Clinical Pneumonia or Virtual Health?

“So, are you saying Bobby really didn’t have pneumonia?” Mrs. Halstead asked. Her eleven-year-old son, a boy with multiple medical problems, had been in the office ten days before with fever, a bad cough, right-sided chest pain with each deep breath, and very loud crackles in the lower portion of his right lung. His blood count was normal and his chest x-ray looked almost normal – you could argue that it looked a little streaky in the right lower lobe, but the city radiologist who read his x-ray without actually listening to his lungs thought it was a normal set of pictures.

Bobby felt good at his follow-up appointment, and his lungs sounded clear. So, had I been wrong in diagnosing him with pneumonia when the radiologist didn’t agree with my interpretation of the films?

I remembered the case of Fanny Brown, my receptionist’s mother. She had a nasty cough and was losing weight. Her chest x-ray was normal, but her CT scan showed a tumor the size of a baseball – we all know a chest x-ray isn’t always the final word on what is wrong with a patient.

I tried to explain to Mrs. Halstead that a camera, even one used for x-rays, has its limitations.

“If you see a pretty rainbow and pull out your camera to capture it, but the picture doesn’t show the rainbow, does that mean you didn’t see a rainbow?” I tried.

There is an old Swedish military and Boy Scout joke, which I heard in both places: When the map and the terrain disagree, you go by the map in the military and by the terrain in the Boy Scouts. I spent more time as a Boy Scout than as a soldier – my inclination has always been to trust my assessment of the terrain.

I was on call for Christmas, and had a few days off around New Year’s. Catching up on my journals, I was delighted to find a piece in the December 25th edition of The New England Journal of Medicine by Abraham Verghese, MD, entitled “Culture Shock – Patient as Icon, Icon as Patient”. Dr. Verghese describes teaching residents, who seem more inclined to look at their patients through the “eyes” of the electronic medical record than through bedside clinical observation. He also talks about what to do when the map and terrain don’t seem to agree. He quotes Alfred Korzybski, the Polish-American philosopher credited with founding the theory of general semantics, who said, “the Map is not the Territory”. I’m not sure which of the two Korzybski thought was more real.

Bobby Halstead had been ill, and now he was well. I don’t know what his mother really thought of my diagnosis of his pneumonia, but it was a great illustration of what Dr. Verghese wrote about a short while later in “The Journal”: Our technology, invented as a way to document clinical reality, has almost become more real than the disease states it was designed to document.