THE  ART  OF  MEDICINE

The ART of SEEING

Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. — Sir William Osier

When we first arrived in Montreal, my wife and I initially planned to stay for three years, and then assess our professional situation. As it happened, our third anniversary in 1976 roughly coincided with the surprise election of the separatist Parti Quebecois, led by the mercurial journalist-turned-politician Rene Levesque.

The election results sent the anglophone community in Quebec into a state of shock. I vividly recall walking into Royal Victoria Hospital, at the north end of the McGill University campus, at 9 a.m. on the morning after the election and finding it virtually deserted. The corridors, .coffee shops — completely empty. It was as if an official order had been issued to vacate the entire premises.

Virtually no one, it is safe to say, had anticipated the PQ victory, and the ensuing days and weeks were full of discussion about what its election might mean for government policy on a broad range of issues, including health care. Even in those early days, colleagues began to talk out loud about the very real possibility of leaving the province. Tens of thousands of anglophones ultimately ended up doing so, perceiving that in Levesque's Quebec they would become second-class citizens.

Curiously, perhaps, my wife and I did not seriously consider making an exit. We had both been so happy, personally and professionally, that leaving was not a consideration. Our children were enrolled in excellent schools and had adapted nicely to Canadian culture. Barbara had completed her residency in dermatology and gone into private practice in leafy Westmount, a short walk from our home. She also had a part-time consulting appointment at the Royal Victoria Hospital.

I was busy teaching as an associate professor at McGill University and working as a consulting physician, also at the Royal Victoria Hospital. The administration had allowed me to practise medicine the way I wanted to practise it and to develop my leadership skills. An important mentor for me was Dale Dauphinee, a gastroenterologist who chaired the department's Medical Education Committee and later served as executive director of the Medical Council of Canada.

Dauphinee had a distinct style of management. He was very calm, at once articulate and deliberate. In meetings, his tendency was to sit back and let others lead the discussion. But when a critical issue was on the agenda, or when he felt a poor decision was about to be made, he would sit up and sharply slap his hand on the table and say, "I'm sorry, that's not good enough. We have to do better." It wasn't done in anger, but with firm resolve. That impressed me. He was usually so restrained that on those rare occasions when he decided to exert his authority, it became all the more effective. I tried to model my own managerial performance on those lines, walking softly and carrying a stick that I wielded only when necessary.

All too quickly, it seemed, our three years became five years and then 10. In my capacity as head of the Royal Victoria Hospital's general internal medicine, I was allowed to hire six consecutive chief residents, all of whom went on to enjoy distinguished medical careers. These included Ken Flegel, a consulting internist at the Royal Vic, senior associate editor of the Canadian Medical Association Journal and a professor of medicine at McGill; Linda Snell, also a professor of medicine at McGill and senior clinician educator at the Royal College of Physicians and Surgeons of Canada; David Dawson, associate professor of medicine at McGill, an attending physician at the McGill University Health Centre, chief of service of a clinical teaching unit and winner of numerous teaching awards; and Sam Benaroya, recently the acting dean at McGill Medical School.

All of them were from different parts of the country, but they all had graduated, in effect, from the flower child school of philosophy that had been so prevalent during the late 1960s and 1970s. They espoused that more humane approach to practice, even though medicine was then beginning to feel the dramatic impact of several extraordinary technological breakthroughs. In some sense, perhaps, their approach was a reaction to those developments, because these physicians clearly expressed the desire to be more than mere operators of machines, however sophisticated — more than the servants of technology.

"I want," they told me, "to be a doctor that can act on the same patient-driven impulses that made me want to choose medicine as a profession."

I had already established a division of general internal medicine. Within that, I also developed an internal medicine unit (IMU), a model group arrangement in which young physicians were invited to practise collectively, just as they would in private practice. As closely as possible, we tried to mimic the way "private clinics" worked outside the hospital. All of these residents-in-chief and many of their subordinates eventually became part of this unit.

But there were two issues that would ultimately lead Barbara and me to make career changes. The first of these was the political climate that developed in the years that followed the ascension of the so-called Pequistes. We largely learned to live with challenging reforms and budget cutbacks, which became routine. But we were increasingly conscious of the population exodus, particularly of young people, who perceived brighter potentials in Toronto, Western Canada or the United States. It was not a vote of confidence in the future of Quebec.

The other factor was language. To practise in Quebec, we had both needed to demonstrate fluency in French one year after our arrival. My wife had no difficulty with this stipulation, but I did. I had never studied the language and had only the very limited vocabulary necessary for day-to-day interaction with francophones. Thus, not long after settling in at McGill, I enrolled in an instructional class. Given my handicap, I was categorized as a pre-beginner, one of 10 in the class.

The first session was a revelation, conducted entirely in French — immersion. I was completely lost. Five weeks later, halfway through the course, I still had no clear idea what anyone was saying. However, I did manage to understand the teacher when she told me that I was among the most difficult students she had ever had.

"You must be Chinese," she said.

cTm Jamaican," I protested.

"What language did your parents speak?"

"Chinese."

"Well, that's it, then. That's why you have so much trouble with French."

I was not alone, apparently. A colleague of mine, enrolled in the same class, was taking the pre-beginner's course for the fourth time.

One wintry weekend, Barbara brought home a long-playing record designed to teach French, along with a 50-page booklet. I spent the entire weekend playing the record, studying the book and memorizing vocabulary. By Monday, to my own and others' amazement, I could actually conduct a simple conversation in French.

At our next class, my teacher greeted me with the usual, "Bon soir, Hebert." I responded with a 15-minute monologue in French. I was very proud of myself and my progress — until I took the French exam of the Office Quebecois de la langue francaise (French language test for professionals). The pass mark was 75. I earned a 65.1 had failed.

"What am I going to do now?" I asked my wife.

Then I had an idea. I called up the government office that administered the exams. I introduced myself in French and explained everything that had happened. I spoke for 10 minutes. We had a very cordial conversation. The official in charge said to me, "Your French is very good. Why don't you come down to the office for a chat? Come tomorrow. WeTl examine you in person." Perhaps he wanted to make sure that I was, in fact, who I said I was.

The next day, I went to see him and an exam board of four others. We spoke in French for 20 minutes, after which he told me in French, "You passed."

Of course, he said it so fast in the heavily accented Quebecois

style — and my French comprehension was still so rudimentary

— that I didn't understand what he had said. He repeated it a

few times in French and then finally, when I still was struggling,

shouted at me in English, "You passed! You passed!"

In terms of language, then, there was no need for Barbara and me to leave Montreal. We were happily ensconced in a lovely Westmount home, once owned by the president of the Sun Life Insurance Company. And yet, a feeling of linguistic inadequacy continued to nag at me. In internal medicine, you needed to understand and be able to communicate nuances. It's exactly such nuances that constitute a critical part of the art of medicine. And the nuances of Quebecois French, I felt, were — and would always be — beyond my ability to master.

The same was true professionally. McGill and the Royal Victoria had given me a wide berth, allowing me to create the internal medicine unit — the first new one in Canada for almost 50 years — and to hire staff.

But I also knew that if I were ever going to leave Montreal, now was probably the right moment. I was in my early 40s, old enough to be considered a seasoned physician, but still young enough to build the next stage of a career. I had become something of an evangelist for the importance of general internal medicine as a distinct discipline, writing for the Canadian Medical Association Journal and speaking at 14 medical schools across the country on the topic. And increasingly, the Canadian medical establishment's governing bodies had been willing to embrace that idea.

As a result of these efforts, the Royal College of Physicians and Surgeons subsequently decided to elevate the role of general internal medicine and invited me, under its auspices, to chair a new special committee on internal medicine, with the power to set national standards. I would remain in that position for five years.

In turn, several colleagues and I constructed a Royal College training program geared more directly to general internal medicine, so that it would no longer be an orphaned specialty of the curriculum. Residents in their fourth year could now choose to focus on general internal medicine alone. And we insisted that all residents spend a full year in a clinical teaching unit—a model that had been established by the legendary Sir William Osier. At our discretion, medical schools that did not comply could be awarded only provisional accreditation, the equivalent of a reputational black eye. That gave us some real leverage.

In time, on the recommendation of Edmonton's Dr. Allan Gilbert and its own administrator Ted Gyles, the Royal College also created the Canadian Society of Internal Medicine, with Toronto Western Hospital's Dr. Peter Clark as its first president.

In the meantime, Barbara and I had finally resolved to make a move. I received a very kind offer from the medical school at McMaster University, but they wanted me to refashion myself as an epidemiologist, which I felt loath to do. I had an equally generous offer from John Dirks, a former colleague of mine at the Royal Vic, who had moved to Vancouver as physician-in-chief and chairman of the department of medicine. It included a staff position and an associate professorship. But during a long courtship, it became clear that Vancouver was not particularly looking for a general internist, and apparently even regarded Dirks, a nephrologist, as something of an outsider. Nor did I feel that Vancouver then was at, or even near, the cutting edge in medicine.

We had already listed our home for sale — my fallback position, if no acceptable offer materialized, was to go into private practice — when Peter Clark called me one morning from Toronto. By the afternoon, we were having coffee in Montreal and he was insisting that I come to Toronto and assume his position as divisional head of general internal medicine. He planned to step down and take a leadership job with Credit Valley, a new hospital under construction west of Toronto. He conceded that he did not yet have formal authorization to make the offer, but assured me that it was just a formality.

He was good to his word. That spring, I accepted Toronto Western's offer to become director of general internal medicine and director of the residency training program. While Clark waited for Credit Valley Hospital to open, he would remain for a year to assist me.

Soon after I accepted the offer to work in Toronto, Montreal's Royal Victoria decided to create a Teacher of the Year Award for the department of medicine. In 1983, this represented, a breakthrough for teaching at McGill, where promotion was always based on research and publications (the classic publish or perish philosophy). I was honoured to be designated as the first recipient. But, two days after I was notified of the citation, department officials learned that I had agreed to move to Toronto. They promptly revoked the award. At a subsequent meeting, the dean insisted that he did not want me to leave. But by then it was too late. It was clear to me that despite the creation of the award, teaching — and innovations in teaching — was not considered part of the promotion system at McGill. They were unlikely to bend on this point.

As advocate for general internal medicine, my argument was quite simple. The practice of medicine for the past quarter century had been marked by two dominant features — an explosion of science and technology that began in the late 1950s, and the emergence of medical subspecialties (cardiology, gastroenterology, nephrology, respirology, endocrinology, infectious diseases, etc.).

Indeed, the two went hand in hand because technological innovation made possible new diagnostic tests and equipment that not only extended our tool kits, but required specialists capable of using them and understanding the results. Thus, nephrologists could become experts in dialysis. Cardiologists could master the intricacies of echograms and cardiac catheterizations. Gastroenterologists learned how to use the endoscope for a variety of scoping procedures.

Technology was not only cutting-edge and glamorous; it was rewarding. Government payment schedules effectively encouraged the compartmentalization trend. If physicians performed these procedures, they were paid additional fees. In this environment, specialists in general internal medicine became somewhat marginalized. We were often asked, "What's your role here? What's your specialty?" Not having one became a liability. In a graduating medical class of, say, 60 interns, 58 would typically choose to immerse themselves in a medical subspecialty for their residencies. Part of this was pure pragmatism, because there were far fewer jobs for general internists than for specialists.

These developments, however, were not without consequence, particularly with respect to aging populations and multi-system diseases. If you had chronic lung disease, you saw a respirologist. If you also had a heart condition, you'd also see a cardiologist. If you also had diabetes, then you'd have to see another specialist, an endocrinologist. And if you suffered a stroke, you'd see; a fourth specialist. Elderly care thus tended to become seriously compartmentalized, with no single physician acting as quarterback, a situation that left many patients confused and dissatisfied.

Although the Royal College had supported my initiatives, the broader reception I received was neutral, at best. While physicians in Winnipeg and Halifax were sympathetic to my position, I was treated coolly in Vancouver and with some hostility in Toronto. In fact, at a meeting of several chiefs of medicine in Toronto to discuss these issues, one of them — he shall remain nameless — actually fell asleep. At another Toronto meeting, at Wellesley Hospital — it relied almost totally on subspecialties at the time — my pitch for a general internal medicine unit was dismissed. I maintained that if they continued on this path, residents would eventually choose to go elsewhere.

One prominent rheumatologist rose and declared that he disliked the tone of my speech because it implied that I was arberter teacher than he was. And he'd been teaching for 40 years.

That wasn't remotely my intention, of course.

"I accept your opinion, sir," I said. "But I need to tell you that things have to change."

That exchange was typical of the battle I had to fight.

Wellesley Hospital did eventually change — but not fast enough. By the time it switched to a clinical teaching unit run by general internists, it was too late. In 2002, Wellesley effectively disappeared. Its teaching role was relinquished and its various departments were absorbed by St. Michael's Hospital.

It is not possible to draw a straight line between the renewed emphasis on general internal medicine and improved patient care.,In fact, no study I am aware of has shown that changing the medical curriculum has bettered hospital results. Nevertheless, I'm convinced that this shift to new ideas did sharpen the skills of medical residents and lead to better job satisfaction. In turn, I would bet, that also led to improved patient care.

On July 1, 1984, Canada DAY, my family arrived in Toronto to v begin the next chapter of our lives. For the previous 10 years, we had used the holiday to take the kids to a swimming pool or a park. On this occasion, I had an orientation day scheduled at the hospital. I set off cheerfully in the morning in my car and had not gone very far down Bathurst Street when I spotted a woman in a black cap trying to wave me down. Thinking she needed my help, I stopped.

It turned out she was a police officer, tagging me for speeding.

"But I was only going 60 kilometres an hour," I protested.

"The speed limit is 50," she said. "Oh, you have Quebec licence plates I see."

"Yes," I said, "the speed limit is 60 in Quebec, and I've just moved here, and it's my first day of work at the hospital. I'm on my way there now."

It was no use. She showed no mercy and promptly wrote up the ticket.

Welcome to Toronto, Dr. Ho Ping Kong.

Toronto western, I felt, was the right place for me. Its large down town patient population, to which I was accustomed, meant that I would be faced with a goodly share of diagnostic challenges.

Not long after I began to practise there, I was reminded again how important it is during examinations, not only to look at the patient, but to see what you are looking at. In this instance, it wasn't my own powers of observation that mattered, but those of a sharp-eyed emergency ward nurse.

I was in the ER one afternoon when my resident, Dr. Jeannie Callum, presented a young woman named Emily, about 30 years old, who had been admitted with severe abdominal pain. Her blood pressure was normal but, while there was no specific mass detected, her abdomen was distended and there was marked tenderness. Then, while I was checking her, the nurse mentioned in passing that something strange had happened when the blood pressure reading had been taken. Emily's hand, involuntarily, had gone into spasm and formed itself into a cupped shape — a reaction medically known as carpopedal spasm (sometimes called Trousseau's sign or the obstetrician's hand).

I immediately turned to Dr. Callum and said, "I think your patient has acute pancreatitis."

"How do you know?"

I knew because, in patients with such conditions, it is not uncommon for the hand to go into spasm when the blood pressure cuff is applied. The precise physiology is complex: when you have pancreatitis, you release enzymes that lead to the formation of calcium deposits in the peritoneum, the lining of the abdominal cavity. In turn, serum calcium levels fall, sometimes precipitously. The low calcium (hypo-calcemia) causes spasm in the hand (carpopedal spasms). The hand then cups in the rough shape of an obstetrician delivering a baby. Some patients with low calcium levels also exhibit a facial tic known as Chvostek's sign; to detect it, the cheek is tapped gently with a finger over the facial nerve.

Our diagnosis was subsequently confirmed by a CT scan that revealed abdominal inflammation, and by high readings of the enzyme amylase in the blood. The treatment for this condition must be tailored to the specific situation, but in general it is important to rest the pancreas by not eating, and to administer calcium supplements to correct the deficit and eliminate the carpopedal spasms. Undiagnosed or unchecked, acute pancreatitis can lead to serious abdominal and lung problems.   

There are, of course, dozens of names like Trousseau's sign and Chvostek's sign in the professional literature, usually named for the physicians that first discovered them (and sometimes for their patients). They tend to date from a period before the introduction of evidence-based medicine when experience and observation counted far more than science.

ANOTHER INTRIGUING CASE I  RECALL involved a 30-year-old woman named Julia who had been referred to me with lumps on her Achilles tendons. She'd already had both a biopsy and an MRI, but no formal diagnosis. And she was clearly frustrated. When she initially appeared in my office, she refused to show me the lumps, explaining that she hated doctors. Finally prevailing upon her to let me examine one foot, I found lumps that were the size of small, two-inch potatoes. The second foot was the same. The nodules were large enough that Julia could wear only loose-fitting running shoes.

"I'll tell you what you have," I said. "You have tendinous xanthomatosis."

This is a rare, genetic condition under which lumps form on various parts of the body, including heels, elbows and knees. It is caused by an abnormality in the metabolisnvof cholesterol, which results in very high cholesterol readings. Hers was 10 (four is considered normal). Some forms of the disease are treatable by drugs. But Julia's form of the illness is more pernicious and less amenable to such therapy. I had to tell her that while we might be able to control the size of the nodules, we likely could not make them disappear. In the meantime, we also had to bring down her cholesterol levels, which would otherwise put her at risk for coronary heart disease and stroke.

I did, eventually, learn the source of Julia's animus against doctors. She was a single mother whose husband had died a few years earlier, at the age of 30, from pancreatic cancer. The tragedy had left her with bitter feelings for the medical profession. More than a decade later, I am still treating her, and Pm pleased to say she no longer holds us in contempt.

However, the larger lesson of this story is that a dozen fancy medical scans and even invasive tests were not required to diagnose the illness — only the powers of visual observation. That isn't always the case, of course. But it is the case more often than you might expect.

A patient's testimony— Julia H.

I was born in England and came to Canada at five. My dad was a cabinet maker. My mother worked for a cookie manufacturer. I have a high-school education and have worked ever since. I am 49. My illness just appeared, suddenly, without warning or known cause. I woke up one morning and had these lumps on the back of my feet. One was smaller than the other. That was about 13 years ago. No one else in the family has it.

I saw my family doctor, who said it was a result of wearing high heels. But I don't wear high heels. I didn't argue, but I knew that was wrong. I saw a second general practitioner who eventually sent me to Dr. Ho Ping Kong — HPK. I don't really mind doctors. I just like to joke around about it. But I was initially reluctant to show him the bumps, because it was embarrassing. Now, I'm okay with it. After looking at the lumps and feeling them, he told me I have a kind of xanthomatous. I went for various tests, a biopsy, an MRI, etc., which confirmed the diagnosis.

So it turns out there are two kinds of this illness and mine is the more serious type. It may take years to get better. It may not get better. It may get smaller or not. There is no pain, fortunately. I function and walk normally. It's just the visuals. I wear ankle boots in the winter, and Crocs in the summer. The bumps are just localized to this one area. I'm on Crestor for cholesterol, five milligrams per day. I take thyroid pills and have blood work done every three months. There are much worse things out there. Sol accept it and I live with it. I can manage. It's part of my life. It seems to be working.

I see no other doctors. I'm comfortable with HPK. Some doctors don't sit and talk to you. Everybody's in a rush. But he isn't. We sit, we talk, we have a laugh. You should be able to do that. When I come here, I feel like I'm going to my second home. Doctors need to do that. They 'need to make the patient feel safe and comfortable.

……

Not long ago, A colleague of mine, a rheumatologist, sent Evelyn to see me — a Chinese-Canadian medical research scientist in her mid-50s: Complaining of fatigue, she had been losing weight (about 20 pounds) and had developed tachycardia (a fast pulse), a tremor and a nagging cough. For the initial diagnosis, asthma, she'd been prescribed a puffer but, after a few weeks, it was clear this remedy was not working.

When Evelyn appeared in my office, her pulse rate was 140 beats per minute. I asked her to remove her sunglasses and;, the moment she did, I was pretty sure I knew what was wrong with her.

"Tell me," I said, "are your eyes always like that?"

"Yes," she replied.

Her eyes were fixed and unblinking. In medical parlance, this was Stelwag's sign, a possible indicator of Graves' disease or hyperthyroidism. Its cause is essentially unknown, but it is likely an autoimmune disorder. And it is quite common in Asians, especially women. A familiar symptom of the ailment is bulging eyes, otherwise known as proptosis. The condition sensitizes human organs and tissue to adrenalin — the so-called fight-or-flight chemical.

On further examination, I found confirming evidence: an enlarged goitre — a swelling of the thyroid gland — and a thyroxine count near 100 (normal is 9-19 pmol/L). In fact, she was very close to thyroid storm, a potentially fatal event in which the thyroid gland suddenly releases large amounts of hormones.

A patient's testimony—Evelyn

It was 2005, the end of September, and I had just finished writing research grant proposals. My husband and I went fishing in the Thousand Islands. I developed a sore throat, came back and started coughing. This went on for a few months. The cough was so bad that, at times, I could not talk. My colleague suggested I see a respirologist. I was also losing weight, quite a lot of weight. I was happy having lost the weight but then, in one month, I lost 10 pounds. I now weighed less than 100 pounds, so I figured something was wrong. So instead of seeing the respirologist, I was referred to Dr. Ho Ping Kong. He was away on holiday and I remember a day where just crossing the street, I experienced severe shortness of breath.

So I went to a walk-in clinic. I suggested to the doctor /there that it might be asthma. She listened to my lungs, but they were clear, so she gave me a puffer. I used it for a week without effect and finally went to see Ho Ping Kong. He took a full history, but his first question to me was "Are you nervous?" I said, "I know you are a big-shot doctor, but I am not intimidated." In fact, nervousness is one of the symptoms of this thyroid condition. So he hadn't even looked at my thyroid but he already knew. He told me right away what I had.

But I was surprised because in the year 2000, I'd had thyroid surgery to remove a cyst on one side. I'd lost half the thyroid. You wouldn't think half a thyroid could produce hyperthyroidism. It should have been hypo, not hyper, so it never crossed my mind. In fact, since I was a child, various doctors had looked at my eyes and suggested I might have a thyroid problem, but the tests had always come back normal. After a few more tests, he diagnosed Graves' disease, a form of hyperthyroidism. I took medication for about two years and I've been fine since then. I've been very privileged to have had him. As a medical researcher myself, it's hard for me to trust doctors. But that's not true of Dr. Ho Ping Kong.

……

Hyperthyroidism is often difficult to diagnose because patients don't always exhibit the full range of symptoms. It might only be indicated by tachycardia or weight loss. For that reason, it is sometimes known as masked hyperthyroidism or apathetic hyperthyroidism.

In Evelyn's instance, everything pointed to the correct diagnosis, except her cough, which instinctively I ignored. But the other indicia (the fast pulse, weight loss, racial legacy and, most especially, fixed stare — what I saw when I looked directly at the patient) told me as much as I needed to know.

It's important to make clear that no part of my argument should be interpreted as an indictment of medical technology. Quite the contrary. The truth is that many of the remarkable advances made in our understanding and treatment of disease would simply not have been possible without technological innovation. Technology has catalyzed less invasive surgical procedures, significantly reducing the length of hospital stays, rehabilitation times and costs. For tens of millions of ambulatory patients, a wide range of innovations — pacemakers, insulin pens, prosthetic devices, oxygen masks, to name a few — have greatly improved the quality of life.

In my own field, computed tomography (ct scans), magnetic image resonance (mris) and ultrasound imaging have made diagnosis of illness easier, faster and more precise.

For example, when I started practising in the 1960s, and for many years afterward, diagnosing something like a liver abscess was often difficult. Any number of conditions might have fit a patient presenting with fever and right-sided abdominal pain. Today, a single ultrasound or CT scan can make detecting that potentially fatal condition relatively easy.

In other instances, these scans can provide a critical complement to diagnoses made by the powers of human observation. In my early years in Toronto, I was sent a case involving Yolanda, a 40-year-old Guyanese woman suffering from sarcoidosis. One of many ailments still imperfectly understood, sarcoidosis is a multi-system disease characterized chiefly by inflammation, often of the lungs or lymph nodes. In some ways, the affected tissue resembles tuberculosis. Unlike TB, it is not infectious. It is, however, serious and can lead to serious complications, including respiratory failure and death, from involvement of the heart's electrical system.

Yolanda had already been diagnosed when she reported new and crippling pain in her hands. After she refused a bone biopsy recommended by a plastic surgeon, she was referred to me. I examined and felt her hands and immediately concluded she had sarcoidosis of the hands and bones. An MRI later verified that diagnosis.

Oddly enough, while I saw very little sarcoidosis in Jamaica, I saw it in England among Jamaicans who had moved to the U.K. — perhaps the result of living in a colder climate. The same later proved true in Toronto, among the expatriate Jamaican community. Fortunately, especially among young women, the ailment responds well to prednisone and is usually self-limiting. On the other hand, it can also affect the eyes, liver and the brain.

In Yolanda's case, it was the combination of physical diagnosis •—- seeing and feeling her hands — and the marvel of the MRI that allowed us to correctly identify her condition.

Of course, it is one thing to recognize a telltale symptom in a patient. It is another to know how to interpret it. On one occasion, a colleague of mine, an orthopedic surgeon, asked me to examine Nadia, a young woman of 29 years he suspected of having nephrotic syndrome — a kidney disorder. He was treating her because she had been born with what is known as a meningocele — a hernial protrusion of the meninges that damages the spinal cord. Despite her disability, she had been a talented wheelchair athlete in university and had found work after graduation in a bank. His diagnosis of nephrotic syndrome had been based on what appeared to be a solid clue — a sharp drop in protein (albumen) levels in Nadia's blood. When that happens, edema is often the result and, indeed, her legs were swollen.

When she came to see me, Nadia was wearing earrings. That might seem like an irrelevant detail. In fact, it is anything but. Her jewellery allowed me to see that her earlobes were moving involuntarily. That, in turn, immediately told me that something was wrong with her jugular venous pressure (JVP), one of the major clinical indices of heart failure. I suspected that her long years of enforced sitting had damaged her lungs, leading to right-sided heart failure, with incompetence in the heart's tricuspid valve.

Alternatively, I thought she might have cardiomyopathy, a disease of the heart muscle that causes edema and other serious problems. I was intuitively skeptical of the nephrotic syndrome diagnosis because her edema was largely confined to her legs, instead of where it usually is with this condition, in the face. I sent her to see a heart specialist (Dr. Tom Parker, who later/ became physician-in-chief at St. Michael's Hospital) who, after performing an angiogram and a cardiac biopsy, confirmed the cardiomyopathy, for which we treated her successfully.

Again, it was the mere sight of the involuntary earlobe fluctuations with each heartbeat that had pointed me in the right direction. When you see that, you know immediately that something serious is going on. Thus, while I never advise patients to wear earrings to appointments, I am never disappointed when they do. It certainly makes spotting anomalies in jugular venous pressure easier.

not far prom my hospital office is a pharmacy I frequent. Over the years, I came to know its owners, an industrious couple from China. One day, I stopped in to pick up a prescription. When the owner approached the counter, I immediately noticed a lump in his neck.

"David," I said, "you have a small lump in your neck."

"Yes," he said, "I was planning to come and see you about it."

"What else is going on, medically?"

"A year ago, on a flight to Hong Kong, my nose became very stuffy and I had a nosebleed."

"Do you know what this is?" He shook his head.

"It's probably nasopharyngeal carcinoma." He came to my office the next day for an examination, a CT scan and a biopsy, which confirmed my instinct.

How could I make the diagnosis so quickly, on the evidence of only a lump and a nosebleed? I knew that David was in a vulnerable category. South Chinese men and women in their 40s are the prime victims of the disease. My own father had been diagnosed with it, also in his 40s, and been successfully cured with radiation. David's case was more advanced and he thus underwent both radiation and chemotherapy, and four years later he seems to be cured.

Sensitive clinicians, however, will not only rely on their eyes to make a diagnosis. As we will see in the next chapters, they will also learn to use the extraordinary powers of the human ear and of human touch.

………………..