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?