You can observe a lot by watching

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"I have trained myself to see what others overlook. "
—Sherlock Holmes 1

The article by Grandjean and Huber in this issue 2 is a timely reminder of the importance of skilled observation in medical care. Osler 3 considered observation to represent “the whole art of medicine,” but warned that “for some men it is quite as difficult to record an observation in brief and plain language.” This insight captures not only the never-ending feud between written and visual communication, but also the higher efficiency of images. Leonardo da Vinci, a visual thinker with a touch of dyslexia, 4 often boasted in colorful terms about the superiority of the visual. Next to his amazing rendition of a bovine heart he scribbled, “[Writer] how could you describe this heart in words without filling a whole book? So, don’t bother with words unless you are speaking to the blind…you will always be overruled by the painter.” 5

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Ironically, physicians have often preferred the written over the visual. Oliver Wendell Holmes Sr., professor of anatomy at Harvard Medical School and renowned essayist, once wrote a scathing review of a new anatomy textbook that, according to him, had just too many pictures. “Let a student have illustrations,” he thundered “and just so surely will he use them at the expense of the text.” 6 The book was Gray’s Anatomy , but Holmes’ tirade exemplifies the conundrum of our profession: to become physicians we must read (and memorize) lots of written text, with little emphasis on how much more efficiently information might be conveyed through a single picture.

This trend is probably worsening. When I first came to the United States 43 years ago, I was amazed at how many of my professors immediately grabbed a sheet of paper and started drawing their explanations to my questions. But I have not seen much of this lately, and that is a pity, since pictures are undoubtedly a better way of communicating.


Figure 1. The Pink Puffer.

Figure 1. The Pink Puffer.

Take for example The Pink Puffer ( Figure 1 ), a picture that Frank Netter created in the 1970s. If we force ourselves to pay attention to detail, this image discloses a treasure trove of evidence-based clinical information. First, the patient is shown in tripod position. This sitting up, leaning-forward “thinker” posture not only accounts for the Dahl’s sign discussed by Grandjean and Huber, but also relieves dyspnea by maximizing inspiratory pressures. 7 It also lifts the shoulder girdle, thus improving the action of both pectoralis major and minor. 8

Netter’s patient is also exhaling through pursed lips. This reduces the respiratory rate and carbon dioxide level, while improving distribution of ventilation, 9,10 oxygen saturation, tidal volume, inspiratory muscle strength, and diaphragmatic efficiency. 11,12 Since less inspiratory force is required for each breath, dyspnea is also improved. 13,14 Diagnostically, pursed‑lip breathing increases the probability of chronic obstructive pulmonary disease (COPD), with a likelihood ratio of 5.05. 15

The man in The Pink Puffer is using accessory respiratory muscles, which not only represents one of the earliest signs of airway obstruction, but also reflects severe disease. In fact, use of accessory respiratory muscles occurs in more than 90% of COPD patients admitted for acute exacerbations. 7

Next Article:

If a picture is worth a thousand words, a patient is worth ten thousand

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