Practice of Medicine

Good doctoring is not rocket science — it is also not digital

by John Mandrola, MD

 

Sometimes I worry about where technology is leading the healthcare profession.

It is not just the distraction of white screens and electronic health records. These are bad, terrible, in fact. The concern I have runs deeper than just monopolistic EHRs.

We, and I mean we as in the caregivers, are losing touch with the basics. I see it everyday, especially, but not exclusively, in the younger generation of nurse and doctor. The collective loss of fundamentals is happening so slowly and steadily that no one seems to notice. Indolent is what we say in medical-speak.

Here is what I mean.

What makes the practice of medicine work well is not at all complicated. It starts with a story. What is a person’s story? A BNP level, a set of shadows on an ultrasound, a white count, a rhythm strip with squiggles, these are not stories.

I begin almost every new patient visit with words like this: “What is bothering you most ... I want to know what you say, not your doctors.”

When I do this, it is as if magic occurs. I met with a clinician a month ago at the Heart Rhythm Society meeting in San Francisco. He told me something that I’ll never forget about the patient encounter:

I can almost always tell within a few minutes of meeting an (AF) patient what the correct treatment will be. It’s as if God himself speaks, and tells me the right course for that patient.

I know that sounds like hyperbole, and maybe it is, a little. But what it highlights is the power of observing people, their faces, their clothes, their families, their reading material. You simply cannot know the correct course for a person from a chart, an x-ray or an ultrasound.

As a consultant, I see people for abnormal heart rhythms. But often, the heart rhythm is not what is bothering them. Often it is that their body hurts, or they can’t sleep, or they are unsteady, or they can’t remember things.

You see the trouble? A doctor is tasked with treating the person in front of them, not his ECG, or low ejection fraction.

This is what is getting lost.

As the healthcare machine increasingly embraces mobile sensors, digital records, and binary quality metrics, what used to be the care of people has tragically become the treatment of aberrations of 1s and 0s.

There is more.

It is not just loss of the human narrative; it is also the loss of the human touch, the act of the physical exam. I was recently made fun of on Twitter for suggesting that the treatment of congestive heart failure aided by an invasive monitor stuck into a pulmonary artery would prove no better than a doctor’s observation. The believers in all-things-tech laughed me off the social platform.

But that’s BS. And such a defeatist approach to fundamentals is what I am talking about. Consider the case of CHF.

When fluid builds up in the body, patients, especially educated ones, will tell a story of increased breathlessness, swelling or a fullness in the abdomen. They know; and they will tell you if prompted and listened to. The physical findings (observations) of CHF are also quite reproducible. These are not complex findings mind you, rather, they are simple things such as a scale reading a higher weight, distension of neck veins, crackling of breath sounds, a palpably full abdomen, and swelling of the legs. There is also the appearance of the person from the door. We call this the “general appearance.” And it is everything, except quantifiable.

Good doctoring is not rocket science. But it is also not digital. It is not on a white screen. It is not numbers from a pulmonary artery. And it does not come quickly. It requires seeing patients alongside mentors over years.

What worries me is that we are taking our eyes and ears off people. We are distracted, perhaps intoxicated, by the 1s and 0s.

This is not to say that technology and computers can’t help us. Of course they can. But no machine, not even an Apple product, can replace looking and listening to the person we are trying to help. Machines and sensors don’t tell stories.

Perhaps the next generation of smart people will figure out a way to keep the fundamentals of medical practice and let technology aid us rather than distract and intoxicate us.

My tiny nudge is to remember the first rule of getting out of a hole: stop digging.