Yehia Y. Mishriki, M.D.

Author: Yehia Mishriki

I was born and raised, for the first ten years of my life, in Egypt. My family left Egypt on the pretense that my father would be receiving additional medical education in the United States and return to Egypt. However, soon after arriving in Beirut, Lebanon, my parents visited the American Embassy and applied for asylum in the United States. We arrived in New York City on April 15th, 1966.
I received a BA in chemistry from Franklin and Marshall College in 1976 and my MD degree from Loyola University Stritch School of Medicine in 1979.
I began my postgraduate education as a surgical resident at Long Island Jewish Hospital but decided that internal medicine would better suite my educational and career goals. I completed an internal medicine residency and chief medical residency at Winthrop-University Hospital. I had secured a gastroenterology fellowship at Montefiore Medical Center in New York in the hopes of entering academia, as the concept of academic general internal medicine was nascent, at that time, and unfamiliar to me. However, the chief of medicine asked me, shortly before completing my chief residency, if I would be interested in being a fulltime member of an academic general internal medicine division he was developing. I immediately took him up on his offer and declined the gastroenterology fellowship. I was also appointed Assistant Chairman of the Department of Medicine. I was involved in creating the outpatient experience for the medical residents to mirror that of an ambulatory practice rather than a traditional resident clinic.
To be closer to my wife’s family, I accepted the positions of Associate Chairman of the Department of Medicine and Internal Medicine and Transitional year residency programs at what is now Lehigh Valley Health Network. A few years later, I stepped down from these positions and assumed the position of Chief of Ambulatory Care at LVHN, a position I held for ten years.
I currently have published about 90 articles in peer-reviewed journals, two book chapters and a handful of abstracts and poster presentations with medical residents for the ACP Eastern Chapter meeting. I published a series entitled “Puzzles in Practice” in Postgraduate Medicine between 1997 and about 2010 and have reviewed articles for numerous journals including Annals of Internal Medicine.
My roles models on how to practice medicine and how to comport oneself as a physician have been my father a pathologist who paid attention to every miniscule detail in his work and who studied and read his pathology journals and textbooks every single weekday during his long career and Sir William Osler the quintessential internist and historical “father’ to all those practice and teach internal medicine.
I have had three professional philosophies –
1. An internist ought to be able to solely manage eighty percent of his or her patients’ problems.
2. Teach as you would wish to be taught.
3. “Guerir parfoit, soulager souvent, consoler toujours” (Cure sometimes, relieve often, comfort always).

Taking a patient’s blood pressure; what could be easier than that?

I was shocked to find out that medical students, entering their clinical years, have not been taught the proper method and interpretation of blood pressure measurement. The current approach almost invariably uses electronic sphygmomanometers and, while convenient, it is often not performed well and misses important information which simply cannot be gleaned from an electronic sphygmomanometer.

First, and foremost, the patient must be comfortably seated with their back supported and their feet planted on the ground or supportive surface. The patient is to have rested for at least five minutes and not have had any caffeine to drink in the previous hour.

The bladder of the cuff should encircle at least 80% of the patient’s arm and the width to length ratio of the cuff should be at least 40%.

I would recommend that the systolic pressure be estimated first by palpation. One does this by reasonably rapidly inflating the cuff to 80 mmHg while palpating the radial pulse. If the pulse remains palpable, slowly increase the cuff pressure (approximately 10 mm Hg every 2 to 3 seconds) until it disappears.  Note at what pressure the pulse is obliterated. Next release the pressure of the cuff completely and raise the patient’s arm above their head (especially if he or she is obese) for at least ten seconds so as to help drain any excess venous blood that had accumulated in the arm as that has may muffle Karotkoff sounds.

Next while supporting the patient’s relaxed arm at heart level, pump up the cuff to 20 mm Hg above the previously estimated systolic blood pressure. Slowly deflate the cuff at no more than 2 mm every second while listening for Karotkoff sounds. The appearance of Karotkoff sounds (stage I) signals the patient’s systolic blood pressure. Continue to deflate the cuff paying attention to a time when Karotkoff sounds become muffled or disappear (stage II). This stage is not always present. Continue to deflate the cuff listening for the recurrence of Karotkoff sounds, if they had disappeared, or an increase in their intensity if they had only been muffled (stage III). Continue to deflate the cuff until Karotkoff sounds muffle again (stage IV). Continue to deflate the cuff until Karotkoff sounds disappear completely (stage V). True diastolic blood pressure is found between stages IV and stage V. However, if those stages occur within a narrow range, the disappearance of Karotkoff sounds identifies the diastolic blood pressure. Persistence of Karotkoff sounds well beyond phase IV is termed “systolic persistence” and, in such a case, I would record the blood pressure with three digits – systolic, phase IV and phase V readings

I would also strongly recommend that blood pressure be tested in both arms. A difference of 10 mm Hg or more can indicate, amongst other things, arteriosclerotic vascular disease and has been correlated with an increased risk of cardiovascular events.

A very prominent auscultatory gap (i.e., stage II) in which there is disappearance of Kartkoff sounds also correlates with an increased risk of cardiovascular events.2

In patients over the age of 60, those with “resistant hypertension”, diabetics and/or patients with chronic kidney disease check for evidence of possible pseudohypertension. To do so, determine if the radial pulse is still palpable after the blood pressure cuff has been inflated to above systolic. If so, this signifies stiffening of the radial artery due to Monckeberg’s medial sclerosis. This procedure is known as “Osler’s maneuver”. Such a finding carries significant ramifications.3

1. Williams, J. S., Brown, S. M., & Conlin, P. R. (2009). Blood-pressure measurement. N Engl J Med, 360(5), e6.

2. Cavallini, M. C., Roman, M. J., Blank, S. G., Pini, R., Pickering, T. G., & Devereux, R. B. (1996). Association of the auscultatory gap with vascular disease in hypertensive patients. Annals of internal medicine, 124(10), 877-883.

3. Mishriki YY. Resistant hypertension: A stepwise approach. Cleveland Clinic Journal of Medicine May 2023, 90 (5) 273-274; DOI:

The doctor-patient relationship in the twenty-first century

“Therefore, send not to know for whom the bell tolls. It tolls for thee.”

John Donne

I would like to thank the class of 2008 for the opportunity and honor of speaking with you today and also to thank the Arnold P. Gold Foundation for sponsoring this important event. This is what most, if not all, of you have been waiting for. The chance to finally leave the classroom and apply the knowledge you have been accumulating to the care of patients. It is an important milestone in your careers. The responsibilities we bear are enormous but the privilege with which we are entrusted is even greater.

When I first received this invitation, the very first thing that came to my mind is a well-known saying, “La médecine c’est guérir parfois, soulager souvent, consoler toujours” which translated means “to cure sometimes, to relieve often, to comfort always”. This aphorism has been attributed to the famous French surgeon Ambroise Pare but recent scholarship suggests that it had been roaming through medicine for centuries. It emphasizes that while curing is important, albeit inconstant, caring and comforting are always the healer’s objectives. I hope that this sentiment will always guide your interactions with your patients as you continue in your careers.

What is “humanism”? The Oxford English Dictionary has five major definitions of the word humanism. The one which is germane to our field is, “The character or quality of being human; devotion to human interests”. As I thought about humanism in medicine, I was struck by the fact that it was even necessary to discuss humanism and its role or place in the healing arts. Is it not implicit that the practice of medicine is, above all, a human endeavor which brings the physician and patient into a deep and, at times, almost mystical relationship?  A relationship in which, at times, the patient shares some of her deepest concerns and hopes with her physician, trusting that that physician will accept her unconditionally and do his utmost to help heal her be it physically or emotionally. This relationship, of course, flows in both directions. We physicians also get much from this relationship . The essayist Anatole Broyard reflecting on his own experience as a patient, wrote, “Not every patient can be saved, but his illness may be eased by the way the doctor responds to him – and in responding to him the doctor may himself be saved.”

Now to be perfectly honest, there are times in which some patients can be frustrating and exasperating and one may wonder why one has ever agreed to take them on as patients. However, I assure you that, at times, your patients will be frustrated and exasperated by you and will wonder why they ever came to you in the first place. That is the nature of human relationships and, in my opinion, does not detract from them. One must always keep in mind that the role of patient can be very difficult. With more severe illnesses, patients often feel helpless and afraid not to mention the sense of not being in control. It is the responsibility of the physician to help the patient regain some sense of control and to give hope, when appropriate. At the very least, the patient must be made to understand that, regardless of the prognosis, the physician will always be there to alleviate suffering and to offer an understanding ear. In my case, I have cared for many older patients for more than two decades and I can assure you that getting older is not for sissies.

There are many reasons why we physicians might lose our humanistic bearing . Medicine is an arduous profession, one which can be physically and emotionally draining. A century ago, Sir William Osler recognized the effects of clinical practice on its practitioners when he wrote, “In some of us, the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started. Against this benumbing influence, we physicians and nurses, the immediate agents of the Trust, have but one enduring corrective – the practice towards patients of the Golden Rule of Humanity as announced by Confucius : “What you do not like done to yourself, do not do to others.” In modern day practice there seem to be even more numerous external pressures – productivity quotas, time constraints, mountains of paperwork and streams of bureaucratic red tape, to name a few. Nevertheless, when dealing with patients, one must always remember, “but by the Grace of God, there go I”.

So, does being a humanistic physician entail listening attentively and showing genuine concern? Yes, that is part of it but by no means all of it. Does one place the occasional gentle touch or give an understanding look? That too is important. It is also important to realize that as healers, there is nothing that is beneath you when it comes to caring for your patients. If a patient cannot cut his food, do it for him. If she needs to get on a bed pan, help her to do so. If a patient is nauseated and vomiting, hold his forehead while he vomits into an emesis basin. That patient will more likely remember that act of kindness that the fact that you diagnosed his pheochromocytoma. Sir William Osler, one of the two physicians I admire the most (my father is the other) epitomized the humanistic physician. He had been on his way to a ceremony all decked out his academic regalia when he stopped off at the home of a young boy who was dying of diphtheria and who was not eating. Osler, entered the sick room and sat on the bed by the boy. He spoke to the boy while he peeled an orange and told the boy that it would be the most wonderful thing he had eaten. Piece by piece the fed the lad until the boy had eaten the entire orange. Osler, who was one of the most venerated physicians of his time, returned that evening and did the same thing. He then returned every day, bringing with him his academic regalia, which he slipped on outside of the boy’s room, and then fed the boy an orange. Sir Osler did this twice a day for several weeks and the boy eventually recovered.

What stories will each of us be remember for?

Several generations ago, the proper professional demeanor was of unemotional detachment. Thankfully, we have outgrown that stage. More recently, it has become acceptable, and even desirable, to show sympathy, empathy and emotional concern. And that is good. However, I would like to suggest something even more radical. The mystic poet John Donne wrote in his thirteenth meditation – “No man is an island, entire of itself; every man is a piece of the continent, a part of the main. Ifa clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee”.

What I would put to you, therefore, is that we should love our patients. We are, after all, part of the larger human family. What has dawned on me in the last few years is that our patients are, in a very real sense, our aunts and our uncles, our brothers and our sisters. Treat your patients as you would your family. There has been much written and discussed recently about diversity and the importance of acknowledging and celebrating it. I am all for that. However, there is much more that binds us as human beings than makes us different. I have never met anyone who did not wish to feel needed and loved; who did not wish to feel special and part of a greater whole. I would suggest to you that you should respect our diversity but embrace our commonality.

What is truth?

“Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half—so the most important thing to learn is how to learn on your own”

David Sackett, M.D.

“Nullius in verba” – Motto of the 1660 Royal Society

I had an excellent clinical experience while rotating through the internal medicine service at Cook County Hospital in 1977. I distinctly recall that when making rounds with the chief medical resident, he brought along with him a chart cart with multiple medical textbooks for us to confirm what was being taught.

While reading a recent paper on physical examination findings in endocrine disorders, I came across the famous ‘Queen Anne sign’, also known as the sign of Hertoghe, which describes loss of the lateral third of the eyebrows in some patients with hypothyroidism. I had read, years ago, that this sign was not factual and stopped teaching it to medical students and residents. This got me to thinking about all the things we have been taught in medicine which are not true but have ensconced themselves in the medical literature and have come to be believed as true. This is analogous to the aphorism, “Repeat a lie often enough and it becomes the truth.”

By way of example, I describe a small smattering of medical “truths” which, in fact, are not as a means of highlighting the need to continually reassess what one knows.

1. Evaluation and treatment of acute appendicitis.

As a surgical intern in 1979, acute appendicitis was believed to be a one-time event which required surgery for definitive diagnosis. In 15% of cases, the excised appendix showed no evidence of inflammation or infection. This moderately high false positive rate was felt to be necessary so as not to allow any cases to go untreated (i.e., surgically).

The most recent data on treatment of acute appendicitis is that, barring any complications such as perforation or systemic infection, treatment with antibiotics in low-risk patients is recommended. This represents a change in guidelines based on new data. However, one form of appendicitis I have never heard discussed is of chronic (or relapsing) appendicitis. The literature on this entity is decades old but primarily in European journals. Recurring episodes of appendicitis have been documented in patients with recurring episodes of abdominal pain. I personally have two family members who were found to have chronic appendicitis discovered after they underwent appendectomy while undergoing laparotomy for unrelated reasons. One had recurring episodes of abdominal pain for years which had evaded definitive diagnosis.

2. Roth spots.

Ask any medical student or resident what eye findings are found in infectious endocarditis and they will immediately respond, “Roth spots”. I, myself, taught that for years until I discovered that Roth had never described white centered hemorrhages (the description of what constitutes a Roth spot) in patients with infectious endocarditis. In 1872, he did describe retinal red spots (previously described by Bowman) as well as white spots but not white centered hemorrhages. That description was made by Litten in 1878, six years later. The eponym “Roth spot” is, nevertheless, enshrined in the medical literature. Joseph Sapira, in his exquisite physical diagnosis book, goes into the history of the description of these retinal lesions.

3. Tactile fremitus.

Most of us were taught that to check for tactile fremitus, one should have the patient say “99” while palpating the chest with the palm of the hand. It turns out that this is not ideal but came about because of a direct translation of a German medical paper which advocated having the patient say “neun und neunzig” (i.e., ninety-nine in German) when checking tactile fremitus. The diphthong “eu” creates the sound “oy” which proves to be a more effective way of detecting changes in fremitus than the sound “ine” (in most cases). I, therefore, had patients say “toy boy” while checking fremitus until a resident pointed out that that phrase sounded inappropriate. I switched to having patients say, “oy oy”, instead.

4. Thyroid hormone replacement therapy.

There is a near unanimous consent in the medical field that hypothyroid patients that require thyroid hormone replacement, levothyroxine (i.e., T4) is all that is needed to restore a euthyroid state. Recommending a mixture of T4 and T3 is frowned upon. That was my stance for many years until I read an article by Kent Holtorf, MD who made a very convincing case that that may not always be ideal. Nearly every physician who has taken care of hypothyroid patients has had several who continued to complain of not feeling completely well despite having normal TSH and free T4 levels. This has frequently been explained away by stating that, since hypothyroid symptoms are nonspecific, the patient’s sense of not feeling perfectly well was not related to their thyroid status but to other nebulous causes. The article by Kent Holtorf goes into great detail in explaining the physiology of thyroid hormone action, the varying effects of the three deiodinase enzymes and how there might be a disconnect between pituitary deiodinase activity and cellular thyroid function and the effects of various disorders and states on thyroid hormone activity at the cellular level which are not reflected by the pituitary TSH level. A discussion with an endocrinologist colleague acknowledged that the final say on proper thyroid hormone replacement was still a work in progress.

5. Determining right atrial pressure via jugular venous examination.

This one is my mea culpe. Although I have always been extremely impressed by Dr. Sapira’s textbook on physical examination, I never did review the section on examination of the jugular venous system as I arrogantly felt that I had reasonably mastered the skill. Today, however, I did read that section to my great embarrassment. The method recommended by Dr. Sapira is nothing like the traditional method which has been etched into numerous high-quality textbooks. Dr. Sapira makes a very good case against the traditional method and its landmarks (i.e., the sternal angle of Louis) which he cynically dubs “the cardiologist’s constant”. I will let the reader pursue this topic at his or her leisure.

Maintaining one’s knowledge base and skills in medicine is difficult. Expanding on that knowledge base is very difficult and time-consuming. In addition, confirming the validity of what one already “knows” is nearly impossible. Nevertheless, an effort should be made as often as reasonably possible to confirm that what one knows is, in fact, factual.

Diagnostic pitfalls

“Remember, diseases don’t read books.”
Yousri Youssef Mishriki, MD

“Uncommon manifestations of common diseases are more common than common manifestations of uncommon diseases.”
Yehia Yousri Mishriki, MD

Why can diagnosis in medicine, at times, be so difficult?

Here is a paraphrase of a typical sentence in my internal medicine textbook when I was a student/resident – “In disease x, one finds an elevated white blood cell count. At times, however, the white blood cell count can be normal or low.”

It would not suffice to know the breadth and depth of medicine, which is impossible, to always correctly diagnose one’s patients but one must also be aware of the variability of presentation of all those diseases. Sir William Osler knew as much when he wrote his epic book, ‘The Principles and Practice of Medicine’ in 1892 wherein he described the various ways in which typhoid can present and cautioning that, “This diversified symptomatology has led to many clinical errors…”. The more modern medical literature also describes the varieties of ways diseases can present atypically. For example, Cushing syndrome, due to excess cortisol production, has occasionally been described as “cyclical” rather than continuous, with variable other presentations such as periodic hormonogenesis, unpredictable hypersecretion of cortisol, fluctuating cortisol excretion or intermittent Cushing syndrome. Even in monogenetic illnesses, where one would expect a stereotypical presentation, there can be a variability of presentation due to environmental effects and exposures, post-zygotic mutations, and epigenetic influences.

In his book, ‘Thinking Fast and Slow’, Daniel Kahneman described two methods of thinking when making decisions. In the fast pathway, pattern recognition is fast, intuitive, and often driven by heuristics (cognitive shortcuts for reaching immediate solutions to a problem) and is primarily subconscious. In the slow, analytic pathway, thinking is deliberate, effortful and under conscious control. Physicians toggle back and forth between these two methods depending on the details of the cases they are analyzing, their experience and knowledge and their whim. Tversky and Kahneman posited that most inferential errors produced by heuristics and biases were due to “faulty probabilistic reasoning”. However, Jain did not agree that the diagnostic process was probabilistic, and I believe that he is, at least partially, correct. Nevertheless, once an initial diagnosis comes to mind as a result of a heuristic, biases are bound to arise, particularly anchoring and confirmation biases which interfere with one’s ability to objectively proceed with the evaluation. Furthermore, one must simultaneously avoid the diametrically opposed biases of representativeness restraint, a tendency of looking for typical manifestations of a disease while ignoring atypical variants (“when you hear hoof beats, think of horses and not zebras”) and aggregate bias, a belief that general population data do not apply to one’s patient. A setting for cognitive dissonance, if ever there was one.

What are clinicians to do? Those in the know recommend cognitive bias mitigation which involves “deliberate switching” from intuitive to analytical processing and the use of “debiasing strategies”, what I term ‘metacognition’ or thinking about one’s thinking. After one has generated an initial possible diagnosis or diagnoses, one must step back and carefully question oneself as to whether one has fallen prey to some of the more common biases. Needless to say, this is time consuming, and time is a very rare but critical commodity in accurately diagnosing one’s patients.  


“The first figure of a physician to stand out clearly from the mists of antiquity”

Sir William osler

You may have noticed that this website has an ancient Egyptian motif. The hieroglyph and statue are both of Imhotep (“He who comes in peace”), circa 2667-2600 BC.                             

In 2012, I read an article in Consultant 360 titled, “Imhotep: The Physician/Architect Who Led Us From Magic to Medicine.” As I was baptized in the Coptic Catholic church, I have always believed that the Copts are descendants of the ancient Egyptians and, therefore, strongly felt the link to Imhotep. Unfortunately, “proof” that the Copts are the descendants of the ancient Egyptians is somewhat controversial. Nevertheless, there are genetic (i.e., the Akhenaten gene) and linguistic links from the Copts to the ancient Egyptians.

Furthermore, searching for evidence of Imhotep’s medical credentials has proved to be elusive. When I went back to review the paper from Consultant 360, I noticed that there was no author. In addition, the first citation I looked up from that article did not exist. The Dictionary of World Biography states, “while the specific qualifications of Innotek (Imhotep) as a healer are not as clearly documented, it is thought that his duties as a priest who was regarded as a magician may have initiated his reputation as a medical man.” Even the Wikipedia page dedicated to Imhotep found the claims for his having been a physician unreliable. What does stand scrutiny, however, is that Imhotep was the chancellor to the Pharaoh, Djoser, architect of the step-pyramid at Saqqara and royal astronomer. So great was respect for Imhotep that he was deified a few centuries after his death. The first mention of his medical credentials dates to 2,200 years after his death.

Much of what is known about ancient Egyptian medicine is found in a handful of papyrus rolls. These have included the Ebers Papyrus, the Hearst Papyrus, the Berlin Medical Papyrus, the Kahun Medical Papyrus, the London Medical Papyrus, the Edwin Smith Papyrus and another papyrus in Berlin. The most important of the papyrus rolls is the Ebers Papyrus, written circa 1550 BC. It is believed to be a compilation of older writings but parts of it existed during Imhotep’s lifetime and could reflect his approach to medicine and magic. The Edwin Smith Papyrus has also been proffered as “proof” that it reflects a rational evidence-based approach to medical healing. In it the text instructs the physician to examine the patient and elicit physical signs that may indicate the prognosis. Unfortunately, while the front of the papyrus deals with the care of wounds, beginning with the head, the verso has magical spells to exorcise demons.

In the book, Hippocrates Now. ‘Father of Medicine’ in the Internet Age, Helen King puts forth a conjecture that the recent desire to label Imhotep ‘Father of Medicine’ in the place of Hippocrates is “to reverse a valorization of West over East which has been common in histories of medicine into the twentieth century.” Certainly that has also been true with regards Chinese medicine and scientific advances, often superior to Western thought and technology of past eras, but which have only come to be acknowledged in recent decades.

Two final points. First, I was taught and I did teach the Hippocratic tenet, ‘Primum non nocere‘ (First do no harm). This aphorism is not found in the Hippocratic oath as such, although not causing harm is. More recently, I have taught a modern version, “Saltem plus boni, mali efficare conare” (At least try to do more good than harm). Interestingly, ‘Primum non nocere‘ is Latin whereas Hippocrates was Greek. Second, the 1946 book Hippocratic Wisdom by William Petersen, gives this advice, “Why bother with Hippocrates when there is so much to learn in modern texts? Because today, as never before, knowledge of the historical continuity of the tradition that combines theory and practice is indispensable. The student obtaining knowledge and skill only at the top levels of the modern medical skyscraper should know something of the foundation structures and the service plants in the basement and sub-basement if he is to be something more than a technician.” Sage advice.

Medicine’s Roots are Inviolable

For many, Medicine is a calling. I knew I wanted to be a doctor when in my early teens. This was reinforced by the fact that my father was a doctor who, sometimes, discussed his pathology cases at home. The depth and breadth of what he knew was breathtaking and who would not want to be so immersed in and knowledgeable of one’s profession.

Caring for patients can be, simultaneously at times, the most exhilarating, invigorating, edifying, heart warming or heart wrenching experience. At times it can be positively spiritual. It is also, on occasion, maddeningly frustrating and, sadly, the frustrating aspect has been progressively less due to difficult patient interactions and more and more due to the environment in which medicine is practiced.

I have said, and still believe that a doctor should love his or her patients. They become a part of the family and, just as with any family, there will occasionally be that difficult uncle or cousin who drives you mad. Nevertheless, he or she is still your relative and you love them nonetheless.

Forty years since receiving my degree, I have learned and experienced much more than I would have ever imagined, and a significant part of it has not been directly related to the narrow practice of medicine.

I am currently somewhat pessimistic about Medicine’s trajectory. I can see no fruitful remedy unless it comes from doctors and not the bureaucrats, big pharma and/or the government who currently hold the reins. Nevertheless, our patients continue to need us, probably more than ever, and this should be our guiding light.

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