Clinical Pneumonia or Virtual Health?

“So, are you saying Bobby really didn’t have pneumonia?” Mrs. Halstead asked. Her eleven-year-old son, a boy with multiple medical problems, had been in the office ten days before with fever, a bad cough, right-sided chest pain with each deep breath, and very loud crackles in the lower portion of his right lung. His blood count was normal and his chest x-ray looked almost normal – you could argue that it looked a little streaky in the right lower lobe, but the city radiologist who read his x-ray without actually listening to his lungs thought it was a normal set of pictures.

Bobby felt good at his follow-up appointment, and his lungs sounded clear. So, had I been wrong in diagnosing him with pneumonia when the radiologist didn’t agree with my interpretation of the films?

I remembered the case of Fanny Brown, my receptionist’s mother. She had a nasty cough and was losing weight. Her chest x-ray was normal, but her CT scan showed a tumor the size of a baseball – we all know a chest x-ray isn’t always the final word on what is wrong with a patient.

I tried to explain to Mrs. Halstead that a camera, even one used for x-rays, has its limitations.

“If you see a pretty rainbow and pull out your camera to capture it, but the picture doesn’t show the rainbow, does that mean you didn’t see a rainbow?” I tried.

There is an old Swedish military and Boy Scout joke, which I heard in both places: When the map and the terrain disagree, you go by the map in the military and by the terrain in the Boy Scouts. I spent more time as a Boy Scout than as a soldier – my inclination has always been to trust my assessment of the terrain.

I was on call for Christmas, and had a few days off around New Year’s. Catching up on my journals, I was delighted to find a piece in the December 25th edition of The New England Journal of Medicine by Abraham Verghese, MD, entitled “Culture Shock – Patient as Icon, Icon as Patient”. Dr. Verghese describes teaching residents, who seem more inclined to look at their patients through the “eyes” of the electronic medical record than through bedside clinical observation. He also talks about what to do when the map and terrain don’t seem to agree. He quotes Alfred Korzybski, the Polish-American philosopher credited with founding the theory of general semantics, who said, “the Map is not the Territory”. I’m not sure which of the two Korzybski thought was more real.

Bobby Halstead had been ill, and now he was well. I don’t know what his mother really thought of my diagnosis of his pneumonia, but it was a great illustration of what Dr. Verghese wrote about a short while later in “The Journal”: Our technology, invented as a way to document clinical reality, has almost become more real than the disease states it was designed to document.

8 Responses to “Clinical Pneumonia or Virtual Health?”

  1. 1 Health January 4, 2009 at 9:53 am

    well this medical problem is really very insane. This is utmost insane.

  2. 2 NPs Save Lives January 4, 2009 at 7:18 pm

    Doc, I am also finding this to be true of lab cultures. I have sent several wound cultures to the lab for sensitivity and they have been coming back with no growth? I know that I am getting enough of a sample because the wounds are very purulent with the typical characteristics of MRSA infections. I have also had a few urine cultures come back negative but that’s expected.
    I worked with a local doc who always treated based on what he heard rather than the “normal CXR”. I learned quickly to follow in his footsteps. I have developed a pretty keen sense of something’s not right with this picture from the listening to my patients. Sounds like I’m patting myself on the back? I hope not. Am I saving patient’s lives? I hope every day.

  3. 3 Cathy January 4, 2009 at 8:28 pm

    As a patient I wonder sometimes just what good x-rays really are? I had x-rays of my knees once that showed either none or very small amt. o dearly arthritis. MRI showed end stage arthritis, and I ended up having replacement within just a few months of a clear x-ray.

  4. 4 drtombibey January 7, 2009 at 1:18 pm

    I love it when you get back a report that says, “the previously noted ill defined density in the right hilum now appears less prominent,” and the first report was read as ‘negative.’

    Dr. B

  5. 5 JenButler,FNP January 17, 2009 at 6:10 am

    I have to say, as a primary care provider, I just dont see anything abnormal about this. More often than not my patients results are “normal”,..when the patient is most definately NOT normal. I got a piece of advice over 10 years ago in training..”Treat the PATIENT, NOT the result”. And this small phrase has helped me more times than i can count!If tests alone could diagnose and treat the patients, what would any providers be even needed for? We go through training, and gain experience, and we treat and diagnose to our best ability. The “tests” that patients think are error-proof are more wrong than anything in medicine.They are only as good as the person interpretting them, and we all know an xray shot on day 1 of an injury or infection such as this cxr may not show up until at least 3 days after onset of symptoms anyway.
    I have learned to just not do the test.Not unless i am questioning something further. Even then, I will give the order and have the test done in 2-3 days.If the patient has improved,I tell them to not have the test at all. In the case of cultures,I usually do them, but start treatment the day they come in to the office.If the cultures are negative and the patient is better I tell them to finish all of their treatment.If the cultures show a different organism and sensitivity,I ADD that medication along with what i gave them to begin with to reduce resistance…JUST IN CASE things aren’t just perfect with the test. This has never failed me. Especially when you take the time from the first day to tell the patient what you are doing and why and what could happen.Then when you call them they know what to expect either way.
    Take the case of someone who is in their 80’s who has a fall. They come to see you complaining of back or knee pain,etc. You order an xray to look for injury FROM THE FALL right? Then you get back a result that is “normal”.?????? This is my pet peeve NUMERO UNO!! What 80 something year old doesnt have anything wrong with their knees or back??? I have called the radiologist many occassions and asked this..”So this 88 year old woman with known osteoporosis according to bone density, history of back surgery and knee replacements,…has “normal” xray??” No Arthritis at all huh? nothing? I usually get a pause on the line. Especially me being a FNP. But, my patient is aware of this BEFORE i call them.So there are no surprises. I always say “just because it may say normal, does not mean it is normal” it means it just isnt showing up on this test.And do you need a test to tell you your back hurts? of course not. So if the treatment is going to be same no matter what the “result”, I just save the time,money,energy,and confusion for everyone and do not order the test at all. And i just believe in my own instincts,which have yet to fail me. Sometimes Modern medicine can be a little too modern, dont ya think?

  6. 6 Steph January 20, 2009 at 10:20 am

    As a patient, it’s hugely refreshing to read this post and indeed, Jen Butler’s comment.

    I find it very sad to witness modern medicine becoming so reliant on clinical tests. I presume the fear of litigation is partly responsible? It’s now a rarity to come across a physician who is prepared to stake his reputation by making a provisional diagnosis before using tests to back-up. So many doctors these days seem to feel the need to order tests first rather than use their clinical skills (and instinct) to hazard a diagnosis. This all leads to delays in treatment for the patient and perhaps even no treatment at all, thanks to a wrongly interpreted ‘result’. I’ve always found it humorous the way some docs take great delight in phoning the patient to tell them what they haven’t got i.e. when tests come back ‘normal’. This news may be a relief to the doc but it’s no help to the patient who is in need of help with troubling symptoms.

    I also find that some docs can be so anxious to deliver test results that they overlook asking the patient the most vital question of all, “How are you?”

  7. 7 How to Get Six Pack Fast April 15, 2009 at 4:29 pm

    Not that I’m impressed a lot, but this is a lot more than I expected when I stumpled upon a link on SU telling that the info is quite decent. Thanks.

  8. 8 anna hemroids June 24, 2010 at 6:05 pm

    I loved the Boy Scout joke. How true it is! But you may have had the map upside down!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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