Friday, 23 Aug 2019

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A New Look at Old Pictures

When I teach rheumatology in the clinic, I often search on Google Images to find pictures to illustrate important findings. Google Images is a treasure trove of photos and drawings about medicine and, in just a flash of an instant (actually 0.33 seconds), I can show the house staff a butterfly rash, Heberden’s nodes or a swan neck deformity.  X-rays are also on display and you can find flagrant examples of advanced disease: an exuberant osteophyte threatening the neck of a patient with DISH or the frightening end-result of psoriatic arthritis, an eroded digit that looks like an iron spike about to pierce the phalanx on the other side of the joint.

These pictures remind me of those of an old textbook I bought as an intern on the suggestion of an attending who questioned my skills as a diagnostician. (He also questioned my diligence in writing follow-up notes as well as charting laboratory values, but that is a story for another time). The book is called “HAMILTON BAILEY’S Demonstrations of Physical Signs in Clinical Surgery” and was authored by an august old school consultant named Hamilton Bailey.  Bailey, who served as Surgeon of the Royal Northern Hospital in London, had an extraordinary career. During the First World War, he volunteered for the Red Cross and served with the British Expeditionary Force in Belgium. He was taken as a prisoner of war, almost executed on suspicion of sabotage and repatriated to England via Denmark. He then joined the Royal Navy and served at the Battle of Jutland helping with casualties on HMS Iron Duke. After the War, as a registrar in London, he pricked his finger which became infected, leading to an amputation which he depicted in his own text.

In the book’s Preface, Bailey fretted about the waning diagnostic skills of the new generation of physicians who he felt didn’t use their eyes, hands or brains to make clinical assessments. Indeed, he notes that, “A former chief was wont to picture the modern graduate of medicine, when summoned to an urgent call, driving up to the patient’s house followed by a pantechnicon containing a fully equipped X-ray installation, and a laboratory with a staff of assistants.” House calls are, of course, rare these days and those physicians who do visit the home are unlikely to bring either a pantechnicon (whatever that is) or a squad of laboratory assistants. Bailey wrote regretfully, “Without these aids the future doctor would be unable to formulate a diagnosis.” Hamilton Bailey wanted students to look at the patient and recognize the tell-tale signs of disease. The first edition was published in 1927. My copy was the fifteenth, its longevity a testament to its popularity and enduring value as a catalogue of human misery.

Suffice it to say, the pictures of rheumatoid arthritis (RA) in Bailey’s text look exactly like those depicted on Google Images today as if nothing happened in the last 90 years, the field stagnant, gold the gold standard, biologicals never invented, ulnar deviation rampant and joint destruction inevitable. Making the diagnosis of RA on the basis of such pictures would certainly not require a rheumatoid factor, an anti-CCP or a CRP nor, for that matter, an actual physical exam so classical and pathognomonic is the appearance.

While Hamilton Bailey’s concern about physical diagnosis was and is germane, diagnosing advanced disease is never the same challenge as diagnosing early disease. Indeed, while I have shown Google Images as teaching points for years, I worry that I am leading the trainees astray concerning the usual presentation of arthritis that a rheumatologist sees today. As they say, a picture is worth a thousand words. The question is whether the words are still true. I don’t mean that the pictures are doctored (pun intended), manipulated or enhanced by Photoshop to exaggerate or distort the image. Rather I wonder how often the severe findings seen on Google Images are encountered in actual practice.  

Consider a few examples. In my experience, early RA can present with very subtle findings, often little beyond some joint puffiness that could easily pass for pudginess. While such joints can be quite tender, the swelling from pannus has yet to develop (and hopefully won’t!) as arthralgia transforms into frank arthritis. Someone without experience in rheumatology could certainly be confused about the true nature of RA:  subtle synovitis that is hard to see and feel or bulging synovium that distorts the undulating terrain of the knuckle pads.   A picture of bulging synovium would, of course, make it to Google Images.

Other images of RA today appear on the screens of television and the pages of newspapers and magazines in advertisements for medications. I have long been skeptical about the depiction of sick people on television or in the popular media. In general, the people shown look far healthier than they should be given the gravity of their conditions. The woman receiving growth factors to boost her blood counts after chemotherapy has bright shining hair and full cheeks that frame a confident and hopeful smile. The grandfather with COPD looks robust and spry and hardly short of breath as he plays ball with his grandson after puffing on his inhaler.   

Those images are a variance with my clinical experience.  Those depicting patients with RA or psoriatic arthritis in the ads are not.  

Most of my RA patients now are indeed quite healthy.  Because of an array of effective medications, early diagnosis, and treat to target approaches, many patients can experience significant benefit including remission and do not progress to deformity. Such treated patients work, they dance and they lift weights at the gym. They also ride bikes and I don’t mean a Mongoose or a Schwinn. I mean a Fat Boy with a 1500 cc twin cam engine that screams. One of my patients wanted to switch from an injectable to an oral agent because he didn’t have a storage place on his Harley to keep his medication cold when he rode out to Sturgis.  

Another example is perhaps more telling. The Google Images of ankylosing spondylitis (AS) show the progression of a man whose deformity progresses over 36 years. As a young man, the patient stands tall. He has a military bearing, looks strong and is well-muscled.  With time, his body shrinks and bends. At the penultimate picture, the man’s head looks tucked inside his chest. His back is straight, set off at a 45 degree angle from his legs. His thighs are thin and have lost their muscle. A cane seems to get him upright. In another nearby image of  X-rays of a patient with AS, the spine looks, not like bamboo, but carved granite, the thick syndesmophytes fusing the spine into a single rigid piece.

Diagnosing the man whose face points straight down and whose SI joints looked cemented together is not hard work. Deciding which patients with low back pain with negative X-ray films have an inflammatory arthritis is hard work. Nevertheless, the extreme examples are the ones shown in the textbooks and on the web.  

For teaching modern rheumatology, the museum pieces are not always relevant. Rather, we need more pictures and X-rays of patients at the start of their AS, years before the deformity has occurred, when the sacroiliac joints have the faintest erosions and vertebral corners barely glimmer let alone shine. We also need pictures of women since they too develop spondylitis, a fact easily forgotten if the only patients featured are men.

The field of rheumatology has entered a new era, one that no doubt would have dazzled and gratified Hamilton Bailey who could slow down on collecting the dramatic even shocking changes that advanced illness can cause to the human body. While such findings are fascinating, modern medicine fortunately has made many of them rare.  Diagnosis in medicine often follows intuition and pattern recognition, not a rational and orderly path down an algorithm tree. It is therefore essential that information sources show the right patterns to allow the novice, the trainee and even the primary care provider to have the right pattern to match up with the case he or she sees in the office.

If early recognition of inflammatory disease is at the crux of modern treatment, why show end-stage disease except as a warning?

The reality of today is that people with inflammatory arthritis-whether RA or spondyloarthopathy-can look normal and have subtle findings that can easily be missed.  Google Images, however, will always display the worst case scenarios just as will the American College of Rheumatology slide collection or textbooks including those like Hamilton Bailey’s devoted to physical diagnosis.  

I think that is fine to have such images for both historical and heuristic value but to label these pictures as such. It is important to understand that these pictures do not show what arthritis is but rather what it was, can be but, most certainly in this day and age, should no longer be.

 
Disclosures: 
The author has no conflicts of interest to disclose related to this subject

David Pisetsky, MD, PhD is Professor of Medicine and Immunology at Duke University Medical Center and staff physician in Rheumatology at the Durham Veterans Administration Medical Center. He received his BA from Harvard College magna cum laude in 1967 and his PhD and MD degrees from the Albert Einstein College of Medicine in 1972 and 1973. He was then an intern and resident in Internal Medicine at the Yale-New Haven Hospital from 1973-1975.  From 1975-1978, he was a clinical associate at the National Cancer Institute. He joined the faculty of the Duke University Medical Center in 1978 as Chief of Rheumatology at the Durham VA Hospital, a position he held until the end of 2018. He served as Chief of Rheumatology and Immunology at Duke from 1996-2007. Dr. Pisetsky has conducted basic and translational research in the field of autoimmunity, focusing on the pathogenesis of systemic lupus erythematosus (SLE) and the immunological properties of nuclear macromolecules, including DNA.  More recently, he has investigated the immune activities of HMGB1, a nuclear protein with alarmin activity, as well as microparticles. These studies have provided new insights into the translocation of nuclear molecules during cell activation and cell death and the mechanisms by which cell death can influence innate immunity.  In 2001, he was awarded the Howley Prize from the Arthritis Foundation for his work on the immune properties of DNA.  Dr. Pisetsky has had grant funding from the NIH, Veterans Administration and foundations. He has published over 400 articles, reviews and chapters and has edited several textbooks and volumes. His essays and narratives have appeared in JAMA and Annals of Internal Medicine.  From 2000-2005, he served as Editor of Arthritis and Rheumatism and, from 2006-2011, he was the first Physician Editor of The Rheumatologist. In 2016, he was awarded the ACR Presidential Gold Medal - the highest award the ACR can bestow in recognition of outstanding achievements over an entire career. He has received a number of awards for his writing. He has served as the President of the United States Bone and Joint Initiative.


Rheumatologists' Comments

Wonderful article. Even Osler and Kussmaul complained about the waning exam skills of students in their time. I had to look it up: Pantechnicon van - Wikipedia says A Pantechnicon van, currently usually shortened to pantechnicon, was originally a furniture removal van drawn by horses and used by the British company "The Pantechnicon" for delivering and collecting furniture which its customers wished to store. The name is a word largely of British English usage. Webster says same.
Agree that this is an important discussion. How are physicians changing diagnostic skills if they are not examining patients? Is there an over reliance on tests, or check boxes in the electronic health record? At least a Pantechnicon van required that you talk to the patient, and perhaps position the patient for the xray, thereby examining the patient.
David your insightful article speaks to 2 important issues: 1) the way our young doctors learn is changing and 2) the faulty lessons learned by classic or extreme disease representations, that omit the subtleties of an early accurate diagnosis. But isnt this the way all of us were taught? In med school, the RF and ulnar drift; in residency the nodule swan neck; in fellowship the rheumatoid lung and pathogenesis; and in 10 yrs of practice its the carpal tunnel onset or early detection of a small effusion or contracture and knowing who should get more or less treatment. Don't you have to know the extremes long before you can appreciate and identify the nuances?
I very much appreciate the comments of my colleagues who have made excellent points.  Physical diagnosis has always been at the heart of medical practice and remains so today. The role of physical diagnosis has not changed. The findings have. Because of earlier diagnosis and more effective treatment, the physical findings of many diseases (e.g., rheumatoid arthritis) that used to be “classic” are now rare.  That's good. To teach rheumatology, I think that we have to be modern and describe the disease that we see today and not harken back to the past when advanced-and often untreated- disease was the norm and the findings so striking. Dr. Cush raises an important point about current medical training where students often begin their learning in tertiary hospitals where serious illness, advanced disease and “classical” physical findings abound. For physicians who go into general practice, the spectrum of illness is vastly different. Often, these individuals have never been taught how to manage common problems; nor are they taught how to evaluate early illness. That needs correcting. I think that, just as the pictures of medicine need updating, so too does medical teaching.