Images in Medicine

Several medical journals that I receive (if not read) regularly have a section devoted to interesting images. The New England Journal has “Images in clinical medicine,” Circulation has “Images in cardiovascular medicine,” and the Journal of the American College of Cardiology has “Images in cardiology.” Each generally contains a short case description, along with one or more images – photographs of patients, histologic sections, radiographs, MRI images, and the like.

I find myself drawn (no pun intended) to these sections first, much as I review the cartoons in the New Yorker before I read any of the articles. But, unlike the New Yorker’s cartoons, there is generally nothing funny at all about the pictures. Instead, they are often evidence of a tragedy – in Circulation, there was an MRI documenting progression of Fabry cardiomyopathy despite enzyme replacement therapy; in JACC, there was a chest CT documenting cardiac compression from a giant tuberculous pericardial cyst. NEJM had a photograph of the oropharynx of a 13 year-old girl with respiratory diphtheria. Clearly not good news for any of the patients involved.

What then, is so compelling about all the pictures?

Perhaps it is nothing more complicated than the novelty. After all, the cases are typically something that I would never see in my clinical practice, and there is a long history of medical fascination with the odd-ball presentation of a common illness, or better yet, the true “zebra” – an odd-ball presentation of a rare condition. In fact, there are entire museums devoted to medical oddities, like the Warren Anatomical Museum  at Harvard Medical School or the Mutter Museum in Philadelphia. They are the “Ripley’s Believe it or Not” of Medicine.

It is also true that so much of medicine today revolves around the interpretation of images including scans of all sorts. Indeed, there has been explosive growth in medical imaging  over recent decades. Even so, I don’t think that explains the appeal of these journal features. After all, images are routinely included in case reports and CPC’s, so why devote a section primarily to the images?

I think it has to do with the fun of making a diagnosis. All better if the diagnosis is something unusual, and you can nail it by looking at a picture. Good doctors (well, good internists anyway) like playing detective. Here’s a clue; what’s the answer? I think it also reminds us of the power of observation in medicine. Who among us has not made a (presumptive) diagnosis of a stranger on a subway or passer-by on the street? These images remind us that we know things that others don’t know, and see things that others don’t see.

What do you think?

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