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Vol. LIX, No. 11
June 1, 2007

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'Mark of an Expert'
'Great Teacher' Tierney Tackles Mysteries at CC Grand Rounds

On the front page...

He's Lt. Columbo without the wrinkled rain coat. He's Dr. House absent the cranky attitude. He's a little bit of all your favorite TV detectives and doctors past and present, only he's better: He solves multiple mysteries in less than an hour. He is Dr. Lawrence Tierney, Jr., of the University of California at San Francisco, the latest medical sleuth to take on "mysterious cases" during a recent Clinical Center Grand Rounds.

"This is another rendition of 'Stump the Chump,'" Tierney joked, referring to a Q&A game played on NPR's show Car Talk.


  Dr. Lawrence Tierney, Jr.  
  Dr. Lawrence Tierney, Jr.  

A UCSF professor of medicine, the associate chief of the medical service at San Francisco VA Medical Center and a physician respected by peers and students alike who has captured a teaching award nearly every year for the past couple of decades, Tierney is far from being "the chump" he joked about. And, in fact, he never seemed to be stumped during the hour-long session in which two NIH clinicians, Dr. Michael Sneller and Dr. Tara Palmore, presented cases featuring slides of symptoms, test results and medical histories from actual patients. Preparation for the exercise started several weeks earlier when Dr. Jeffrey Cohen, head of the medical virology section in NIAID's Laboratory of Clinical Infectious Diseases and chair of Rounds' Great Teachers lecture series, solicited several NIH physicians for their best head-scratchers-ailments that had proved challenging to diagnose.

"I chose cases that were relatively common diseases- but often with unusual or less obvious signs or symptoms-that I thought would be good for teaching," Cohen said. "Often there are one or two clues that if one can tease out from the rest of the data, provide the key to the diagnosis. This is the mark of an expert diagnostician like Dr. Tierney."

Sneller explained, "I supplied 3 or 4 cases I had seen over the past few years that I thought were interesting.They had stumped the physicians who referred the cases to me, but we were able to come up with the correct diagnosis in a day or two after the patient arrived here."

The only rules were that Tierney would not know the cases ahead of time, and that the answers would be fairly routine diseases. While master detective Tierney did meet Sneller and Palmore beforehand, Cohen said, "we did not tell him what their medical specialty was or even what institute they were from. [Tierney] was very curious about this, as is a good detective, but neither revealed their background until after grand rounds."

The first case, titled "Disease of the Flesh," featured a 46-year-old male bus driver with skin ulcers on his lower legs and feet. After just a few details were presented, Tierney suggested several potential diagnoses for the audience's consideration.

"You have a disorder which is sub-acute, and not specific in its presentation...he has what sounds like purpura, but you never know unless you examine such a patient," ventured Tierney. "[The rash] being on the feet and lower legs makes you wonder about vasculitis. Hepatitis C really leaps to mind.Hmm, the lesions become more numerous. This is where it gets a little tricky, because we usually don't think of cryo hep C as causing painful ulcerations."

Throughout the hour, he kept up a constant conversation with himself, allowing attendees to hear how a medical detective's mind nudges and prods at each aspect of a new problem.

Master medical detective Tierney (second from r) poses with those who tried to stump him: (from l) Dr. Michael Sneller, Dr. Jeffrey Cohen, chair of Rounds’ Great Teachers lecture series, and Dr. Tara Palmore.
Master medical detective Tierney (second from r) poses with those who tried to stump him: (from l) Dr. Michael Sneller, Dr. Jeffrey Cohen, chair of Rounds’ Great Teachers lecture series, and Dr. Tara Palmore.

"We picked cases that we thought he would have difficulty with," Cohen explained. "Of course he got the first case after reading only the first slide. We started with a 'softball' to warm him up, and saved the hardballs for later."

At several times during the presentations, Tierney anticipated data or asked for a test that the next slide would show. He was often a step or two ahead in the game, methodically whittling down disease suspects until only a few remained. "Why abandon the fungal infection?" an audience member called out to Tierney. "Well, I didn't entirely," he volleyed back, further explaining his mental gymnastics aloud.

The culprit plaguing the bus driver turned out to be hepatitis C-associated mixed cryoglobulinemia — " cryo hep C" — a suggestion Tierney had indeed pitched almost immediately. He averaged less than 15 minutes to solve each case.

"Dr. Tierney demonstrated the ideal diagnostic process, thinking through the problem systematically in the way I think we should all be doing it," noted NIAID's Palmore, days after the session. Associate program director of the Infectious Diseases Training Program, she offered "two cases that had been presented at infectious diseases grand rounds, and had not particularly stumped some of our infectious diseases experts. We wanted cases with classic features that could be recognized by a non-infectious diseases specialist."

Although she said her cases were not overly challenging, she admitted it can sometimes take a while to hone in on one disorder. "I see patients who are often referred for second opinions or as diagnostic mysteries without definitive diagnoses," she concluded. "It can take days to weeks to make a diagnosis. [Tierney] did an amazing job! [One] case was harder for him because he is from a part of the country in which histoplasma is not endemic."

Tierney took full advantage of his time here. He met with several NIH-Howard Hughes scholars and M.D./Ph.D. students for breakfast, went on ward rounds later in the morning, held forth at Grand Rounds at noon and then had dinner with the Clinical Research Training Program fellows that evening.

In addition to being an artful and engaging model, Tierney was able to offer vital instruction about recognizing an illness. The most important lessons he demonstrated were to "keep an open mind about the cases and not fixate on a single diagnosis," Cohen concluded. "Integrate all of the information. Two of our cases had two separate, independent diagnoses and he recognized all of them." NIH Record Icon

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