The Patient Was…

Truth be told, the hardest part of writing this piece for the blog was choosing a title. I went back and forth between “Technology versus Clinical Medicine” and “Technology and Clinical Medicine.” The “and” won the day, because technology and clinical medicine are, at their best, complementary. Often, however, emphasis on one, especially the technical, leads to different pathways and systems of caring for patients. Outcomes, costs, and the experiences of patients may also vary significantly.

I’ll state at the outset that I am in awe of advances in medical technology. In many areas of medicine, new technologies have changed the methods of diagnosis, treatment, and follow-up care. The problem I see, and want to address, is an overemphasis on technological choices and solutions, and the neglect of more clinical and non-technical aspects of care.

Just a generation ago, perhaps the most revered physician was someone designated as a “brilliant diagnostician.” That acclaim reflected the understanding of both the medical profession and society at large that clinical insights and acumen were at the heart of diagnosing most illnesses. There weren’t that many advanced technologies to help. Doctors had to talk with and listen to patients, perform careful examinations, and consider multiple entities as they ruled in or out various diagnostic possibilities. The luxury of ordering CAT scans, PET scans, MRIs, ultrasound examinations, and other technological aids to diagnosis simply did not exist.

The introduction of various forms of technology has changed the very nature of medical care. Physicians are more likely to be staring at a computer screen rather than looking at the patient in their office. If it is true that most patient visits are for things that are not serious and are often self-limiting, what has been gained when electronic entry of data and information supersedes face-to-face conversation?

Am I guilty here of longing for a return to a “Norman Rockwell” vision of Americana? Perhaps. Today, although physicians still rank very high among respected professionals, opinions about medical and health care in the U. S. have changed dramatically. Technology is not the only cause of this shift in attitudes, but it certainly plays a role. Personal care has been supplanted in many instances by “systems” care, where algorithms drive decisions that affect people’s lives. Layers of bureaucracy now exist between patients and physicians that did not previously interfere with the patient – doctor relationship. The fact that a man, seen on video fatally shooting a healthcare executive whom he had never met, is praised by many for his actions is an appalling example of something gone wrong.

The essence of most medical diagnosis is still a careful history (from the patient, or others if necessary) and physical examination. Sir William Osler (1849 – 1919), sometimes called “The Father of Modern Medicine” and considered one of the greatest diagnosticians, is reported to have said: “Listen to the patient. He is telling you the diagnosis.”

Taking a careful history and performing a thorough physical examination takes time. And time is something that the current practice of medicine does not readily allow. In many clinical settings, even new patients are allotted only 10 to 15 minutes of time with the physician. (In China, average time with a physician for an office visit is about 4 minutes). Important patient information and data are often recorded by someone else, with little attention paid to those details by the doctor.

When I first entered private medical practice, I interviewed with a well-known group practice. They allowed 10 minutes for a patient visit, even if it was a new patient. When I said that was simply inadequate, they reluctantly agreed to allow me fifteen-to-twenty minutes for new patients. Although I liked the doctors and the location of the practice, I declined to join them. In my own solo practice, I spent at least one hour with every new patient, and one-half hour on return visits. I think I knew more about my patients and their lives than most of my colleagues did about theirs. And it helped me make good clinical decisions, using less technology, with less patient cost and inconvenience. It also meant less income for me, but it was a trade-off I was willing to make.

After several years of sharing space with another physician, I purchased my own office. It had a full x-ray unit, and the doctor who was selling the office to me said that it was his greatest investment. He took x-rays of almost every patient, no matter what their symptoms were. When I asked where he kept the films, he said he disposed of them. He offered that he didn’t know how to read them very well, anyway, so why keep them. But people and insurers were willing to pay more for this simple “technology” than for the time the doctor actually spent with them.

I conducted two informal surveys while I was in practice. These weren’t rigidly controlled clinical trials or any sort of organized data collection. But I was able to gather enough information to convince me of the validity of my observations. In short, although my use of technology was far less than that of most of my colleagues, my patients did just as well as theirs. Paradoxically, this led to some of my more interesting referrals from other doctors.

 In those cases, a referring doctor had recommended an invasive procedure (a medical technology intervention requiring access into the body), and the patient refused. The doctor referred them to me, telling the patient that I was an “anti-invasive, anti-technology doctor,” and if I recommended the procedure the patient could be sure it was necessary. In about half of the cases involving cardiac angiography (a procedure where catheters or thin tubes are inserted through the skin, and maneuvered through blood vessels into the heart, and dye is injected to visualize the structures), I found that the procedure was not necessary. Of note, at about the same time a group at Harvard Medical School reached the same conclusion in patients referred to them for the same invasive procedure.

Much use of medical technology nowadays might be described as “Throw it against the wall and see what sticks.” If there are multiple tests that can give essentially the same information, many patients are subjected to all of them. The philosophy seems to be “Why have a technology and not use it?” It is true that each new technology might provide a small nugget of new data; but if that does not help in the diagnosis or management of the patient, is it justified to subject the patient to the cost, inconvenience, and possible risk? When I asked a cardiologist in a busy group practice how a patient “flowed” through their office system, I was told that the patient first gets a whole series of tests and then sees the doctor, so the test results are all available. When I asked how the doctor knew which test the patient would need the answer was, “They all need all of them.”

The case of a 40-something-year-old advertising executive who consulted me exemplifies some of what I’m talking about. He had reported to his primary physician that he sometimes felt “palpitations” where his heartbeat seemed irregular, and he felt lightheaded and unsteady. His doctor found nothing on examination and thought he should undergo a complicated, invasive procedure to analyze his heart rhythm. Although on my examination his heart was entirely normal, as was his electrocardiogram (a recording of the electrical signals and activity within the heart), a detailed description of exactly what he felt during the episodes convinced me that he was experiencing episodes of a common heart rhythm disturbance (arrythmia) called atrial fibrillation (commonly called A Fib).

He admitted to none of the usual causes of A Fib and was especially emphatic in denying drug or alcohol use. When I asked if he ever felt an episode of palpitations while under stress, he said his life as an affluent, single, straight male was essentially stress-free and that he had a very active business-related social life. The idea of a business-related social life without alcohol intrigued me, but he had denied alcohol use; I was not about to call him a liar. So, I took an indirect approach and inquired whether he ever had an episode of palpitations while driving a car in heavy traffic or other frustrating traffic-related conditions. He said he rarely drove and usually used car services. When I asked why he suddenly reddened and admitted that he often drank heavily at social events and didn’t trust himself behind the wheel. He didn’t want to admit he had a problem with alcohol, but further discussion revealed that his episodes of arrhythmia usually followed alcohol ingestion. I don’t think that any amount of testing would have revealed what taking a detailed medical history did: He had alcohol-induced atrial fibrillation, a common phenomenon, by the way.

When I was taking the oral part of my Cardiovascular Board Certification examination, I was sent to Emory University in Atlanta, Georgia. Examination protocol at the time mandated that you be tested in a city other than where you trained or practiced, so there would be no local influence on your grading. I was asked to examine a young, indigent, uneducated man who was on the teaching ward of the hospital. He could give very little detailed information about himself, but he had come to the hospital because of extreme difficulty breathing. On my examination, he had clear and unmistakable signs of a severely damaged heart valve and was in a state of advanced heart failure where his heart could not adequately pump blood around his body and blood under elevated pressure leaked back into his lungs.

I went to the office of my examiner and proceeded to describe my findings. I asked to see the patient’s chest x-ray and electrocardiogram, which confirmed my diagnosis.

“What other test results would you like to see?” the examiner asked, pointing to a bulging file of data on the patient.

“Nothing else,” I replied.  “The diagnosis is clear. And the only available treatment is surgery to replace the damaged heart valve.”

The examiner continued to press the issue of reviewing more tests that they had performed. I kept insisting I didn’t need to see anything more, and that any other information they had accumulated was superfluous to the care of this individual. I did not want to appear arrogant or argumentative, but I felt justified in my position. Finally, I asked if the examiner himself had actually ever seen the patient. He had not.

We both went to the patient’s bedside. It took only a few moments for the examiner to confirm what I had found. On return to his office, he acknowledged that I was correct in what I had said. When I asked why they had done so much testing on this young man, whose diagnosis was so evident from the simplest of measures, he said it was a teaching hospital and the physicians in their training needed exposure to all the technologies available at the time. It was a legitimate argument. But it would have been better, in my opinion, to include that appropriate use of technology was also a legitimate educational goal.

Let me reemphasize that I am in awe of the progress in medical science and technology. We can do things for patients today that were literally unimaginable years ago. Advances in pharmaceuticals, devices, and technologies have helped to enhance the functioning and extend the lives of people around the world. But time-honored skills of talking to and examining patients are still needed, and we should learn to use both them and technology appropriately and rely equally on each of their contributions to the care of our patients.

Using the image of a stethoscope as a metaphor for the “old fashioned” rendering of medical care, my plea is to make the stethoscope a useful tool again, rather than merely a neck ornament as it seems to have evolved.