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Teaching and Learning Moments: The High Points of Low-Yield

Kumar, Bharat

doi: 10.1097/ACM.0b013e3181bf4a9c
Other Features: Teaching and Learning Moments

Mr. Kumar is a third-year student, SABA University School of Medicine, Saba, Netherlands-Antilles.

If you've ever heard of the term “low-yield,” then you're probably a medical student. We use it to describe a topic that is unworthy of memorization. What to expect during a physical examination of the nails is considered low-yield, as are mastering Beau lines and Bywater lesions. Clinicians, however, are far less in favor of such oversights, a lesson I learned during my internal medicine rotation as a third-year medical student.

My supervising intern and I visited Mr. Watson, a homeless, 47-year-old African American diabetic, whose foot was recently amputated. He was, in many ways, a medical student's dream, volunteering a textbook history of diabetes and readily agreeing to a full physical examination. The intern uncoiled the stethoscope hanging around his neck and began auscultating Mr. Watson's heart, while I started less obtrusively with an examination of his radial pulse. As I did so, something else caught my eye.

His nails were, in a word, repugnant. Reflecting a hard life on the street, they were more like claws, encrusted with filth and frayed away at the edges. As I stared at them with macabre fascination, I noticed something else in the pallor of his nailbed. Whenever I felt a pulse, all five of his nails momentarily gained a rosier hue, almost like tides on a beach. But before I could fully appreciate this phenomenon, the intern aborted these feckless thoughts by noting the utter lack of murmurs, gallops, or rubs in Mr. Watson's heart sounds. It was then that I decided to quickly direct his attention to Mr. Watson's nails and appeal for another auscultation of the aortic area. He humored his pupil and obliged wholeheartedly. This time, however, more attuned to the prospect of regurgitation, he observed something faint yet insidious—the characteristic blowing diastolic calling card of aortic insufficiency.

The nails were the first subtle clue to a perilous process. The oscillation of color in Mr. Watson's nails reflected his wide pulse, largely due to the evolving aortic regurgitation superimposed on his preexisting hypertension. Fearful that this new murmur was due to infective endocarditis, the attending physician ordered an echocardiogram and blood cultures. As expected, Mr. Watson was found to be septic with a fungus most likely a result of his recent foot surgery and was subsequently treated to clear the infection.

There is no doubt that the end diagnosis of endocarditis would have been established at some point in the near future. Yet, Mr. Watson's grotesque nails attracted the necessary attention to start the cascade of events that led to his early diagnosis. Were his nails more adequately maintained, my five-second cuticle inspection would have yielded nothing, leading to a longer and costlier hospital stay. So, yes, it is completely true that nail inspection is low-yield. After all, we simply do not need to know it to pass a standardized examination. To pass a more sublime threshold, though, like the one that separates us as medical students from the doctors we seek to become, perhaps it is best once in a while to embrace such topics because low-yield subjects may lead to high-yield diagnoses.

Bharat Kumar

Mr. Kumar is a third-year student, SABA University School of Medicine, Saba, Netherlands-Antilles.

© 2009 Association of American Medical Colleges