Chapter 1. An Atlas to Enhance Patient Care, Learning, and Teaching

People only see what they are prepared to see.

—Ralph Waldo Emerson

Whether you are viewing Figure 1-1 in a book, in an aquarium, or in the sea, you immediately recognize the image as a fish. Those of you who are more schooled in the classification of fish might recognize that this is an angelfish with the tail resembling the head of the angel and the posterior fins representing the wings. If you are truly prepared to see this fish in all its splendor, you would see the blue circle above its eye as the crown of the queen angelfish.

Making a diagnosis in medicine often involves the kind of pattern recognition needed to identify a queen angelfish. This is much the same as recognizing a beautiful bird or the painting of a favorite artist. If you are prepared to look for the clues that lead to the identification (diagnosis), you will see what needs to be seen. How can we be best prepared to see these clues? There is nothing more valuable than seeing an image or a patient who has the condition in question at least once before you encounter it on your own. The memory of a powerful visual image can become hard wired into your brain for ready recall.

In medicine it also helps to know where and how to look to find the clues you may need when the diagnosis cannot be made at a single glance. For example, a patient with inverse psoriasis may present with a rash under the breast that has been repeatedly and unsuccessfully treated with antifungal agents for candidiasis or tinea (Figures 1-2 and 1-3). The prepared clinician knows that not all erythematous plaques under the breast are fungal and looks for clues such as nail changes (Figures 1-2 and 1-4) or scaling erythematous plaques around the elbows, knees, or umbilicus (Figure 1-3). Knowing where to look and what to look for is how an experienced clinician makes the diagnosis of psoriasis.

As physicians we collect clinical data through sight, sound, touch, and smell. Although physicians in the past used taste to collect data, such as tasting the sweet urine of a patient with diabetes, this sense is rarely, if ever, used in modern medicine. We listen to heart sounds, lung sounds, bruits, and percussion notes to collect information for diagnoses. We touch our patients to feel lumps, bumps, thrills, and masses. We occasionally use smell for diagnosis. Unfortunately, the smells of disease are rarely pleasant. Even the fruity odors of Pseudomonas are not like the sweet fruits of a farmers' market. Of course, we also use the patient's history, laboratory data, and more advanced imaging techniques to diagnose and manage patients' illnesses.

It was our belief in the value of visual imagery that led to the development of the first edition of The Color Atlas of Family Medicine. We delivered more than 1500 images to doctors around the world, first as a large color textbook and then as an interactive electronic application for easy use on the iPhone, iPod touch, iPad, and all Android devices. Our images were so valuable for learning and practicing medicine that they were requested for use and then incorporated into other primary care and specialty textbooks, websites, CME presentations, and test-preparation services. Now it is our pleasure to bring you our second edition of The Color Atlas of Family Medicine with more than 2000 clinical images.

We also have added many new chapters on such important topics as diabetes, hypertension, headache, osteoporosis, alcoholism, tobacco addiction, and global health. Although these topics were covered to some extent in the first edition, we decided to create these new chapters so that the text and images would become a comprehensive resource for the full range of family medicine. Electronic applications for the new color atlas will be available in all major platforms at the same time that the new book will be released.

The larger our saved image bank in our brain, the better clinicians and diagnosticians we can become. The expert clinician has a large image bank stored in memory to call on for rapid pattern recognition. Our image banks begin to develop in medical school when we view pictures in lectures and textbooks. We then begin to develop our own clinical image bank by our clinical experiences. Our references are printed color atlases and those color atlases available on the Internet and electronically.

Studying and learning the patterns from any atlas can enhance your expertise by enlarging the image bank stored in your memory. An atlas takes the clinical experiences of clinicians over decades and gives it to you as a single reference. We offer you, for the first time in the United States, a modern comprehensive family medicine color atlas, which includes areas such as oral health, dermatology, podiatry, and the eye.

We all see visible clinical findings on patients that we do not recognize. When this happens, open this book and look for a close match. Use the Appendix, Index, or Table of Contents to direct you to the section with the highest yield photos. If you find a direct match, you may have found the diagnosis. Read the text and see if the history and physical examination match your patient. Perform or order tests to confirm the diagnosis, if needed.

If you cannot find the image in our book try the Internet and the Google search engine. Try a Google image search and follow the leads. Of course this is easiest to do if you have a good differential diagnosis and want to confirm your impression. If you don't have a diagnosis in mind, you may try putting in descriptive words and look for an image that matches what you are seeing. If the Google image search does not work, try a Web search and look at the links for other clues.

Finally, there are dedicated atlases on the Internet for organ systems that can help you find the needed image. Most of these atlases have their own search engines, which can help direct you to the right diagnosis.

Table 1-1 lists some of the best resources currently available online.

If you are seeing a patient with a mysterious illness that remains undiagnosed and you figure out the diagnosis, you can often bridge the issues of mistrust and anxiety by showing the patient the picture of another person with the diagnosis. Use our atlas for that purpose and supplement it with the Internet. This is especially important for a patient who has gone undiagnosed or misdiagnosed for some time. “Seeing is believing” for many patients. Ask first if they would want to see some pictures of other persons with a similar condition; most will be very interested. The patient can see the similarities between their condition and the other images and feel reassured that your diagnosis is correct. Write down the name of the diagnosis for your patient and use your patient education skills.

Do be careful when searching for images on the Web in front of patients. Sometimes what pops up is not “pretty” (or, for that matter, G or PG rated). I turn the screen away from the patients before initiating the search and then censor what I will show them.

If you teach, model this behavior in front of your students. Show them how reference books and the Internet at the point of care can help with the care of patients.

Images taken by you with your own camera of your own patients complete with their own stories are more likely to be retained and retrievable in your memory because they have a context and a story to go with them. We encourage our readers to use a digital camera (within a smartphone or a stand-alone camera) and consider taking your own photos. Of course, always ask permission before taking any photograph of a patient. Explain how the photographs can be used to teach other doctors and to create a record of the patient's condition at this point in time. If the photograph will be identifiable, ask for written consent; for patients younger than age 18 years, ask the parent to sign. Store the photos in a manner that avoids any Health Insurance Portability and Accountability Act (HIPAA) privacy violations, such as on a secure server or on your own computer with password protection and data encryption. These photographs can directly benefit the patient when, for example, following nevi for changes.

Digital photography is a wonderful method for practicing, teaching, and learning medicine. You can show patients pictures of conditions on parts of their bodies that they could not see without multiple mirrors and some unusual body contortions. You can also use the zoom view feature on the camera or smartphone to view or show a segment of the image in greater detail. Children generally love to have their photos taken and will be delighted to see themselves on the screen of your camera.

The advent of digital photography makes the recording of photographic images less expensive, easier to do, and easier to maintain. Digital photography also gives you immediate feedback and a sense of immediate gratification. No longer do you have to wait for a roll of film to be completed and processed before finding out the results of your photography. Not only does this give you immediate gratification to see your image displayed instantaneously in the camera, but also alerts you to poor-quality photographs that can be retaken while the patient is still in the office. This speeds up the learning curve of the beginning photographer in a way that could not happen with film photography.

Many of the images in this atlas are from my collected works over the past 27 years of my practice in family medicine. My patients have generously allowed me to photograph them so that their photographs would help the physicians and patients of the future. To these photos, we have added images that represent decades of experiences by other family physicians and specialists. Family physicians who have submitted their images to Photo Rounds in the Journal of Family Practice are also sharing their photos with you. Finally, 12 years of providing students with cameras during their Family Medicine clerkships at the University of California at Los Angeles (UCLA) and the University of Texas Health Sciences Center at San Antonio (UTHSCSA) have allowed our students to add their experiences to our atlas.

It is the goal of this atlas to provide you with a wide range of images of common and uncommon conditions and provide you with the knowledge you need to make the diagnosis and initiate treatment. We want to help you be the best diagnostician you can be. We may aspire to be a clinician like Sir William Osler and have the detective acumen of Sherlock Holmes. The images collected for this atlas can help move you in that direction by making you prepared to see what you need to see.