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The Making of a Medical 'Mosaic'
'Great Teacher' Fitzgerald Demonstrates Diagnostic Thought Process

By Carla Garnett

On the Front Page...

True story: A 39-year-old infectious disease doctor is driving north from Bethesda through Connecticut one mid-August day when he begins to experience a low-grade fever, nausea and vomiting. By the time he reaches his destination of Portland, Me., on the following day, his symptoms are worse. Not knowing what is wrong and unable to continue his trip, he checks himself into the ER, suddenly finding himself on the wrong end of the treatment table. He is admitted for observation and testing.

Continued...

Over the next few days, the mysterious ailment would be treated with antibiotics and eventually resolved. But how are such knotty medical puzzles untangled? In the age-old tradition of physicians' rounds, the Clinical Center temporarily acquired the talents of a "proper Baker Street sleuth," as Dr. Faith Fitzgerald, professor of medicine at the University of Calfornia-Davis, offered a rare glimpse inside the mind of a gifted clinician. She led a packed Lipsett Amphitheater June 12 on a step-by-step journey to diagnosis of four clinical mysteries — within 15 minutes of receiving the first clues.

"When I was a child, I wanted to be Sherlock Holmes," she said. "I read the Conan Doyle selected stories, which I recommend to you all as paradigmatic of the diagnostic thought process, since Arthur Conan Doyle — unable to make a living as a clinician — started writing stories and stole the persona of one of his professors, Joseph Bell, to use as the prototype of a detective."


Dr. Faith Fitzgerald

Doyle, she continued, wrote Bell's amazing powers of observation and deduction into Holmes, "who was a rip-off of clinical medicine. Think of the way we approach things. Look at the patient and see what the crime was — that's the disease, and the scene of the crime — that's the patient." Clues are collected from the medical history and exam. The list of suspects is the differential diagnosis. Further forensic studies are conducted "and then we execute," she said, pausing with comic effect, "the criminals."

In her first case — dubbed the "Feverish Physician" — Fitzgerald quickly strolled through a humorous and fascinating path of revelation that often featured rapid-fire soliloquies and stream-of-consciousness commentary. The title of the case was her first clue, she admitted. A diagnostician confronted with a doctor complaining of fever automatically first thinks "occupational exposure to just about anything." The fact that the symptoms were initially noticed while the patient was driving through Connecticut raised the possibility of tick bite and Lyme disease, she added, puzzling through the sketchy tidbits of information provided by Dr. Paul Plotz and Dr. John Hurley, lead organizers of the CC's Contemporary Clinical Medicine — Great Teachers series.

A monthly feature of CC Grand Rounds lectures, each talk has been delivered by a speaker acknowledged by colleagues to be an outstanding teacher — one who has mastered not only a field of medicine, but also the fine art of leaving a clear path for others trekking through the field.

NIH deputy director for intramural research Dr. Michael Gottesman, who introduced Fitzgerald, commented on the impact of the Great Teachers lectures and on the vital role clinicians have in research.

"This series has been a wonderful opportunity for people to learn what's happening in clinical medicine and it has reminded us that it's really the astute clinician who is the most important part of clinical research," he said. "The observations made in the clinic lead to the discoveries made at the bench, which hopefully can be returned to the clinic. If we lose sight of that, we're going to lose sight of how to make advances in clinical research."

Fitzgerald delivered the final lecture in the popular series' debut 2001-2002 season. In a unique presentation, Plotz, Hurley and several co-conspirators, some of whom were seated in the audience, devised a slide show consisting of actual symptoms and clinical data for four distinct "mysterious cases." As each slide was advanced an additional piece of the puzzle was revealed.

Quickly showing her teaching skill, Fitzgerald easily engaged audience members in the deductive process, prompting informed guesses from other would-be medical detectives.

"Unlike most of the discussions," she said, setting the stage, "I suspect this will not be an aggregate of data — although I'll try to throw some of that in as well. What it is is the synthesis of that combined order and discipline and chaos that is the diagnostic thought process."

Describing her first impression years ago of a gathering of Nobel prize winners, Fitzgerald said she was surprised by what she observed.

"They did not have an orderly, disciplined thought process," she explained. "I had always thought that was the key to success in science — carefully examine, collect the data, observe it, perform experiments upon it, reaffirm it, enumerate it. But, no, what these people did was less linear than it was mosaic. They had an uninhibited cascade of — to my mind — unconnected ideas, all of which appeared in their minds and somehow seemed to hold equal pre-eminence. I thought initially, 'They are all crazy!' What was fascinating was that they'd all throw up these little ideas as if they were the bright bits of a mosaic, look at how they fell, see if it satisfied and if it didn't they'd throw them up again and try again.

A medical Sherlock Holmes, Dr. Faith Fitzgerald greets colleagues before showing off her powers of deduction at a recent CC Grand Rounds. 

"That is, I suspect, what you can do when you're a Nobel laureate," she concluded, drawing chuckles from the crowd, "and don't have anything to prove as to your intellectual prowess. You can explore areas that are silly and don't seem to be connected. But it also may be the mark of great science and great clinical medicine."

By the second or third slide of each malady, Fitzgerald had created her own mosaics and formed theoretical diagnoses as the facts seemed to dictate. Met with such vague and general symptoms as fever, nausea, weakness and anemia, and jokingly lamenting the paucity of clues, she tackled the probability of infectious diseases, connective tissue disorders, psychiatric ailments and cancers. In all but the final case — in which her verbal and mental meanderings were necessarily curtailed due to time constraints — she correctly diagnosed the ailment before the final slide revealed the answer, to the amazement and enthusiastic appreciation of the audience.

"Three out of four is not bad for an hour, right?" she quipped, smiling broadly.

And just what was plaguing the "Feverish Physician" in her first case, which completely confounded other doctors for weeks after examining the patient firsthand? Fitzgerald correctly surmised leptospirosis, a rare, severe and contagious bacterial infection caused by exposure to a germ found in a warmer climate's fresh water that has been contaminated by animal urine. It seems the physician-patient had recently been exposed to the ailment not during the course of one of his exotic work cases, but during a leisurely fishing trip not far from his home.

Already a mainstay of CC Grand Rounds, the Great Teachers lecture series will resume in September.


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