Buffalo

Most of us (I'm guessing here) have read the stories written by Scottish physician Sir Arthur Conan Dolye. Most of us (still guessing) think that medical doctors must have learned from Sherlock Holmes.

And that is where we go wrong (I'm not guessing any more). Great stories like A Study in Scarlet or The Sign of the Four have never appeared in our curriculum of medical students. Of course they should. A doctor's job is more or less a detective work, piecing together the evidence, poring over observation of every system and the eventual "whodunit" revelation.

In suggesting this, I am making no claim for the prowess of the London-based consulting detective. I couldn't profess to know what Sherlock Holmes have mastered. Yet I firmly believe that this is essential if we are to be good clinicians.

This reminds me of recent encountering a lady with hypertension in my clinic last week, together with medical students. They were supposed to listen and afterward, to respond with wisdom and perspective. After talking about the treatment plan for a while, I observed a rash over my patient's sun-exposed area. "Why don't we have a quick look at the rash and see if it's related to the medication?" I continued as I examined her.

"Doctor, I observed a buffalo hump at her neck," one of my students reminded me when my patient dressed up. "We're taught that such weird fat deposition at the base of the neck indicates Cushing's syndrome, aren't we?"

"Yes," I acknowledged with reluctance, "she did have a buffalo hump. Good observation. But be not beguiled." With this, I went on to tell my students why I didn’t think our patient has the syndrome with prolonged elevation of corticosteroid levels. "Well, there is absolutely no excessive fat over the trunk and face. She stands up from squatting position without difficulty."

Instead of continuing a lecture upon Cushing's syndrome, I paused and asked my patient, with the aplomb of Sherlock Holmes, "May I ask if you used to carry loads of heavy objects over your neck or above your shoulder blades?"

"Oh my, how do you know? I was a farmer."