Osler and pus.

[mjl1717]

Seriously. Does any one know if William Osler or do you have many "astute clinician collegues" (spelling?) or friends who can actually smell pus?

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[Hayden2102]

Seriously. Does any one know if William Osler or do you have many "astute clinician collegues" (spelling?) or friends who can actually spell pus?

What?

 

[deleted109597]

uh, wtf?

 

[mjl1717]

uh, wtf?

Yeah baby it aint law school and the competition is keen!!! Some of your fellow clinicians can actually smell pus even if they dont tell you. (all jokes aside) One lad told his attending that he smelled pus at a female with septic tubes. Later on it was found out she had PID and he confessed that he could smell pus. Rare and odd maybe but I wouldn't say it magical or that far fetched.. [Even if average John with stethascope around his neck is oblivious to this]

 

[Hayden2102]

Yeah baby it aint law school and the competition is keen!!! Some of your fellow clinicians can actually smell pus even if they dont tell you. (all jokes aside) One lad told his attending that he smelled pus at a female with septic tubes. Later on it was found out she had PID and he confessed that he could smell pus. Rare and odd maybe but I wouldn't say it magical or that far fetched.. [Even if average John with stethascope around his neck is oblivious to this]

Dude, read your original post and see if it makes sense to YOU.

 

[mjl1717]

Dude, read your original post and see if it makes sense to YOU.

OK buddy, you got me on that. I meant smell pus not spell pus. My fault..

 

[Law2Doc]

Seriously. Does any one know if William Osler or do you have many "astute clinician collegues" (spelling?) or friends who can actually smell pus?

I don't know about this specific claim, but there are certainly a handful of old school clinicians who can actually diagnose a whole lot of diseases with just their senses, that require the rest of us to use technology and labs. There have been numerous articles in the various professional magazines (NEJM etc) in recent years bemoaning the loss of such clinical skills, and there is some suggestion that the inability to diagnose clinically contributes to the rise in healthcare costs. Almost every med school has one aging Yoda who can lay his hands on a patient and tell you with remarkable accuracy what is wrong with them. Unfortunately this skill is becoming an endangered species, thanks to science.

But considering Osler was a well known cocaine addict, if he snorted, he probably didn't have the greatest sense of smell by his later years.

 

[THP]

I don't know about this specific claim, but there are certainly a handful of old school clinicians who can actually diagnose a whole lot of diseases with just their senses, that require the rest of us to use technology and labs. There have been numerous articles in the various professional magazines (NEJM etc) in recent years bemoaning the loss of such clinical skills, and there is some suggestion that the inability to diagnose clinically contributes to the rise in healthcare costs. Almost every med school has one aging Yoda who can lay his hands on a patient and tell you with remarkable accuracy what is wrong with them. Unfortunately this skill is becoming an endangered species, thanks to science.

But considering Osler was a well known cocaine addict, if he snorted, he probably didn't have the greatest sense of smell by his later years.

I agree that that stuff is cool from a novelty standpoint, and downright impressive, but you would be crazy in today's medical-legal environment to try and diagnose PID by smell alone. I'm not trying to minimize the importance of physical exam findings. In order to be a great physician you must have great physical exam skills.

 

[Law2Doc]

I'm not trying to minimize the importance of physical exam findings. In order to be a great physician you must have great physical exam skills.

The growing concern is that relativley few people have these skills anymore. If our generation doesn't get them, we will not be able to teach them to the subsequent generation. So we are in an end-game scenario, and there will be no more "great physicians". Much like a lot of sci fi movies, reliance on technology can have negative consequences.

 

[mjl1717]

Excellent comments Law 2 Doc!!!!! I totally agree and would never discount any
"extra" diagnostic skill. Ideally Id like to be a healer. Also if someone from above offered me any ecleciastical(spelling?) diagnostic skill. {I wouldnt look a gift horse in the face} Id grab it and let the pundits talk and debate. By the way I didnt know that about William Osler.

 

[DragonWell]

But considering Osler was a well known cocaine addict, if he snorted, he probably didn't have the greatest sense of smell by his later years.

Uhh, I think you may be confusing Osler with his contemporary, William Halstead, the "father" of modern surgery. Halstead was a well known cocaine addict, and some think his painstaking attention to surgical detail was partially a result of his being geeked out.

 

[deleted109597]

Unless you have problems with your nose, anyone can smell pus. That being said, smelling it while it is inside the body is possible, but it is likely to be from some other source, such as inflammatory mediators. Some people can just smell when people are sick. Dogs can sense when people are going to have seizures, and that too may be from smell (since dogs don't have ESP).

I know some clinicians who can differentiate between chlamydia and gonorrhea based on smell.

 

[Law2Doc]

Uhh, I think you may be confusing Osler with his contemporary, William Halstead, the "father" of modern surgery. Halstead was a well known cocaine addict, and some think his painstaking attention to surgical detail was partially a result of his being geeked out.

I was actually taught that both of them, (as well as Freud) were famed physician cocaine users.

 

[Bertelman]

I once read that Osler, disappointed that a family would not consent for an autopsy, took matters into his own hands (so to speak). He was convinced the patient had died from kidney disease.

He took the transrectal route, retrieving one of the kidneys. Family never knew any better.

...I don't remember if he was correct...

 

[boston]

none of this is far fetched... once you smell pseudomonas in a pussed out wound, you won't forget it.

 

[Bertelman]

There have been numerous articles in the various professional magazines (NEJM etc) in recent years bemoaning the loss of such clinical skills, and there is some suggestion that the inability to diagnose clinically contributes to the rise in healthcare costs. Almost every med school has one aging Yoda who can lay his hands on a patient and tell you with remarkable accuracy what is wrong with them. Unfortunately this skill is becoming an endangered species, thanks to science.

Unfortunately, these Yoda skills are difficult to confirm or quantify. As much as we respect them as a profession, that's not the strength of modern medicine. Assuming we can't pick and choose our characteristics, I would take the precision of modern day testing, antibiotics, etc. over the snake oils of the past.

I'd also argue that another signifcant contributor to healthcare costs is our litiginous society, which I'm sure L2D can discuss. Most doctors don't WANT to order a battery of tests to everyone who presents to the ER, but if they don't, their lapses may be used to convince jurors the patient's life would have been saved had they gotten that CXR or whatever. Defensive medicine is too pervasive these days. We think less about doing the right thing, more about not doing the wrong thing.

"Dr. Osler, are you telling me that you cannot, in fact, smell pus percolating in a female's pelvis? Then you, sir, are not fit to be a physician."

 

[Law2Doc]

I'd also argue that another signifcant contributor to healthcare costs is our litiginous society, which I'm sure L2D can discuss. Most doctors don't WANT to order a battery of tests to everyone who presents to the ER, but if they don't, their lapses may be used to convince jurors the patient's life would have been saved had they gotten that CXR or whatever. Defensive medicine is too pervasive these days. We think less about doing the right thing, more about not doing the wrong thing.

Yes and no. Tests still have to help you get to the answer, either directly, or to rule out something else in the differential. If you can narrow the scope to a likely diagnosis for which you can get a very targeted test, you save the patient a lot of money AND stave off lawsuits. If you take the shotgun approach and order every test under the sun in the hopes of not missing anything, you still may miss something, may find things a patient could have been better not knowing about, and will cost the patient a lot of money.
I doubt the handful of master clinicians still out there get sued at a higher rate than the young guns who order every test and study possible.

 

[deleted109597]

The shotgun approach is not as common now as it was just a few short years ago. However, the problem with rising costs now comes from the fact that crazy expensive tests can diagnose disease in 0.1% of the disease carrying population, but that running the test on the other 99.9% is cheaper than paying the lawsuit for missing that one guy (or girl).

 

[DragonWell]

I was actually taught that both of them, (as well as Freud) were famed physician cocaine users.

I remember reading that using coke recreationally was not an uncommon past time for med students back in those days, due to it's availability for anesthesthia use. A little experimentation and addiction are two different things, though. I've read a few books on med history and Osler, and I don't remember anything about cocaine addiction. Google revealed nothing, either.

(bring up melodramatic music) For god's sake,people, a man's reputation is at stake here!

Actually, I'm just kind of curious where you guys heard that.

 

[SecretDove]

Some people can just smell when people are sick.

I definitely can. I used to get really annoyed with an old roommate because when she was sick and slept in the smell of her illness overtook the floor where her bedroom was and sometimes floated up the stairs to my room.

I can't explain the smell but it's usually overwhelming to me even though no one else notices it. People tease me and think I'm crazy. I'll ask the person if they feel sick or if their throat hurts. Sometimes they'll say no and I'll tell them they'll feel sick the next day.

 

[mjl1717]

Unless you have problems with your nose, anyone can smell pus. That being said, smelling it while it is inside the body is possible, but it is likely to be from some other source, such as inflammatory mediators. Some people can just smell when people are sick. Dogs can sense when people are going to have seizures, and that too may be from smell (since dogs don't have ESP).

I know some clinicians who can differentiate between chlamydia and gonorrhea based on smell.

I can agree with most of your post but saying "anyone can smell pus" is not true(thats why I bought it up) since many are :

1)too vain to do that
2)too unconscientious to do that.
3)dont think of it
4) technical blockheads-order [ETKM- "Every Test Known to Man"]
5)think of medicine as totally science without any art

Addendum- you are totally correct the insurance companys are not buying or paying for that "shot gun approach to dx" like they did say in the 60's and 70's. And even the hospital will say to doc "Wud you order that test for??{slang}"
But Id say this after this post, I will definitely be more sniff conscious.

 

[deleted109597]

I can agree with most of your post but saying "anyone can smell pus" is not true(thats why I bought it up) since many are :

1)too vain to do that
2)too unconscientious to do that.
3)dont think of it
4) technical blockheads-order [ETKM- "Every Test Known to Man"]
5)think of medicine as totally science without any art

I said everyone can. I didn't say everybody does, or even cares to. Some fields purposefully avoid it. It semantic really.

 

[mjl1717]

I once read that Osler, disappointed that a family would not consent for an autopsy, took matters into his own hands (so to speak). He was convinced the patient had died from kidney disease.

He took the transrectal route, retrieving one of the kidneys. Family never knew any better.

...I don't remember if he was correct...

Yes Bertelman, thats awesome info, I didnt know that.!!! Almost makes me want to do a pathology residency or at least get a Masters in path {And go even more in debt!}.
So I can become a more profound clinician and do some "Osler moves"