Q&A: Diagnosing a career in pediatric ID

James H. Brien, DO, reflects on more than 30 years of presenting the popular quiz, What's Your Diagnosis?

This year, one of the presentations at November’s Infectious Diseases in Children Symposium will mark the end of an era.

For the final time, James H. Brien, DO, a recently retired pediatric infectious disease specialist at Baylor Scott & White McLane Children's Medical Center and an Editorial Board Member of IDC and Healio Pediatrics, will present his final What’s Your Diagnosis? in-person quiz.

Although he is stepping away from the meeting, Brien said he will continue to write his monthly column of the same name, which has been running for more than 3 decades. He recently spoke with us regarding the trajectory of his career, the work that goes into preparing the challenging cases that he presents to readers and attendees, and about the educational impact of What’s Your Diagnosis?

Healio: Where were you in your career when you began What’s Your Diagnosis?

Brien: I have a long-standing interest in visual diagnosis, beginning in my third year at the Texas College of Osteopathic Medicine, which is now the University of North Texas Health Science Center (TCOM), when I was on a summer-long clerkship at Fitzsimons Army Medical Center in Denver in 1975. The Army faculty there encouraged clinical photography, and I invested in my first good camera. This continued through my residency there and my years at Fort Hood that followed. Then, on the first day of my ID fellowship with James W. Bass, MD, MPH, at Tripler Army Medical Center in Hawaii, Bass sent me to the post exchange to get a better camera, and he taught me more techniques of medical photography, from getting parental consent to snapping the picture, to incorporating pictures into lectures. As I gave more and more lectures at bigger meetings, I think I caught the eye of Ted Eickhoff, MD, FIDSA, the original medical editor of Infectious Disease News. Ted asked me to begin writing a case-based visual diagnosis column using a mystery case in a multiple-choice format with a discussion of the answer. When I was a staff physician at Brooke Army Medical Center in San Antonio, Texas, I wrote my first column in IDN, published in the November 1988 issue. Soon afterward, Phil Brunell, MD, the original Chief Medical Editor of IDC, asked me to write a similar column in this sister publication. My first case published in IDC was in the April 1989 issue, about cat scratch disease. IDN would alternate an adult case with a pediatric case every other month. The pediatric case would also appear in IDC. After a couple of years, I ran out of good adult material, and my column eventually stopped appearing in IDN.

As of October 2022, I have published 383 columns in IDC. The reason the number is not more is due to some relatively short breaks in writing, beginning with the first Gulf War in 1990 to 1991, when I was deployed with a combat support hospital to Iraq. I also had to stop when I was assigned to the Office of the Army Surgeon General during 1995 to 1997, when I only published a few columns between November 1995 to August 1997 due to the demands of the job and activities surrounding retiring from the Army and starting a new job in Temple, Texas, at Scott & White Medical Center. After settling in, I began writing the column again in IDC, beginning with the September 1997 issue, which has been uninterrupted for 25 years.

Healio: What is it about pediatric infectious diseases that intrigues you most?

Brien: What intrigues me most about infectious diseases is the challenge of making the correct diagnosis and finding the cause or organism responsible for the disease that is making the child sick. My long-standing motto is “treatment is easy, diagnosis is hard.” At the risk of oversimplification, I would say that if you know the diagnosis, it is fairly easy to find the latest recommendation for treatment and follow-up.

I have never tried to conceal the fact that I am not very bright. I struggled in college and nearly gave up, opting to work in the Shell oil company refinery in Deer Park, Texas, in 1969 to earn money and get my head screwed on straight. When I married my high school girlfriend, Ellen, in 1970, she inspired me to go back to college and get my degree with a new sense of purpose and finish the hard work of my chemistry degree and get the premed requirement needed to apply to medical school, which I did for the 1972 TCOM entering class. I did not get in that year but made the alternate list, which encouraged me to try again, and I successfully enrolled in 1973. Again, I struggled just to be barely average. I did well on clinical rotations, but the academics remained a struggle. It was only through my 4 months spent on pediatric electives at Fitzsimons Army Medical Center that I was able to get selected for this very competitive residency.

All along the way, I knew that differential diagnosis was the greatest challenge to me academically. Halfway through my first year, it nearly caused me to drop out of pediatrics for something easier. But, for some reason, instead of leaning away from it, I gravitated toward it. Ultimately, I incorporated differential diagnosis and medical photography into this visual diagnosis column. I’m still no brighter than I’ve ever been, just better organized.

Healio: Can you walk us through your process for preparing cases for What’s Your Diagnosis?

Brien: I usually start by thinking of any recent patients, of whom we obtained pictures that may be of interest to the readership. Also, I have a large file of unused cases that I frequently consult for ideas. I will occasionally use the season of the year for the issue to be published and incorporate it into a message of interest — immunizations, summer safety, back-to-school alerts or some “hot topic” in the news. I also receive quite a few cases from the readership, many of which are excellent candidates for the column. I will offer the doner of the case the opportunity to be a “guest columnist,” and together we will write some of the best columns we have published.

After selecting the case to use, I research the topic to try to be as current as possible. Then I select some diagnoses that might normally be in the differential to list in the multiple-choice question in a “Board question” format, and then I write the discussion.

Healio: Can you name two or three of your favorite cases, or perhaps the most challenging cases?

Brien: Counting the columns that I wrote for IDN, there have been just over 400 columns written over the last 34 years. I have never given any thought to any columns or cases that I liked the best. I just hope to minimize grammatic and scientific mistakes. And I have made some bone-headed mistakes. One such case that stands out was that of a donated case of erythema migraines published in the June 2007 issue as Lyme disease. Shortly after it came out, I was contacted by the leading Lyme expert, Eugene Shapiro, MD, at Yale School of Medicine, informing me that for a couple of reasons, we really don’t see Lyme disease in Texas. What we had in that case was a different tick-born disease called southern tick related rash illness. After further review, I realized he was right and published a correction. And there have been numerous lesser mistakes made along the way. But back to the question of favorites: I really can’t think of any. There have been many challenging cases used, usually rare, once- or twice-in-a-career cases, like the case of ecthyma used in January 2020, or cutaneous myiasis in the December 1991 issue, to name a couple. They are all interesting or challenging, or I would not use them.

The most gratifying cases I can recall were not infectious disease cases at all. Maybe that’s what made them stand out. One was a 17-year-old male who had been seen several times by different providers for mysterious symptoms, including fatigue. When I entered the room, I saw what appeared to be a tired but healthy-appearing adolescent male with a dark, almost bronze-appearing skin. My first reaction was to ask him to take his shirt off and raise his arms, revealing equally “tanned” axillae — the old medical school maneuver to clue in Addison disease. After seeing his electrolytes, he was referred to my endocrine consultant who confirmed the diagnosis. For some reason, this noninfectious disease case brought me great pleasure. Unfortunately, I did not get pictures, so no column. The next was a neonate with “ringworm” that turned out to have neonatal lupus. This case also is the only time the parents refused to allow publication of the pictures, so again, no column.

Healio: What do you want readers/attendees to take away from What’s Your Diagnosis?

Brien: For readers of the column and attendees of the meeting, I can only hope that everyone will find something that will be useful to them in their everyday practice to help their patients. After all, isn’t that why we read and attend meetings?

Healio: What would you like to say to readers/attendees? Floor is open.

Brien: I would like to say thank you for your loyalty over these 3-plus decades of reading my columns and attending my slide shows at the meetings. I would keep going if not for my faltering memory. So, I choose to move on with as much grace as possible and try my hand at something a bit easier. However, I would like you to remember that education is a lifelong pursuit. Just when you think you are done with the Krebs cycle from your biochemistry course, you may find the need to review it again years later. Such is the nature of education. When you retire from seeing patients, as I have now, you may choose to pursue anything but medical education, which is fairly natural. However, after a professional lifetime of exercising that intracranial muscle, I would encourage you to remain active in some form of academic pursuit, whether it’s studying the pollination of orchids or the planetary orbits of the solar system — anything to stimulate a long-standing passion you may have, anything to keep you from putting your mind to rest, for it would surely atrophy.

Editor’s note: Join Dr. Brien and other distinguished faculty members at this year’s conference in New York City, Nov. 19-22. Visit https://www.healio.com/meeting/idcnewyork/home for more information.