Every Patient Tells a Story (22 page)
Three components? Oh right. I didn’t recognize the sound but I do recognize the description. This must be pericarditis.
An inaudible voice from the front row spoke. “Correct,” Dr. Obeso said, flashing her remarkably white smile. “This is pericarditis. What you are hearing is a pericardial rub—the result of an inflamed pericardium [the sac in which the heart sits] rubbing against the smooth muscle of the heart. Here’s another patient with the same type of rub.” We listened again to a different recording, trying to store the noise somewhere in our individual brains so that we’d recognize it, if and when a patient with a heart that sounds like this walks into our offices one day.
The American College of Physicians started these refresher classes in clinical skills in 1995 with little more than a library of recommended titles and a couple of computer terminals. The current lab director, Dr. Patrick Alguire, first began teaching at the lab a couple of years later when the college decided to add a course in performing skin biopsies and suturing—surgical procedures that many internists do infrequently enough to need a refresher. But, says Alguire, it soon became clear that doctors wanted help not just with these unusual procedures but with skills they need to use a whole lot more often.
First they added classes in the breast exam and genital exams using patient-instructors to teach these procedures on their own bodies—an innovation already commonplace in medical school. Over the next several
years they added classes on how to examine different parts of the body: the muscles and joints, the eyes, the thyroid gland.
The diversifying syllabus, says Alguire, was a response to the growing evidence that physicians were entering practice with important gaps in their clinical skills, gaps that would be difficult to fill by simply reading. “We saw from the very first course that there was a huge need for this kind of hands-on learning. When you finish your training you get out into practice and you are suddenly confronted with all the stuff maybe you didn’t learn—or didn’t learn well enough. It’s the stuff you didn’t know you didn’t know—until you needed it. That’s been the driving force behind the center.” Perhaps not surprisingly, says Alguire, most of the students at the center are young—doctors in their thirties and forties.
This is the first year the center has offered the heart exam. Alguire had been looking for a way to include it for several years but hadn’t found a good method to teach it. And then he saw Harvey—the electronic dummy I had spent my morning with. He thought it would be perfect for the doctors who had requested assistance with the heart exam. Seven classes were offered over the course of the conference that first year. All were filled; most had waiting lists. The word was that the course was worth the wait in line for the chance at an unoccupied seat, that it was an efficient and effective way to brush up on the basic cardiac exam skills.
The life-sized mannequin is capable of simulating a dozen different heart conditions, offering high-quality digital recordings of the sounds of the abnormal heart. It can show the pulses in the arteries of the neck and where, on the chest, the heart beats most forcefully. It reproduces the differences in the sound depending on where on the chest the microphone is placed. All these characteristics are essential clues for the clinical diagnosis of a wide variety of diseases of the heart. And unlike our catch-as-catch-can training in the hospital, this Harvey could teach them all—a kind of one-stop shopping for the heart exam.
Listening is the third and final sense we use routinely in the physical exam. Doctors often listen to the lungs and the gut. We strain to hear the first
and last sounds of blood rushing through arteries narrowed by our blood pressure cuffs to look for hypertension. We listen to the vessels of the neck, searching for pathologic blockages in the arteries that carry blood from the heart to the brain, a potential source of strokes. We press our stethoscopes firmly into the belly beside and above the navel to check for sounds of turbulent flow into the kidneys—a cause of high blood pressure resistant to routine antihypertensive medication. But mostly, we use our stethoscopes to listen to the beating of the heart. Detecting deviations from the expected lub-dup is one of the oldest and most valuable tools we have for diagnosing important and sometimes life-threatening diseases of the heart.
In many ways, the heart exam stands as a symbol of the entire physical exam. It’s not the most complicated exam—the neurological exam is the probably the most complex. Nor is it the most technically difficult exam—looking at the retina of the eye may get that honor. And it’s not the most time-consuming exam—that would probably be the psychiatric exam. But the heart exam was the first examination developed in modern medicine and the one most strongly linked with the physician’s role as diagnostician and caregiver.
Moreover, the heart exam is a subtle exercise and requires well-developed skills to detect the nuanced variations from expected heart sounds. A thorough understanding of the anatomy and physiology of the heart and the circulatory system is essential in interpreting these quiet deviations and identifying the lesion they suggest. As such, it has functioned as the proverbial canary in the coal mine, the first alert that physician skill and interest in the physical exam was waning.
Salvatore Mangione chose the heart exam to test in his 1992 study of doctors’ skills not only because it was an area in which he had noted waning skills but also because of this position in the pantheon of examination abilities. He describes it as the “tip of the iceberg” of the physical exam—the most apparent component to doctors and patients alike of this much larger practice, this sensual science of the body, the physical exam. Technology is eroding, melting away this ancient, massive, and essential part of the way a physician knows the human body.
If and when the physical exam is saved, says Mangione, we will know it
when the heart exam is restored to its former preeminence as the signal of a highly skillful, well-trained physician.
A Different Way of Listening
On my first day of medical school I was given the short white coat that signified my status as a student of medicine and my first stethoscope. These two symbols of my entrance into medicine were presented in very different manners. The white coat was given in a ceremony on a beautiful September morning in 1992. A sun-drenched hall was filled with rows of folding chairs for me, my ninety-nine new colleagues, and our families. The two deans of Yale Medical School, Gerald Burrow, head of the medical school, and Robert Gifford, the dean of students, stood at the front of the room, welcoming us into the profession. The late morning sun poured through a wall of windows, reflecting off the polished wood floors of the hall, suffusing the room with a fog of light. After a few words of welcome, Dean Gifford explained that the short white coat that we were about to receive indicated our status as medical students; these would be replaced in four years, upon graduation, by a full-length garment that signified our role as full physicians and teachers. Then each of us was called to the front of the hall to receive our own white coat. As we walked up the aisle, a brief bio was read, our first introduction to our peers for the next four years.
My husband squeezed my hand as my own name and credentials were read and I shuffled down the row of chairs to walk up the aisle, put on the crisp white jacket, and took my place among my new colleagues. Pride and excitement shone on everyone’s face. When the last name was read, faculty and family joined in giving us a round of applause. It was a magnificent moment.
My first stethoscope had a far more ignominious entry into my life that day. After the ceremony we were sent off to finalize the complex logistics of registration. After filling out and signing a sheaf of forms, we were given our schedules and the key to our mailboxes. They were already overflowing with the typical packets of welcoming materials—sheets listing courses and
books, still more forms to fill out for library and ID cards, manuals on policies and procedures, rule books, discount cards for local stores, and advertisements for various tools of the trade—and a stethoscope.
The stethoscope itself was one of those advertisements—a gift from Eli Lilly. If I received that gift today I would have different feelings about it, but this was before I had really thought much about the meaning of these gifts from the pharmaceutical industry. It came in a slender white box with the name of the manufacturer written in a tasteful script. It had the elegant proportions of a box from a jewelry store. I put everything down and picked up the box. Inside, the stethoscope lay draped on a black cardboard background contoured to keep the precious instrument in place.
Lifting the stethoscope out of the box, I was impressed by its heft. The disc at the end was polished chrome. The name of the drug company was written on the diaphragm—but that first day, I didn’t even see it. Shiny gray rubber tubing extended from the disc and split, ending in a length of curved chrome and two gray rubber earpieces. Despite the elegant presentation, it was an ugly industrial object and yet I loved it. To me, it was far more important than the white jacket of the morning service. This was the real evidence of where I was going, the proof that at the end of all this there would be patients and healing—just as close to me as this disc was to these earpieces.
And yet as I think back on this I realize that this was my first clue to the status of the physical exam. The white coat, symbol of authority, knowledge, and progress, was the focus of the official welcome. The stethoscope, the symbol of the physical examination of the body, of our role as caregivers, was an industry-supported trinket—a freebie.
At home after that first day at school, I pulled the stethoscope out again. The silvery arms crossed and reached down as graceful as a dancer in first position. I put the soft rubber pieces to my ears, expecting them to sink into place. They didn’t. I pulled the stethoscope off and looked at it once more. I tried again. Still awkward, still uncomfortable in my ears. I flipped the thing around so that the earpieces looked up at me like a leering cross-eyed sailor. I tried again. This time the earpieces fit snugly, the soft rubber adjusting to the contours of my ears so that all other noises were blocked.
I put the silver disc over my heart, head cocked, and I listened. I heard—nothing. I stood quietly. Still nothing. Was there something wrong with the stethoscope?
I took a deep breath. That I heard. I breathed again. The sound was clear, like the sound of wind passing through a hollow piece of plastic. Then I stood quietly listening, listening. After what seemed forever I felt, rather than heard, a quiet rhythmic pressure against my eardrums. I concentrated on that beat, then finally—somehow—was able to hear the now familiar lub-dup. This instrument required a different way of listening.
This was not going to be as easy as it looked.
On another morning, this one nearly two hundred years earlier in Paris, a young physician with the improbably delicate name of René-Théophile-Hyacinthe Laennec was confronted with the problem of examining a plump young woman with chest pain who was suspected of having a diseased heart. The year was 1816. The problem was one of logistics and propriety: how to evaluate the heart of this young woman. The recently developed practice of placing the ear directly on the chest of the patient seemed likely to be ineffective as well as improper. Other techniques of examination, also newly discovered—palpation (feeling the chest for the beat of the heart) and percussion (thumping the chest the way you might a melon)—were attempted but quite useless in this case, reported Laennec, “on account of the great degree of fatness.”
“I recalled a well known acoustic phenomenon,” Laennec wrote several years later. “If the ear is placed at one end of a log, the tap of a pin can be heard very distinctly at the other end. I imagined that this property of bodies could be applied to the case at hand. I took a paper notebook, made it into a tight roll, one end of which I applied to the precordial area [chest] and putting my ear to the other end, I was just as surprised as I was satisfied to hear the beating of the heart in a manner that was clearer and more distinct than I had ever heard it by the direct application of the ear.”
The utility of the device, ultimately called the stethoscope (from the
Greek
stethos
, chest), was immediately apparent to Laennec. It was the first technologic development enabling a “view” into the inner workings of the living body. The device was so successful at transmitting the noises from inside the chest to his ear that Laennec devoted the rest of his career to better understanding the instrument and the body it revealed.
In Laennec’s time, diseases were classified primarily on the basis of symptoms. An illness was defined by the subjective sensations experienced by patients. Doctors didn’t examine patients; they interviewed them. What constituted a “disease” then was assembled from a constellation of subjective symptoms and distinguished based on the type of symptoms, the sequence of their presentation, their severity and rhythm. Physical signs—derived from the pulse, touching, and observations of the skin and excreta—were contributory, but of much less importance.
At the turn of the nineteenth century, two new, closely linked ideas emerged that would change medicine forever. First was the growing understanding that disease was caused by the disruption of individual organ function. An Italian physician and teacher of anatomy, Giovanni Battista Morgagni, published a book called
On the Seats and Causes of Disease Investigated by Anatomy
, just a few years before Laennec was born. This revolutionary tome presented detailed drawings of diseased organs and then linked these abnormalities to clinical diseases. The connection between the diseased organs hidden within the body and clinically apparent diseases led to the second new idea: if diseases were caused by organ dysfunction, then they shouldn’t be defined by their symptoms—too many diseases presented with the same kinds of symptoms. If the patient couldn’t distinguish which organ was involved—and this was and remains true—then doctors had to find some way to identify the source of disease independent of the patient’s story. For this they turned to the body itself, to the physical exam.
