The Art of Diagnosis: “True Medical Detective Stories”

Below an excerpt from Dr. Clifton Meador’s newest book: True Medical Detective Stories, a collection of true tales about patients who presented with symptoms that mystified their doctors (June, 2012).  In each case, the doctor eventually cracks the mystery, but only by “listening–very carefully” to the patient. 

The book begins with a dedication to the late Berton Roueché, who popularized the medical-detective genre as a staff writer for the New Yorker.

Following the excerpt, I have added a Note on the author.

A Young Doctor and a Coal Miner’s Wife

                                        By Dr. Clifton Meador

A young doctor, Dr. Bill Hueston, and his wife had just moved to the mountains of eastern Kentucky, near the border of West Virginia. The small town was nestled among the coal mines of the region. Nearly all of his patients would be coal miners or family members of a miner. Bill would practice family medicine. His wife, a veterinarian, hoped to build a small-animal practice.

Liz McWherther, the forty-seven-year-old wife of a miner, came to see the young doctor. Over several weeks, she had developed a curious set of complaints. Each morning she woke with a dry mouth and slurred speech. She also noted blurred vision and difficulty urinating. Within a couple of hours of waking, she was completely free of any symptoms. These symptoms had been occurring each morning and going away by afternoon.

Liz had had a series of tests done by the previous physician, but none of these tests were abnormal. The physical examination by Dr. Hueston was entirely normal. She denied drinking alcoholic beverages or using illicit drugs. Hueston had briefly considered some unusual response to marijuana or other drugs that were prevalent in the area. Liz had not been down in the mines, nor did her husband bring back anything unusual into the house.

The complex of symptoms suggested multiple sclerosis or some diffuse neurological disease. However, the rapid disappearance of the symptoms was puzzling. The most perplexing feature was the improvement as the day went on. Nearly all neurological diseases get worse as the day progresses. In most cases after a night’s rest, the neurological circuits are improved, and patients are at their best on arising. Not so with Liz. She was at her worst on arising and rapidly improved within a few hours.

Dr. Hueston went through a long list of possible neurological conditions. None seemed to fit the findings or course of the symptoms. Hueston came to the conclusion that he needed a neurological consultation. The nearest neurologist was over fifty miles away, so he began filling out the request for consultation and other forms required by the miners’ insurance.

Hueston was chatting as he wrote. “My wife and I are new to the area. You know she is a veterinarian. She’s having a hard time dealing with the amount of skin disease in her patients. All of the cats and dogs are loaded with ticks and fleas. She didn’t have that problem in her city practice

Liz’s attention became alert. “Yeah, I had that with my cat. But I fixed it.”

“How’d you get it fixed?”

“I just dust her every week.”

Hueston stopped writing and paused. “You dust her. What do you mean ‘dust her’?”

“I just take my rose dust I use in my garden. Dust it on my cat. Then just rub it in.”

Hueston asked, “Rose dust? What’s that?”

 “I don’t know what all’s in it. It kills the insects on the roses and it sure kills ticks and fleas on my cat. My cat is free of ’em.”

Hueston, now in full alert, asked, “Where does the cat sleep?”

Liz smiled and answered, “Why, she sleeps right on my pillow with me.”

Hueston said, “I want you to go home and wash your cat. Don’t use the rose dust anymore, and don’t let the cat in your room at night. Let’s see what happens and maybe you won’t have to go all the way to Lexington.”

Liz came back a week later. Smiling widely, she told Dr. Hueston she had not had any more dry mouth, blurred vision, or slurred speech. Her urination was completely normal. The “disease” had gone away. She even brought a bag of the rose dust with her.

Dr. Hueston smiled back. He read the chemical contents on the rose dust bag and found what he suspected in the contents—organophosphates.

He went on to explain to Liz McWherther how organophosphates are nerve poisons. They cause some segments of the nervous system to fire continuously. The pupils constrict to pinpoint size. Salivation is inhibited. The urinary bladder does not function normally. If the exposure to organophosphates continues or the dose is large, death can occur.

Everyone wondered why the cat did not get sick. We will never know. Liz’s problems were symptoms that she noted and described.

Cats don’t talk.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

A note on the Author: Clifton Meador has been practicing and teaching medicine for more than 50 years and some of the patients he describes in these stories are his own.

Not only is Meador an engaging story-teller (he has been called the “Will Rogers of medicine”) he  has had a lasting impact both as a doctor, and as someone who has thought deeply about how medicine is practiced in the U.S. His well-known satirical writings on the excesses in our the medical system include “The Art and Science of Nondisease, (the New England Journal of Medicine, 1965) andThe Last Well Person,” an essay he published as an “Occasional Note” in NEJM Journal in 1994.

 “The Last Well Person” begins with this anecdote: “A supervising doctor asks a medical resident “What is a well person?” The resident  replies with some confidence: “A well person is a patient who has not been completely worked up.”

Meador then proceeds to tell a tale takes place in the not-too-distant future. The story’s only character is a 53-year-old professor of freshman algebra at a small college in the Midwest. Despite extensive medical evaluation, no doctor had been able to find anything wrong with the teacher. But he is the only remaining person for whom this is true. Doctors from all over the country flock to the Midwest to check him out.

At the time, Meador warned: “if the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick.” (Dr. Norton Hadler would later adopt the title for his book The Last Well Person: How to Stay Well Despite the Health-Care System, 2004)

 HealthBeat readers who have seen the film version of Money-Driven Medicine http://moneydrivenmedicine.org/ (produced by Alex Gibney, directed by Andy Fredericks) may remember Meador as the Nashville doctor who takes them on a tour of his town. Nashville is best known as the nation’s Country Music Capital, and Meador takes readers past “Music Row,” but as he r reveals, Nashville also is the headquarters for a “massive complex of healthcare corporations.”     

Their pristine headquarters are set high on a hill. In most cases, there are no corporate logos, no signs to identify who the companies are. (Perhaps they are trying to avoid surprise visits by Michael Moore.) But as he drives past, Meador identifies them:

“We have three mother corporations here:  HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, and Health Trust, which is a spin-off of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that’s headquartered here in Nashville.” In the background, we hear the song that Alex Gibney, the film’s producer, chose for this scene: “If you’ve got the money, honey, I’ve got the time.”

Over the years, Meador has watched Nashville’s medical industrial complex develop into one of the country’s biggest money-spinners, while, at the same time, health statistics in Tennessee have slid to the bottom of the national rankings

6 thoughts on “The Art of Diagnosis: “True Medical Detective Stories”

  1. What a fantastic story! Just imagine – had Dr. Hueston not engaged his patient Liz in chatty conversation – and had his ears not perked up immediately during her cat story – this woman may have been referred, tested, misdiagnosed, retested, misdiagnosed some more, on and on ad infinitum – while still suffering her mystifying symptoms.

    Thanks for sharing this book excerpt with us. I’m putting the cat out now….

  2. I thought I recognized this tale about Dr Huerton and his patient who got better each day after waking up feeling unwell. I had heard that story in Maggie Maharrs movie “Money Driven Medicine” which was made from her book by the same title. Patients, unlike Doctors, know well that listening is what they want from their doctors–not just to be social, no: We patients know that we can describe what we feel. If our doctor listens, she or he will be able to name what we describe and help us find what to do with our situation. It’s not easy, but it is simple. Here’s to more listening doctors.

  3. Gertrude–

    Good to hear from you.
    Yes, patients do want “listening” that is more than “social” (my vacation, your vacation . . )
    Patients want doctors who will listen to what they feel, with empathy, and respond to the human being being in front of them. ,
    Med schools don’t teach this, but some doctors (like Clifton Meador) develop these skills on their own.

  4. This is a very interesting article. It’s strange how the rose dust affected that woman so greatly, it just goes to show that it’s very difficult to pinpoint what exactly is causing someone to be ill – there can be so many causes.

  5. Pingback: Unheard Hearts – A Metaphor, by Clifton K. Meador | Health Beat by Maggie Mahar

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