When I was a resident in radiology at UCSF, we had several rotations at San Francisco General Hospital, where we took frequent calls at the Mission Emergency Room, definitely an interesting and exciting learning experience. After the radiology resident would read the films, she or he would hang them on a mechanical alternating viewer (this was in the good ol’ days before digital radiology), and in the early morning, one of the attending radiologists would come in to review and check the films that had been read.
A colleague of mine had been on call the night before, so he told me about reviewing the films the next morning with Hideyo Minagi, who had one of the best “eyes” of any radiologist I had ever seen. Minagi’s style was to keep the films continuously rolling down the alternator. Then he would stop the conveyor to query the resident whenever he saw something abnormal.
As the films were moving down, there was a chest X-ray on a 3-year-old child. “Well, that's interesting,” said Dr. Minagi, as he perused the image for no more than probably half a second or so. My resident colleague’s palms began to sweat, as he had interpreted the film as “normal.”
“No, not correct,” Dr. Minagi blurted out, “that child has Down syndrome.”
“How could that be?” said the resident.
“Because the patient only has 11 ribs,” the attending replied.
Now, I can guarantee you that it’s simply impossible for anyone to count the number of ribs visualized on a chest X-ray in less than five to 10 seconds. Obviously, Dr. Minagi had the subconscious ability to recognize an abnormal number of ribs without explicitly counting them.
Sound supernatural? I suggest not, and to bolster my case, I recommend that you read Blink: The Power of Thinking Without Thinking by Malcom Gladwell (of The Tipping Point fame), a book sent to me last week by Dean Edward Miller.
In his latest book, Gladwell will regale you with tales of people who make these kinds of subconscious decisions accurately without having to compile lots of data. For example, he tells of the psychologist who can view a few minutes of a taped segment of a husband and wife, then predict whether they will remain married over a subsequent 15-year period with more than 90 percent accuracy. Or the art historian who could spot a fraudulent sculpture in 10 seconds after expert testing for several months had indicated otherwise. It turns out the art historian’s view was most probably the correct one.
Blink is highly relevant in this day of high-tech medicine and even more highly sophisticated diagnostic tests, like gene screening, tomographic imaging and the like. It highlighted to me, anyway, that the soft side, or the art of medicine, is still as important, and perhaps even more so. Listening to and observing the patient with all of our innate powers has as much to contribute to the diagnosis and treatment as do all the expensive tests we are able to order with the stroke of a pen.
Let me close with a story told to me 10 years ago by a colleague from Baltimore. I assume it is accurate, although I must admit I haven't been able to verify it independently. The man had been hospitalized at another hospital under the care of a non-Hopkins physician. He knew one of Hopkins’ finest, Willmot Ball, but was not under his care at that time. According to this gentleman, Ball showed up, uninvited and unannounced, at the hospital around midnight to see his friend. He took one look at the man and announced, “Sam, you’re going to die. We have to get you to Johns Hopkins immediately!” And that is exactly what Ball did—I think even driving the patient to the Hospital in his car.
After the man was admitted to the ICU and some tests were performed, the attending made the diagnosis of acute pulmonary embolism. A thoracotomy and successful pulmonary embolectomy were performed. The man is in great health today.
Clinical moxie may be out of favor, but it shouldn’t be out of fashion. Our medical students and residents need to be ever diligent to sharpen their powers of observation and reasoning in clinical situations. Intuitive reasoning can be very powerful and very accurate. Whoever said that first impressions are inaccurate hasn’t read Blink.
