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CHAPTER 8: Further Excursions in the Grey Zone

Dr. Herbert Ho Ping Kong ECW Press ePub



The physician should not treat the disease, but the patient who is suffering from it.

— Maimonides

IN THE LAST CHAPTER, I REVIEWED a series of cases dealing with the complex challenges that physicians face in dealing with syndromes that cannot be clearly identified, despite the obvious physical and mental suffering they inflict on patients. In this chapter, I will look at a few cases in which we can make a firm diagnosis of physical illness, but offer no effective or lasting solution. Here, the art of medicine is likely to be measured by other factors — by the level of care, attention, empathy and advocacy a doctor brings to the bedside. Sadly, in such situations, it is often necessary to deliver bad news to these patients. But that, too, is an art that needs to be developed.

A FEW YEARS AGO, A COLLEAGUE at a nearby hospital referred a very difficult case to me. Marnie was a 40-year-old woman that had been diagnosed with Erdheim-Chester disease. First identified by two pathologists in the 1930s — Austrian Jakob Erdheim and American William Chester — the syndrome is characterized by excessive production of histiocytes, a type of white blood cell that the body normally deploys to fight infection. When histiocytes over-produce, however, they invade the body’s connective tissue and begin to play havoc with key organs, including the heart, bone, kidneys and liver.

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CHAPTER 9: Thinking Outside the Box

Dr. Herbert Ho Ping Kong ECW Press ePub



Discovery consists in seeing what everyone else has seen and thinking what no one else has thought.

— Albert von Szent-Györgyi, Nobel Prize–winning physiologist

IF PRACTISING THE ART OF MEDICINE is principally about bringing more humanity to the doctor-patient relationship, it is not only about humanity. Part of it involves devising creative approaches to diagnosis and treatment, or what I like to call out-of-the-box thinking.

I’m not sure how — or even whether — you can teach future generations of doctors to develop out-of-the-box thinking. The best analogy may be music. You usually need to have years of experience and exposure to the classic forms before you can begin to play jazz. Similarly, in medicine, I would argue that you need to have a broad and deep grasp of basic medicine before you can consider adopting more experimental tactics.

Regardless, it is certainly a skill that physicians young or seasoned would find useful. Quite frequently, disease does not present with the expected or familiar pattern. Especially in an age of multi-system medical problems, disease (and the treatment of it) is becoming a moving target, and physicians need to be agile enough to move with it. I can recall six or seven cases in particular that will help demonstrate what I mean.

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CHAPTER 11: Confronting Rare Diseases

Dr. Herbert Ho Ping Kong ECW Press ePub



Medicine is a science of uncertainty and an art of probability.

— Sir William Osler

ONE OF THE MOST CHALLENGING aspects of a career in diagnostic internal medicine is the opportunity it inevitably presents to treat rare diseases. Typically, patients arrive in our offices after a primary health care physician and two or more specialists have done as much as they can and then, metaphorically, thrown up their hands and asked for diagnostic help.

Sometimes, the right answer turns out to have been hiding in plain sight. But just as often, the solution is difficult because it involves a rare, seldom-seen disease. Both the diagnostic process and the subsequent treatment are important aspects of the art of medicine.

Some years ago, I was invited to become consulting physician in internal medicine to a professional sports team in Toronto. The players needed attention from various specialists, including of course orthopedic surgeons, but they very seldom felt the need to seek my services. They were essentially too healthy. Then someone suggested it might be more useful if I consulted on members of the team’s executive management, so I agreed.

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CHAPTER 1: The Art of Medicine

Dr. Herbert Ho Ping Kong ECW Press ePub



It is more important to know what sort of person has a ­disease than to know what sort of disease a person has.

— Hippocrates

METAPHORICALLY, THE ART OF MEDICINE is a clinic that contains many rooms. In each, a different art is demonstrated.

In one room, there is the art of seeing, diagnosing illness by carefully observing what may be hiding in plain sight.

In a second, there is the art of listening, actively tuning in to the signature rhythms of the patient’s body, hearing both what the patient says and, equally important, what he or she may not be saying.

In a third, there is the art of human touch, which includes not only feeling the pulse, palpating the spleen, the kidneys and other organs to make the diagnosis, but may also include simply holding the patient’s hand to let them know that you care.

Two other rooms are dedicated to what is often called the Grey Zone. One is for patients who exhibit a range of clinical symptoms that defy simple diagnosis. They are clearly suffering, but there is no agreed-upon name for their ailment. How does the sensitive clinician deal with that increasingly common situation?

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CHAPTER 3: Lessons of the Montreal Years

Dr. Herbert Ho Ping Kong ECW Press ePub



He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

— Sir William Osler

THE HARD DECISION TO EMIGRATE having been made, I now faced another thorny question: where exactly to go. A number of friends and colleagues had happily moved to the United States, and I did receive a few informal American overtures. But my first preference was Canada, which I judged to be a gentler society.

Accordingly, I sent letters of introduction to the chiefs of medicine at hospitals in several major Canadian cities. General internists were not in high demand at the time, so I was not exactly deluged with offers. But I did receive replies about potential positions in Halifax, Edmonton and St. John’s. I made a visit to Ottawa, but was discouraged by the February snowbanks that literally reached to the eaves of houses. And one Toronto physician-in-chief expressed interest, but with a caveat: he wanted me to effectively audition in private practice for a few years before applying for a staff position.

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