Physician, Pheal Thyself

PHYSICIAN, PHEAL THYSELF WILLIAM M. LANDAU, M.D.* We must always remember it is the balance ofevidence that determines diagnosis. The sciences concerned with disease deal largely with probabilities, almost wholly so in internal medicine. The probability varies in degree, but it usually falls short ofcertainty. We must learn to take probability as our guide. We have to act. To act we must decide, and to decide we must weigh the evidence, and deal with the probable as ifit were certain. Sometimes we shall be wrong, but generally we shall be right; ifwe hesitate between two opinions we shall be powerless. Remember that also in practical life, in dealing with patients , the habit ofdiscerning the probability and acting decisively is all-important. Nothing is so necessary to every practitioner as the confidence ofhb patients. To gain that he must manifest some measure ofconfidence in himself. Ifyou must wait before forming even a probable opinion, at any rate be decided in delay. Remember, decisive hesitation is far wiser than hesitating decision. . . .—W. Gowers. "A metastatic mystery." Lancet, 3:1593,1905. I guess I sort ofmisinterpreted things; I didn't think being right mattered as long as I was sincere.—C. Brown. In: C. Schulz. "Peanuts," September 14, 1955. Copyright by United Features Syndicate. Perhaps attentionshould be givento the feeling that medical writing and conversation reflect too much what is felt to be the self-imposed, noncommital conformity ofthe larger Society and the Common Language. The symptom of this vague disorder seems to provoke confusion most obviously sometimes when neurological material is under discussion, but we feel that there may be a possibility that the larger systemic involvement might be considered to be ofsomewhat wider significance. Some examples from house officer discussions are: Vibration sense was felt to be diminished in the upper extremities as well [and] . . . the examination ofthe heart was thought to be normal. The liver was felt to be three finger breadths below the costal margin. Pinprick sensation was felt to be diminished in a stocking distribution bilaterally. If the heart is felt to be greatly enlarged, aspiration of pericardial fluid may be attempted . * Department ofNeurology, Washington University School ofMedicine, St. Louis, Missouri. I79 From an X-ray report: It is felt that there is left ventricular enlargement. From consultation and operative notes in a hospital chart: There is what is felt to be a bilateral T2 sensory level. . . . The roots also did not show evidence ofdamage, but in view ofhis history, it was felt that there had been significant damage, although grossly it did not appear so. From a clinical pathological conference protocol: The patient apparently did well until 1959. . . . These findings were felt to be consistent with interstitial fibrosis. . . . Apparently he had been ambulatory with dyspnea on exertion until 2 days before admission. The chest did not appear hyperinflated. It may be felt by some authorities that such everyday usage reflects the pattern that may be set in scientific publications. The following comprise a rapid sampling from anonymous journals, albeit without double-blind control: Clinically, he was felt to be hypothyroid. It was felt that the compressive effects ofan extracerebral hemorrhage were reduced as the volume ofintracranial tissues diminished and the free intracranial space increased. It is felt that direct surgery ofthe third ventricle should be reserved for colloid cysts. . . . openexposure wasthrough a small craniotomy which was felt to be safer than burrhole biopsy in these instances. . . . The handling ofglioblastomas is perhaps subject to greater differences ofopinion than in the case ofany other tumor. This apparent nonuniformity in the membrane indicates clearly an inadequacy ofthe clamp. The author feels that the spatial nonuniformity is a natural property or the normal membrane. It was felt that an experimental analysis ofthb type ofnystagmus might be ofinterest. However, many clinicians still feelthat the immediate use ofone ofthese agents during an acute epbode leads to a more rapid defervescence oflesions and symptoms. . . . we feeljustified in the conclusion that our cases are examples ofmuscular dystrophy . My feeling on the subject b exemplified by the fact that in one patient. . . . In the medical setting one often feels that the language also reflects the hierarchical level of the observer. Verbal forms are not only...