Transcript

Lee Tetreault:

Hello and welcome to Frequently Asked Questions from the session 'GAIT: An Eyeblink Diagnosis'. Today, we are joined by Dr. Sal Mangione. First, let's talk a little bit about you, Doctor, and your background. Can you give a little introduction for our audience? 

Dr. Mangione:  

Yes. I work at Thomas Jefferson University in Philadelphia and Sidney Kimmel Medical College of Thomas Jefferson. And I teach physical diagnosis, which is pretty much what this session is about, but I also teach the humanities, and particularly, I have an interest in observation.

Lee Tetreault:

And this session speaks to An Eyeblink Diagnosis, what is that? 

Dr. Mangione:  

Yes, it's the capacity of physicians, which has always mesmerized the public, of making diagnosis at first sight. It's actually a translation of a German term augenblick, which literally means eye blink. Sometimes, just looking at us, they can figure out exactly what we have, and that, I think, is a wonderful skill.

Lee Tetreault:

Can we talk a little bit about observing gaits? 

Dr. Mangione:  

Yeah, so gaits, and that is the reason why I prepared this talk, is one of those diagnoses that can be made at first sight. And yet, many physicians, and there's plenty of data on that, are not really good at it. There are two fundamental reasons. The first one is that they haven't really been taught during training how to observe abnormal gaits, but more importantly, they haven't really been taught how to observe. In many ways, what this topic is, is an application of the much larger and more important skillset of the physician, which is the capacity to observe.

Lee Tetreault:

Why is it so important to develop our human observation skills at as young of an age as possible? 

Dr. Mangione:  

Yeah. What happens is that as soon as the baby is born, it is absolutely flooded by information. The baby learns very quickly, the human brain learns very quickly to filter out extraneous information, to pick up only a few trees. And then, through pattern recognition, build a forest. The problem with that approach, which usually works, is that by the time you become a physician, or a detective, or an artist, or a hunter, for example, you really have to let in all the information. You have to pick up all the trees, because otherwise, your brain might inform you that you are in a Mediterranean forest, when in reality, you are in the Amazon. It's fundamental for a physician. Many diagnoses can be based on astute observation. William Osler was probably the most humanistic and well-rounded up of physicians of the turn of the century, used to say that all of medicine is observation. But he also added that there is no more difficult art to acquire than the art of observation.

Lee Tetreault:

Can we have some examples of where this observational technique should be prevalent in primary care? For example, you relayed to me a fascinating story about Jonathan Larson, the author of the play Rent. Can you go into that for our audience? 

Dr. Mangione:  

Yes. We have, sometimes, the belief, and I wouldn't even call it the delusion that the technology is gonna give us the diagnosis. The reality is that diagnoses, and there's lots of data on that, come from the interaction with the patient, which is history-taking and physical exam. Sometimes, the physical exam is actually the one that makes the diagnosis. The case of Jonathan Larson is a good example. Larson was the author of Rent, a young playwright. This was his break. He was struggling economically. And the night before the opening of Rent, he showed up three times in various emergency rooms of Manhattan complaining of chest pain. The pain was vague, he was a young man, he was tall and lanky. He looked like an artist. And these guys were busy and they basically said, "Listen, everything is fine. You're just tense, go home, relax. You'll be fine." He went home and he dissected on the kitchen floor from an aortic aneurysm as a result of Marfan syndrome. He had this condition named Marfan, which is associated with a high stature, tall, long people, but at the same time is associated with a weakness of the aortic wall, and so the aorta literally bursts.

Now, what is unique about this folks, is that they are disproportionate. They are all legs and very short torsos. Normally, the center of the body is the symphysis of the individual. If you look at Vitruvian Man, Leonardo da Vinci's self-portrait at the age of 39, the center of Vitruvian Man is the symphysis. But in Marfan syndrome, everything has been shifted up. If you are an astute observer, and you know what is normal, and you pick up the outliers, that's the patient you check pulses. And I bet that that's not what was done in Jonathan Larson, and Larson died. Now, there is no test that will tell you that if you don't suspect it clinically. And that's why relying on tests is literally the tail wagging the dog.

Lee Tetreault:

How does this correlate with how we can communicate better, and communicate with each other, and how does that relate to just human connection, in general? 

Dr. Mangione:  

Well, there is another major reason why observation is very important for physicians, and it's that we establish empathy through eye contact. Empathy is a unique characteristics of human beings, which I think from an evolutionary standpoint was put there so that we don't kill each other. And in fact, in fact, what makes it very difficult, literally for people to kill each other, is to do it at short distance where you see the eyes of the person. Nowadays, of course, with technology, it has become obliterated, that aspect, but you just can't kill people that you see in the eyes. That's how human beings are made. Empathy relies on my capacity to connect with you through observation. I see you and I can detect emotions. And then, of course, I'm willing to help you and to act upon those emotions. I look at you and I say, "You look sad." That's my empathetic connection. And then I'm asking, "What's going on?" so I can help you out. For physicians, empathy is fundamental.

We know that empathetic physicians have better care of diabetic patients, fewer complication rates. Nothing new, Hippocrates talks about how many times, despite being severely ill, patients improved through their contentment with the goodness of their physicians. It's very healing. Now, the problem with that is that today we require physicians to look at computer screen for 40% of their time and patients only 10%, so you're not gonna pick up clinical information, which is valuable, you're not gonna pick up that emotional connection, which is healing, and that is a problem.

Lee Tetreault:

What can people do to get better at observation? 

Dr. Mangione:  

Well, the first one is to become aware that this is an important component of the physician's skillset. Once you have done that, there are two things that I think you can do for yourself. The first one is to become aware of what is normal, so you can pick up the outliers a little bit more easily. We do not teach medical students, for example, human proportions, the characteristics of the normal human figure, they should. For example, where are your ears positioned compared to the rest of the face? What's the width of the upper third of your face, the mid third, the lower third? The fact that you have a more pronounced lower third, what does it implicate? The fact that you have more pronounced in mid third, which is typical, for example, of patients that have sleep apnea or they may have enlarged adenoids. All of these should be taught.

And the other one is what Sherlock Holmes used to tell Watson, "I force myself to look at things that other people overlook." You need to pick up all the trees and there are exercises for it. My advice is to learn how to sketch, which physicians used to do. If you have to sketch something, you're really gonna look at it. And I'm not gonna saying drawing, because drawing implies a sort of completion where the inner critics cannot tell us that we're not particularly good, I'm saying sketching.

I would say, become aware of the normal, become aware that this is an important part of the physician skillset, maybe learn how to sketch, and then lastly, which is very important, the eye doesn't see what the mind doesn't know. The more you know, the more you will see. And I would like to conclude, probably, by suggesting a book, if people are interested, called On Looking, which came out a few years ago, and that was written by a canine psychologist, a woman that actually takes care of the psychology of dogs. And she noticed that whenever she was walking her neighborhood with her dog, the dog was paying attention to things she didn't even see. And then she had a baby and the baby was doing exactly the same, looking at things that she wasn't even seeing. She walked her neighborhood with 10 different professionals, each from different fields, and they all saw different things. The eye doesn't see what the mind doesn't know. Try to know as much as you can of everything. Sherlock Holmes was a polymath. Sigmund Freud was a polymath and they were able to see things that we normally can't. I think the need for being as broadly educated as possible.

Lee Tetreault:

Thank you so much for your time today, Doctor. This is great information.



 

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