Wednesday, October 8, 2014

To Examine or Not to Examine That Is the Question


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.

Sunday, October 5, 2014

Beethoven and Yiddish


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).