The Emperor’s New Clothes
In his famous story, “The Emperor’s New Clothes,” Danish
author Hans Christian Andersen tells of an emperor,
vain and pompous, who is scammed by rogues who tell
him that that they can weave him royal regalia made of a
cloth so exquisite and fine that no one can see it but the
most competent and intelligent of persons.
When the scoundrels mime draping him in this miraculous
fabric, he stands naked, but no one—including
the emperor himself— dare say so, for fear that they will be
thought to be stupid and inept. It isn’t until the Emperor
parades proudly through the streets unclothed that a child
cries out (the only person to do so in a large crowd of
cheering subjects) that the emperor is naked.
Recently, as an attending physician on an internal
medicine housestaff inpatient teaching service, I saw a
middle-aged woman who had been transferred to us from
the orthopedics floor after yet another in a series of episodes
of septic arthritis. She smiled at me when, between
short periodic bouts of weeping and writhing, she told me
that she had had “over 40 operations” on the currently
affected knee alone, as well as at least 20 surgeries on other
joints and various other parts of her body. She had total
body pain, she said, and had spent much of the last 20 to
30 years of her life being recurrently hospitalized and operated
on.
“Why do you think you have had so much trouble?” I
asked her.
“I have Ehlers–Danlos,” she answered. “I guess I’m
just susceptible. That’s what the doctors told me.”
She had no family history of hypermobility syndromes
nor, on my examination, did she have any evident physical
findings of Ehlers–Danlos syndrome variants (which are all
due to genetically variable defective connective tissue) and
generally a clinical diagnosis. It was impossible for me to
test even the few remaining unoperated joints of her hands
and feet for hypermobility, as she cried out in pain at the
merest touch. Her skin was not velvety, nor was it abnormally
stretchable. There was no bruising of her skin, and
her multiple surgical scars seemed to have healed normally;
they were not wide or nodular. Her hard palate was not
high arched, and her feet were not flat.
Did she indeed have Ehlers–Danlos syndrome? Indeed,
every note previously written in the electronic medical
record (EMR) throughout her multiple admissions recorded
it as her history and included it in her long list of
final diagnoses, but not a single one of these notes detailed
any aspects of physical examination that suggested that
those who wrote them (attendings, residents, fellows, medical
students, or nurses) had actually looked for it. Many of
these physical examination notes, both initial and daily
follow-up, which were written during any one of her many
hospitalizations, were identical, almost word for word (except
for the specific joint in peril at the time), although
they were supposedly written by different people on different
days.
It seems that no one at any level of expertise, at least as
was recorded in our EMR, had ever seriously questioned
the diagnosis of Ehlers–Danlos syndrome. There was one
distant note by a medical resident who saw her on an
emergency department visit that added something new in
social history,
which was that the patient had begun training
to be a nurse but never graduated. Was he thinking, as
I was, of Munchausen syndrome? If so, why did he not
specify the positive and negative physical findings for
Ehlers–Danlos syndrome, the underlying disease that she
claimed was the root source of her problems?
My third-year medical student assigned to this patient
gave me her written admission workup to critique, which I
did. There it was again—“Ehlers–Danlos”— both in the
history and in the diagnosis list, but not in physical
examination.
“Tell me about the Ehlers–Danlos syndromes,” I asked
her. She had done her reading and rattled off a highly
competent summary of what she had learned.
“What makes you think this patient has an Ehlers–
Danlos syndrome?” I asked.” You’ve just told me—and
very well—the characteristic findings on PE, but they appear
nowhere, either as positives or negatives, in your physical
examination. Why not?”
She seemed a bit stunned by my question. “I looked
for them, but I couldn’t see them” she answered.
“Then why did you say she had it?”
“You know, I wondered about it, but everybody else
seemed to think she had it.” She threw up her hands and
stomped her foot, angry at herself. “I know that I should
have said something! But I’m just a student, and I didn’t
want to seem stupid.”
The EMR is a wonderful but dangerous tool. Its capacity
for efficient redundancy or, more perniciously, overt
and unedited cut-and-paste from previous notes, allows
doctors—either pressed for time or uncertain of themselves
(as even very good doctors continually are)—to simply replicate
their previous notes or parrot the antecedent notes of
another clinician. This poses an increasingly particular
danger for medical students, who tend to believe that everybody
else must know more than they do. Yet, it is a
hazard not just for students, but for all of us. Uncritical
acceptance of what others have said is not a new phenomenon
in medicine, but it has been much facilitated by the
EMR, a real-world equivalent of the clever huckster weavers
of Andersen’s story. His was a cautionary tale, and we
should take a lesson from it: It is only by using our own
senses and minds and taking the time to record only our
own accurate findings and thoughts—and having the ethical
imperative and courage to do so—that we can serve
our patients well.
On Being a Doctor Annals of Internal Medicine
396 © 2012 American College of Physicians
Although I spoke to my team and wrote in my EMR
attending notes of my doubts, recording my physical examinations
as specifically showing no current findings for
Ehlers–Danlos and suggesting a possible alternative diagnosis
of Munchausen syndrome, I saw no major change of
content in a large number of the subsequent EMR notes by
a variety of other writers. Maybe, unlike the child at the
emperor’s parade in Hans Christian Andersen’s story, I did
not cry out loudly enough to be heard by the crowd.
Faith T. Fitzgerald, MD
University of California, Davis, Medical Center
Sacramento, CA 95817
Requests for Single Reprints: Faith T. Fitzgerald, MD, University of
California, Davis, Medical Center, Division of General Medicine, 4150 V
Street, Suite 2400, Sacramento, CA 95817; e-mail, bioethics@ucdmc
.ucdavis.edu.
Ann Intern Med. 2012;156:396-397.
The Emperor’s New Clothes On Being a Doctor
www.annals.org 6 March 2012 Annals of Internal Medicine Volume 156 • Number 5 397
