Expert

Speaking of physical diagnosis -- and I just was -- I'll never forget one guy at whose feet I sat as a med student on my pediatrics rotation. Double boarded in radiology and peds, he used to come up to Cleveland from Akron to hold forth on rounds, periodically. The ritual was that after he'd given a talk of some sort, the staff would pop up a few Xrays for his analysis. Cold.

On one occasion, we had a child admitted with acute glomerulonephritis, an inflammation of the kidneys, in kids typically due to strep and potentially very serious. What was shown to the doc was just a chest Xray. "Watch this," the peds resident said as she leaned over to me. "Bet he gets it." To me, it was an absolutely normal Xray.

"OK," he said. "Looks like a male, about eight years old.' [It was.] "The vascular markings are a little prominent [to me, they were perfectly normal], like early heart failure. The heart is slightly enlarged [in my eye, it wasn't] but the contour is normal, so it's not congenital heart disease. The most likely cause of failure in a child this age, absent primary heart disease, is glomerulonephritis."

Wow. I'm pretty sure he wasn't in on the diagnosis. I'm also certain as I can be he's among a tiny few who could have diagnosed kidney trouble from a near-normal chest Xray. Up to a point, I can relate, or at least understand how it's possible: not only was he a really brilliant and experienced physician, he had a certain context in which to proceed. I got good at reading mammograms and belly films. Better, I'd say, than radiologists because I knew more about what was going on.

I remain a complete incompetent when it comes to looking at ultrasound images, especially of the breast, and I admire those who can do it. It also makes me uncomfortable to have to rely so completely on someone else's interpretation, because I've found, to the regret of myself and my patient, that they're occasionally wrong about what's solid and what's a cyst. In looking at films, I always want to know what the radiologist has to say; but I reserve the final interpretation for myself. Can't really do that with ultrasound. I took a course, the point of which was to get surgeons to do their own ultrasound-guided breast biopsies. I decided I'd never have the time to get good enough at it.

Some people have special powers. Ernie the Pathologist could look at a slide of a few cells for a nanosecond and say "It's cancer." Pathology was one of my worst subjects in school. To me, everything looked like liver. I did carry my breast aspirate slides directly to Ernie, however, and we'd look at them together. Eventually he got me to the point where I'd have pretty much of a clue. Never enough to make my own calls. Not even close.