Finding Aunt Tilly in a Crowd


It’s been 10 years since I blogged about the importance of pattern recognition and its neural architecture. The ensuing years have only accentuated its significance, and a reminder of it came today in the from of Dr. Lisa Sanders’ Diagnosis column in the Sunday New York Times magazine today.

Although the column doesn’t involve the eyes or visual system directly, in fact it relates to cardiology, it speaks to the heart of pattern recognition and its importance in diagnosis. As the 59 year-old elevator technician was driving with his wife to New York City from their home in Connecticut, he nonchalantly remarked that he had recently been coughing up blood. He was used to walking stairs on the job everyday at work and during the past year had noted progressively become more easily winded. His wife, a nurse, insisted that they pull of the exit to get him checked out at the nearest urgent-care center.

The main finding of concern was was oxygen level of 91 percent when, even with the worst cold, his level should have been at 98 to 100 percent. Urgi-care transferred him to the ED of a local hospital where Dr. Tara Shapiro was assigned as his doctor. Looking at the CT Scan gave her cause of concern that the patient’s shortness of breath and source of blood wasn’t due to a problem with his lungs, but related to the hypertrophy shown in his heart muscle. Shapiro reached out to a cardiologist colleague, Dr. Ronald Wallach, one of the most knowledgeable doctors she knew. When he came to the hospital room to conduct his evaluation, the patient’s wife was reassured by Wallach’s white hair and his air of quiet authority. 

You’ll have to read the column to discover how the smaller than normal EKG waveform done in the emergency department provided Wallach with the principal clue he needed to make his diagnosis, and how that was confirmed through a cardiac MRI. The patient was ultimately referred to a cardio-thoracic surgeon who conducted a heart transplant that saved his life.

Sanders concludes: “I asked Wallach how he could make this diagnosis when other doctors had not. He called it the Aunt Tilly Sign. “If I described Aunt Tilly to you and sent you out into a crowd to find her, you’d probably fail. But if you’d ever seen Aunt Tilly” — he snapped his fingers — “no problem. You’d find her in a second. It’s all about recognition.'”

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