Rejected by JAMA in 2007.

To the Editor:

The history and physical examination of the patient with ischemic cardiomyopathy that was presented in the May 2 Clinical Crossroads column (*) fell short of JAMA’s standards.

First, reporting patterns of “chest pain” in a patient with ischemic heart disease invites errors in history taking because ischemic chest discomfort is often not painful, but “squeezing,” “heavy,” etc.

Second, reporting jugular venous pressure on the basis of venous distention is crude and, unless the patient’s posture is provided, useless.

Third, reporting that a patient’s “pulses were intact,” leaving the arteries anonymous and the pulse-amplitude unspecified, communicates little.

Finally, a typographical error describing the patient’s “normal S1 and S1” [sic] reinforces the inattention given to the case description.

All professions have their slang and verbal short-cuts, but these temptations to substitute reflex for reflection should be resisted.

(*) Zimetbaum PJ. A 59-year-old man considering implantation of a cardiac defibrillator. JAMA. 2007; 297: 1909-1916.

Rejected by JAMA in 2006.

To the Editor:

The courageous effort by Emanuel to outline a new pre-medical and medical curriculum has one contradiction and two omissions.

First, after advocating a year of biochemistry in the pre-medical curriculum, he rightly states that knowledge of the Krebs cycle generally has no practical use at the bedside. This contradiction suggests that devoting a year to biochemistry is excessive.

Second, there is a fundamental, yet unspoken truth about medicine: as an intellectual endeavor, it is extremely easy. While the hard sciences require detailed understanding and nuanced application of difficult quantitative principles, medical textbooks simply demand memorization on a massive scale. One could argue that mnemonic training is the greatest omission in medical teaching and that, of all pre-medical requirements, organic chemistry is the greatest developer of memorization skills.

Finally, I wish there were some way to teach humility more effectively and more permanently. Any physician not cowed by their own ignorance should be drummed out of the profession.

(1) Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA. 2006 Sep 6;296(9):1128-1131.   Pubmed 16954492

Rejected by the New England Journal of Medicine in 2006.

To the Editor:

The death of “Mr. Abbott” (*) whose overlooked aortic dissection was misdiagnosed as an acute coronary syndrome, illuminates more than just the demise of the physical examination. It also illustrates Goethe`s precept “What one knows, one sees” (1).

A patient writhing because of chest pain should immediately be suspected to have aortic dissection (2)(3). Patients with chest discomfort due to coronary events more characteristically lie motionless (3), as noted in older (4), but not newer (5) cardiology textbooks.

Today`s highly specific imaging and biochemical tests have changed the role of physical examination from hypothesis confirmation to hypothesis generation. However, these tests have not, in the words of Dr. Joseph Bell (the model for Sherlock Holmes), changed the obligation of each physician to know “the features of disease… as precisely as you know the features, the gait, the tricks of manner of your most intimate friend” (3).

(*) Jauhar S. The demise of the physical exam. N Engl J Med. 2006; 354: 548-551.

(1) DeGowin RL. DeGowin & DeGowin`s Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987; 37.

(2) Slater EE. Aortic dissection: presentation and diagnosis. In: Doroghazi RM, Slater EE, Aortic Dissection. New York: McGraw-Hill, 1983; 62.

(3) Sotos JG. Zebra Cards. Philadelphia: American College of Physicians, 1989; page 19 and card HE-011.

(4) Pasternak RC, Braunwald E, Sobel BE. Acute myocardial infarction. In: Heart Disease. 3rd ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1988; 1235.

(5) Antman EM, Braunwald E. Acute myocardial infarction. In: Heart Disease. 5th ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1997; 1198.

Rejected by the New England Journal of Medicine in 2005.

To the Editor:

Two features of case 5-2005 (1) deserve comment.

First, hyperacute (“flash”) pulmonary edema did not occur. Suggestive X-ray signs of stage 2 pulmonary edema were present initially, but not appreciated. Resting tachycardia and relative hypotension were also present initially, further suggesting a circulatory system nearing its compensatory limits. Only after normal saline administration did frank pulmonary edema become manifest. Missed diagnosis and iatrogenesis should be added to the differential diagnosis of hyperacute pulmonary edema in the case discussion.

Second, like the proverbial elephant in the living room that is scrupulously not discussed, the claim that “the general physical [examination] disclosed no abnormalities” should have been the discussants’ focus. It stretches probability to believe that all physical signs of heart failure, advanced endocarditis, and aortic valvulopathy were initially absent, yet one discussant accepts this, and another partially excuses it. The patient’s vital signs, marked first-degree heart block, and history of hospitalization for heart disease should, from the beginning, have prompted a directed cardiovascular examination in the emergency room.

(1) Biddinger PD, Isselbacher EM, Fan D, Shepard JA. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 5-2005. A 53-year-old man with depression and sudden shortness of breath. N Engl J Med. 2005 Feb 17;352(7):709-716.   Pubmed 15716566

Rejected by JAMA in 2004.

To the Editor:

Mr. Kraus and Dr. Suarez (1) provide facts and commentary about physician membership in Congress that should be viewed with care.

The authors calculate that non-physician members of Congressional serve a mean of 3 statistically insignificant years longer than physician members. Yet, a tenure difference of 2 years can be highly significant legislatively because committee chairmanships, from where power in Congress emanates, are few in number and are traditionally determined by strict party seniority. Statistics related to long-duration memberships would therefore tell a more important story, but applying measures of statistical significance to Congress must always be done with restraint. The only true measure of legislative significance is votes.

The speculation on why physician representation in Congress has dropped since 1889 is hopelessly incomplete. The authors discuss workforce levels, salary, duty, time, morale, and role models, but omit power, pride, passion, idealism, ego, drive, connections, expense, and, most startlingly, the electorate and its changes over 115 years. Perhaps 20th century physicians have merely heeded Osler’s comment that “Politics has been the ruin of many country doctors” (2). Given the innumerable factors contributing to electability, one might as well explain the surprisingly large proportion of gynecologists among current physician Congressmen by citing Richard Asher’s half-serious observation that gynecologists typically wear “an expression of refinement and sympathy” (3).

The authors suggest it is advantageous to have physicians in Congress to bring health care expertise to bear on health-related issues. This is a narrow view. Among the reasons not to have physicians in office is: we are a socially homogenous and privileged group functioning in a professional environment that does not generally foster development of leadership skills.

Indeed, the greatest benefit carried by medical training would not be narrow expertise on health care, but would be skepticism and the habit of asking good questions. An exception might have been the ninth President of the United States, William Henry Harrison, who was a medical student first in Richmond then Philadelphia (under Benjamin Rush, no less) before leaving to join the Army and follow the path that would take him to the White House. He is chiefly remembered now for dying of pneumonia one month after not having the medical good sense to wear an overcoat or hat while delivering his hour and forty-minute inaugural address on a very cold Washington day (4).

(1) Kraus CK, Suarez TA. Is there a doctor in the House? ... or the Senate? JAMA. 2004;292:2125-2129.

(3) Asher R. An Asher Miscellany. London: British Medical Association, 1984; 86.

(2) Bryant CS. Osler: Inspirations from a Great Physician. Oxford: Oxford University Press, 1997; 179.

(4) Bumgarner JR. The Health of the Presidents. Jefferson, NC: McFarland & Co., 1993; 59-63.