Medicine
Championing the Art of
Deduction
The aspiring doctor, Wakenda Tyler, recalls sitting on the
bench, cappuccino in hand, feeling both uncomfortable and
skeptical. What was she doing hanging out in the Towson mall
on a weekday afternoon with her professor anyway? Gaping at
strangers outside the food court, no less.
An elderly woman passed by. Tyler's bench partner, the
School of Medicine's Edward McCarthy, gave his student a
nudge. The lesson was about to begin.
McCarthy, a professor of
pathology and
orthopedic surgery, pointed out the woman's short and
slow steps, the lack of full range of motion in her legs.
The woman also had an uneven gait, McCarthy informed Tyler,
clearly favoring her left side because of a stiff right
knee.
Then, with a look at Tyler that said "this is child's
play," McCarthy offered his on-the-spot diagnosis.
"Immediately he said to me, 'That person has very bad
arthritis in that one knee. She probably has no cartilage
left there if she was doing that much of a shift,'" Tyler
says. "I was very impressed. 'Wow. How did you know
that?'"
Elementary, dear Tyler. Elementary.
Tyler's slightly voyeuristic mall experience was a
lesson in basic observation, a somewhat "lost art" in the
medical profession, McCarthy says, because of an
ever-increasing reliance on technology. To fill this
perceived void, McCarthy passionately prescribes to his
medical students the value of noticing the "total patient" -
- his or her unique physical and psychological
characteristics -- rather than relying solely on charts,
X-rays, and lab results. True observation, McCarthy says,
injects a needed dose of humanity into the doctor-patient
relationship, which in turn aids in healing.
"You will see someone throw up an X-ray and say, 'This
is the patient who has had a hip injury.' Well, actually,
that is not the patient, that is just an X-ray of a
patient," McCarthy says. "All this technology at our
disposal often becomes a substitute for really seeing and
listening to the patient. I tell people that to become great
doctors, you have to first become a very good noticer."
In his musculoskeletal medicine course, McCarthy
invites some of his third-year students to accompany him to
a public place -- usually a mall or Baltimore's Inner Harbor
-- just to people-watch. He instructs the student to take in
the entire person, noticing gait, complexion, marks on hands
and face, hair, clothes, tics and, if possible, even smell.
In short, he wants specifics. In McCarthy's world, a person
is not merely dark- or olive-skinned, he is Cuban, Native
American, or perhaps a Gypsy. McCarthy says the way people
suffer is often bound to their culture and socioeconomic
status, details that can't be gleaned from even a full-body
scan.
As part of the exercise, the doctor and student then
take educated guesses as to the illnesses and impairments of
passersby. Without pad or pencil, McCarthy says, the student
learns to take detailed mental notes. In his bone pathology
lectures to second-year students, McCarthy conducts other
observation exercises, using slides of paintings.
McCarthy, who ascribes to the belief that doctors need
to be good detectives, says Sherlock Holmes is both his
inspiration and his model. Though McCarthy stops just short
of making the fictional detective's exploits required
reading in his classes, he does enjoy telling students how
Arthur Conan Doyle based his famous character on the
real-life Dr. Joseph Bell, one of the author's medical
school professors who was legendary for his deductive
powers.
For those who master observation techniques, he says,
technology can be used as an "adjunct" to observation, in
some cases reducing the need for costly and sometimes
invasive testing.
The desire to improve the observation skills of med
students is steadily gaining support, McCarthy says, thanks
in part to a study published in the September 5, 2001, issue
of the Journal of the American Medical Association.
Yale researchers set out to test the theory that
studying art works could improve the observational skills of
first-year medical students. Students were assigned
paintings in the Yale Center for British Art and asked to
observe and then describe them in detail. Later, in the
classroom, the students were part of a larger group shown
images of skin lesions and asked to write a description.
Students who received visual training improved their
observational skills by 10 percent, while there was no
improvement in the control group.
Linda Friedlaender, curator of education at the Yale
Center for British Art and co-author of the study, says the
results should serve as a wake-up call. "The technology
related to medicine has changed so much that there is a
growing concern of too many people relying on machines or
images to come up with the medical answers."
Wakenda Tyler, who graduated in May, says her
experience with McCarthy has completely changed her outlook
on clinical medicine.
"Every time I walk into a patient's room now I take a
step back to notice everything, even before introducing
myself," she says. "I see what is in the room, what is the
patient doing. And then I take a very close look at the
patient, eye color, hair color, condition of his teeth.
Things I never paid attention to before. All of a sudden it
made the patient a more complete person." --Greg
Rienzi