhaps diagnosis was only a secondary focus in the case discussion. Nevertheless, in a patient with life-threatening disease, as this patient’s obesity assuredly is, aggressive diagnostic evaluation is warranted. It is unclear whether she received it.

Hoppin AG, Katz ES, Kaplan LM, Lauwers GY. Case records of the Massachusetts General Hospital. Case 31-2006. A 15-year-old girl with severe obesity. N Engl J Med. 2006 Oct 12;355(15):1593-602.   PubMed 17035653

Rejected by JAMA in 2006.

To the Editor:

The courageous effort by Emanuel to outline a new pre-medical and medical curriculum has one contradiction and two omissions.

First, after advocating a year of biochemistry in the pre-medical curriculum, he rightly states that knowledge of the Krebs cycle generally has no practical use at the bedside. This contradiction suggests that devoting a year to biochemistry is excessive.

Second, there is a fundamental, yet unspoken truth about medicine: as an intellectual endeavor, it is extremely easy. While the hard sciences require detailed understanding and nuanced application of difficult quantitative principles, medical textbooks simply demand memorization on a massive scale. One could argue that mnemonic training is the greatest omission in medical teaching and that, of all pre-medical requirements, organic chemistry is the greatest developer of memorization skills.

Finally, I wish there were some way to teach humility more effectively and more permanently. Any physician not cowed by their own ignorance should be drummed out of the profession.

(1) Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA. 2006 Sep 6;296(9):1128-1131.   PubMed 16954492

Rejected by the New England Journal of Medicine in 2006.

To the Editor:

The death of “Mr. Abbott” (*) whose overlooked aortic dissection was misdiagnosed as an acute coronary syndrome, illuminates more than just the demise of the physical examination. It also illustrates Goethe’s precept “What one knows, one sees” (1).

A patient writhing because of chest pain should immediately be suspected to have aortic dissection (2)(3). Patients with chest discomfort due to coronary events more characteristically lie motionless (3), as noted in older (4), but not newer (5) cardiology textbooks.

Today’s highly specific imaging and biochemical tests have changed the role of physical examination from hypothesis confirmation to hypothesis generation. However, these tests have not, in the words of Dr. Joseph Bell (the model for Sherlock Holmes), changed the obligation of each physician to know “the features of disease… as precisely as you know the features, the gait, the tricks of manner of your most intimate friend” (3).

(*) Jauhar S. The demise of the physical exam. N Engl J Med. 2006; 354: 548-551.

(1) DeGowin RL. DeGowin & DeGowin's Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987; 37.

(2) Slater EE. Aortic dissection: presentation and diagnosis. In: Doroghazi RM, Slater EE, Aortic Dissection. New York: McGraw-Hill, 1983; 62.

(3) Sotos JG. Zebra Cards. Philadelphia: American College of Physicians, 1989; page 19 and card HE-011.

(4) Pasternak RC, Braunwald E, Sobel BE. Acute myocardial infarction. In: Heart Disease. 3rd ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1988; 1235.

(5) Antman EM, Braunwald E. Acute myocardial infarction. In: Heart Disease. 5th ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1997; 1198.

Rejected by the New England Journal of Medicine in 2005.

To the Editor:

Two features of case 5-2005 (1) deserve comment.

First, hyperacute (“flash”) pulmonary edema did not occur. Suggestive X-ray signs of stage 2 pulmonary edema were present initially, but not appreciated. Resting tachycardia and relative hypotension were also present initially, further suggesting a circulatory system nearing its compensatory limits. Only after normal saline administration did frank pulmonary edema become manifest. Missed diagnosis and iatrogenesis should be added to the differential diagnosis of hyperacute pulmonary edema in the case discussion.

Second, like the proverbial elephant in the living room that is scrupulously not discussed, the claim that “the general physical [examination] disclosed no abnormalities” should have been the discussants’ focus. It stretches probability to believe that all physical signs of heart failure, advanced endocarditis, and aortic valvulopathy were initially absent, yet one discussant accepts this, and another partially excuses it. The patient’s vital signs, marked first-degree heart block, and history of hospitalization for heart disease should, from the beginning, have prompted a directed cardiovascular examination in the emergency room.

(1) Biddinger PD, Isselbacher EM, Fan D, Shepard JA. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 5-2005. A 53-year-old man with depression and sudden shortness of breath. N Engl J Med. 2005 Feb 17;352(7):709-716.   PubMed 15716566