Sunday, October 6, 2013

A Technician Not a Doctor


William Osler examining a patient.

I recently read an article in JAMA[1] wherein a transplant surgeon describes his consultation with a patient.
From my reading, the surgeon almost accidentally finds out the man had been shot seven times and tortured. Much to my surprise, the surgeon does not want to ask any personal questions for fear that he would be "pry(ing) too much". As far as I can tell the patient was never examined by this highly specialized surgeon at an elite Medical Center. Instead, our protagonist discovers that the patient, a Visiting Professor of Theater, has written plays about his experiences in his native land in Africa by "Googling" him rather than taking the simple human expedient of asking questions. He then orders the patient's play from, reads it, and is justly disturbed. His mother notices this (during Mother's Day) but he ducks her questions for fear of "violat(ing) my patient's privacy". Remember this patient has published all of this. I found this entire story quite disturbing: this physician seems to deny both his and his patient's humanity. He seems to miss the whole fun of medicine: meeting people from all walks of life and helping them. When I discussed this incident with several of my colleagues, one of them very astutely said, "Perhaps we should call him a transplant technician rather than a surgeon".

More of the same. Two weeks ago, I saw patient for a recurrent/persistent meningioma who had been seen by roughly eight physicians or more in the past 18 months, including several from the same "Elite University" as our friend above. On my routine physical examination the lady had a 3.5 cm rock-hard, highly tethered, highly suspicious mass in the lower inner quadrant of her right breast. This was not a subtle finding. As I used to tell my medical students and residents, when I worked at a university, "You do not have to be good at physical examination; you must simply do it". Needless to say, a biopsy of her breast confirmed my suspicions. I suspect that all of us have had similar experiences which are becoming all too common.

What has brought us to this sorry state? Obviously the causes are many and protean. I suspect, however, a major one is the human propensity to seek technical solutions for human problems. This drive is probably as old as the Tower of Babel. Leon Kass in his book The Beginning of Wisdom: Reading Genesis describes that today "science and technology are again in the ascendancy ...en route to a projected human imperium over nature"[2]. A very pointed example with which we are all struggling daily is electronic health records. The government, in its infinite wisdom, has mandated that we use these things while it is unclear that they will improve quality of care or lower costs. They think because computers have lowered costs and to some degree if improved quality in many other industries that that would work in medicine. We could end up with iPatient.[3] One of my junior colleagues made the very apposite point that we should dictate the physical and the impression in these systems for the brain and the hand are what makes us human: what a machine cannot supply.

Early on Sunday mornings I commonly listen to radio program entitled "The TED Radio Hour" on National Public Radio where speakers from all over the world give 18 minute talks on their solution for problems of this world, great and small. Some are pretentious; some are funny; some are trivial; and, once in a great while, some are profound. Abraham Verghese, Professor of Medicine at Stanford University, in his movingly and emphatically supports the use of the hand: the physical examination in our profession. Not just as a rapid and cheap means of making a diagnosis such as I describe above, but, perhaps, more importantly as a necessary human connection to our patients. He describes at the end of his talk how he commonly sees patients who are big machers[4] in Silicon Valley. One of these clever lads (they are almost all lads) lectured Dr. Verghese how physicians will become obsolete in the near future thanks to information technology, the World Wide Web, and the brilliance of the people using these tools. Plato said "the first step on the path to wisdom is to know what you do not know". To this digital troglodyte the good doctor responded, "Young man, you have never suffered"[5].

I believe a partial antidote to all of this would be to follow Sir William Osler's advice to read an hour of the humanities every day[6]. This gives perspective and the constant reminder that we, humans, are not all that clever.

[1] JAMA, August 7, 2013
[2] The Beginning of Wisdom, Leon Kass, pp.242-3
[3] Abraham Verghese, WSJ, June 20, 2009
[4] Yiddish for a "big cheese".
[5] The TED Radio Hour, Feb. 26, 2013. I have modified this slightly. The "young man" is my insertion for dramatic effect.
[6] William Osler, A Life in Medicine, Michael Bliss

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