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Off North Road: Perils of
Diagnosis,
Part I
September 8, 2005
By Russell Hoxsie, M.D.
The following describes my first experience in the outpatient medical clinics of The New York Hospital at Cornell Medical College. The episode in the life of the patient is true, but details, names other than the Drs. Wolf and Wolff, and conversation are the product of my own invention.
Dr. Marjorie Moore entered the room for the first time where I was writing up my notes on the patient I had just seen in the medical outpatient department of New York Hospital. Women physicians were rare (three women of 84 students in my Cornell medical class of 1952) although the medical outpatient service had long been in love with Connie Guion, pioneer internist whose name would later adorn the department's entrance as its founder. Dr. Moore would be my preceptor for three months. She was a soft-spoken middle-aged woman without pretension who projected a sympathetic way toward my insecurities as a third-year student. She became my colleague rather than instructor.
Walter Wyczinski was thirty, white, and a New York cab driver who had suffered stomach pain and weight loss over the previous four months. Appetite was poor yet he often felt best after a small meal. Whenever he drank a beer, the first one gave him relief, but by the fourth or fifth he often threw up and lay down for relief. I saw him in clinic each week and reviewed his case with Dr. Moore.
"He has a peptic ulcer," I concluded with Dr. Moore after my initial history and physical examination. She nodded and approved a G.I. series, standard examination then for the interior of a patient's stomach and upper small intestine. The x-ray showed a peptic ulcer of the duodenum, first section of the small intestine.
"It all fits," I said. "He has a large crater on the posterior wall and his pain is relieved by small meals but made worse when he drinks too much."
"That's a start," she said. Something in her reply seemed questioning but I was so pleased to have made one of my first diagnoses that I didn't take her comment too seriously. What else could there be, I thought? We've been taught we should try to put all our eggs in one basket, in other words fit the patient's symptoms into one all-inclusive diagnosis.
The next week I sat again with my mentor. "He's faithful taking the milk and cream diet, says he's stopped alcohol altogether but still feels pain, especially at night, lost more weight and he can't sleep." I was less confident. There's more to this than I thought. Dr. Moore wanted to know about Walter's home life. What makes him tick, what stresses has he, is he an alcoholic?
"He lives on East 92nd Street in a medium size apartment on the second floor with his wife and two daughters, both in elementary school. Drives a cab and puts in ten to twelve hours of driving around the city every day, even weekends. His parents died some time ago. They had come from Poland before the war so he was born in the U.S. He doesn't know much about the rest of his family, who remain in Poland."
"What about his family life here in New York? Marriage happy? Wife and children healthy? Does he make a good living? How does his wife view his drinking?"
She hadn't begun to exhaust the questions we needed answers for. No wonder she said that we had just started. Intimate details of someone's life were not the easiest to explore for me in those first student days. I look back and realize how constrained my own emotional life had been, how private I was within myself. There were no talk shows where people bared all about themselves. Self-help systems had not evolved. The fifties' blandness and superficiality seemed to reflect the early TV shows of the day, or was it vice versa? I took the doctor's questions as my next assignment.
I spent the next few clinic visits with Walter in the clinic and with his wife at home learning how to encourage a patient to talk about himself. The medical school had embarked on an ambitious program of teaching psychosomatic medicine, the effect of mind on body. This was a new concept for medical schools influenced strongly by the growth of Freudian psychiatry. The medical school had organized a separate department with its own clinical head. Walter Wyczinski became an ideal subject. Clinicians of the time generally favored psychosomatic problems in attributing causes for peptic ulcer. His life as a New York cab driver was anything but serene; long lines of traffic speeding up and down the avenues to beat as many red lights as possible before screeching to a halt inches from the nearest pedestrian; angry shouts at the driver in front who cuts you off at a mid-town cross street; two passengers battling over who got to the cab's door first to go uptown; nights of cruising around Times Square hoping that your next fare would ask for a long trip to Brooklyn. I certainly became more familiar with Walter and his family. Would secrets of his condition now be unlocked?
The second and final part of Perils of Diagnosis will appear on Sept. 22. It describes an unexpected development in the case of W.W.
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