Thursday, May 18, 2017

Inside the diagnosis

kw: book reviews, nonfiction, medicine, diagnostic procedures

It has been said that one human brain is more complex than all the rest of the universe…minus the other brains. Add a body to that brain, and the total human person is complex indeed. Thus, for a physician to correctly diagnose a troublesome condition is akin to a detective gathering clues in the mean streets of an immense, universal city. It is no coincidence that both the author of the Sherlock Holmes stories, and the man who inspired Holmes, were doctors.

Some diseases are simple enough; red, puffy eyelids leaking pus clearly indicate conjunctivitis, or pink eye. That is one of a handful of diseases anybody can diagnose. Most others, not so much. As Stuart B. Mushlin, M.D. tells us in Playing the Ponies and Other Medical Mysteries Solved, a syndrome such as POEMS is indicated when five factors are all present: Polyneuropathy, Organomegaly, Endocrine abnormalities, Monoclonal protein abnormality, and Skin changes. It is a blood disorder that is, fortunately, treatable, but is fatal without treatment.

Dr. Mushlin enjoys a good tussle with the facts of a difficult case. That is a trait he shares with my uncle and his father, who were legendary diagnosticians. In the chapter "The CPC", he describes two cases brought before a Clinical Pathologic Conference. Here, a doctor is presented with all the facts of a case, one from the recent past, and must then discuss before the group his diagnosis and the thought processes that led to it, and suggest treatment. Then the pathologist will either praise or pillory the presenter while describing the actual history and final diagnosis and treatment. It is a great educational setting, in which doctors of all levels of experience learn in ways no textbook can convey.

In this book we learn the great humility a physician must have. Knowing how to listen is a greater asset than encyclopedic knowledge of all diseases (though that helps!). Being willing to take a step back and think again, looking for that evanescent "other factor", can be the key to discerning a subtle syndrome.

I enjoy reading books by doctors. They usually write well. In Dr. Mushlin's case, he clearly enjoys writing, and it came through in my own enjoyment of the reading. I love a joyful teacher. Oh, and the "ponies"? That's about what one of his patients did with the insurance payoff!

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