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LEARNING FROM GOLDOVSKY - When Toxoplasmosis is Toxoplasmosis


Dr. Hafeez Diwan

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Boris Goldovsky, a man I was unaware of until a few minutes ago, made an important dermatopathologic contribution (without meaning to). He lived from 1908 to 2001, and was a famous conductor and producer of opera. It is reported that he had a piano student who played bar 78 from Brahms Op 76 No.2 incorrectly – or so Goldovsky believed. He asked his student to play it correctly, and the student showed Goldovsky that he had played the notes exactly as they were printed on the score. It was later found that ALL the scores of this particular piece (that were available to them at the time) had the same error. It took this student, a rookie, a novice piano player, to catch this error because he played the music exactly as it was printed, something nobody had bothered to do until that point. This incident is so famous that it has a name. Some people call it the “Goldovsky error”.

My own version of the Goldovsky error is as follows: some years ago, while attempting to teach my fellow, Dr. Michael Cohn, during sign-out, I saw a microorganism of some kind in a skin biopsy, and wondered (incorrectly) if it was some kind of fungus. I pontificated on my fungal hypothesis for some time till Michael, discreetly, politely, and respectfully suggested that it looked like Toxoplasma to him. I think he had recently taken his boards (or more recently than I had, at any rate), and so Toxoplasma was fresher inside his head than it was in mine (at least, that’s how I have tried to rationalize his brilliance; Michael is very smart and an excellent dermatopathologist). As soon as Michael had said this, I knew he was right. Subsequently, the patient was proven to have Toxoplasmosis. He was immunocompromised and passed away shortly after receiving this diagnosis. For those of you who are interested, here is the reference for the case report that was published with histopathologic images of cutaneous toxoplasmosis (SA Lee et al., Bone Marrow Transplantation 2005; 36: 465-6; the figure is at the following link: [url="http://www.nature.com/bmt/journal/v36/n5/fig_tab/1705079f2.html#figure-title"]http://www.nature.com/bmt/journal/v36/n5/fig_tab/1705079f2.html#figure-title[/url])

Reflecting on this incident, it seems to me that the Goldovsky error has its roots in the non-novice or expert thinking in a certain way about certain things, because he or she is used to it – his or her experience is precisely what stands in the way of making the correct call. A funny looking microorganism seen in a biopsy of the skin, at least in the States, is more likely to be a fungus than it is to be Toxoplasma. Not knowing exactly what it was, I was unconsciously playing the odds. Michael, without any experiential baggage, simply stated what appeared to him to be obvious: it looked like Toxoplasma and so it was Toxoplasma. Parenthetically, here is the reason why the novice piano player caught the error in the Goldovsky story. The note incorrectly printed was G-natural, which was an absurd note musically speaking (or so I’ve read) at that point. So, [i]skilled[/i] players who played this piece played a G-sharp, probably subconsciously assuming that the sharp symbol had been accidentally left out. This is why the novice, who was playing the piece [i]as it was printed[/i], played a G-natural, which sounded wrong to Goldovsky, which led to the mistake being discovered.
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Dr. Phillip McKee

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Or to put it another way, one can always learn from one's colleagues whether they be Faculty, Fellows or Residents. Reporting cases as a group around a double-headed microscope is a very valuable way of avoiding mistakes. I certainly agree that we do program ourselves with time and often a fresher (and younger) pair of eyes can be invaluable. Lovely blog.
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Guest Dr Gonzalo de Toro

Posted

Nice history Dr. Diwan and Now I learn how they look it in your histological pictures. Two for the price of one. great
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