To Examine or Not to Examine That Is the Question

B''H

I just read an article in JAMA[1] questioning the need for routine physical examination on a healthy patient as there is no "evidence" to support this. The author then presents an anecdote regarding his own father who on a routine physical examination was thought to have enlarged aorta by palpation: leading to an ultrasound showing a normal aorta but question of a pancreatic mass; leading to a CT scan showing a , of course, normal pancreas but a possible liver lesion; leading to a biopsy (of a hemangioma); leading to a hemorrhage; and , finally, the denouement, leading  to a stay in an ICU. Cost: $50,000. Admittedly, the author is trying to pick a bone with routine yearly physical examinations but the article gives impression that examination of a "healthy" organ is worse than useless and calls into question the usefulness of any physical examination.

Since we are in the realm of anecdote let me present a few. In my career, I have picked up on routine examination six or seven abdominal aortic aneurysms of significant size. All of these patients were smokers and had a bruit. My yield on this physical finding is about 80%. I suspect the author's father's internist had never palpated an actual aneurysm. When I taught in a medical school, I told my students and residents that the key to physical examination is not to be Dr. Joseph Bell[2] but just to do it. In other words, the key is to look for the obvious not the subtle.[3] Unfortunately fear of lawsuits has made all of us order tests for insignificant findings.

Beethoven and Yiddish

B''H

Many people have asked me to tell the story of how a Beethoven sonata is related to how people speak Yiddish today. Okay, I will take a crack at it. But a warning, it is very politically incorrect.

First, some background. My wife, spoke five languages fluently, English, German, Yiddish, French, and Hebrew, where German was her best because she has studied it most intensely and spoke multiple dialects, including archaic ones; played flute, alto flute, piccolo, recorders, historical flutes, piano, harpsichord, and harp; had received performance certificates from two music conservatories, one in France and one in Chicago; had studied music with Helen Kotas Hirsch, the first woman to be a first chair with a major symphony in the United States, the Chicago Symphony; and had received a Masters degree in musicology from the University of Chicago where her major interest was 18th-century German music theory (meaning she was unemployable).

Where is Joe Welch?

B''H

(slightly cropped)

While decluttering my house after the death of my dear wife, I found this photograph (yes, that is me), taken circa 1980. Whenever I show this photo, the immediate response is laughter. If I attempted to do this today, assuming I could get this close, the end result would probably be a bullet through my head. Back then, nobody cared. I am sure if I had jumped the fence, something would have happened. We, as a country, have gone overboard.

Consider what happened to the lady who either had a mental breakdown or simply panicked when she approached or tried to run her car into the grounds of the White House. She was shot down like a dog. It is not that she was simply shot but that she was shot so many times "they had difficulty identifying her because of the extent of her injuries"[1]. If you take the time to view some of the videos taken after the incident, you will see the officers involved carrying M-4s: the same weapon our troops use in Afghanistan. Lethal military-style force with overkill was used against an unarmed civilian who probably had a psychological disorder with a baby in a car. And nobody, at least in power, seems to care.

Our country has a long history of periods of overreaction against foreign threats: the Alien and Sedition Acts over fears of the French Revolution coming to the United States; the Know-Nothings in the 1850s after the revolution of 1848 in Europe associated with the influx of immigrants from Germany and Ireland; the Red Scare after 1919,  the Russian Revolution; the McCarthy era in the 1950s; and, I believe today, after 9/11.

On continuing the process described above, I discovered correspondence between my wife's grandfather and his relatives in Europe prior to and during World War II. The letters are written in Polish, Yiddish, and German. When I showed them to my 92-year-old father-in-law to find out who was who, he expressed interest and surprise, asking "where did I get them?", having never seen them. They had sat in his basement for 30-plus years in a box after the death of his mother. I have inherited them. In 1939 the return address on a series of them changed from Lodz, Poland to Warschau (German for Warsaw) with a Nazi stamp on them. Until 1941 the postmarks in Chicago are dated fairly contemporaneously, but after that date the letters were not received until 1946. This entire family perished.