Tuesday, September 29, 2009

Medical Technology-confusing even in 1955

Medicine has changed so dramatically since I graduated medical school in the 1980's, that it is hardly recognizable.

Certainly there has been an enormous growth in knowledge which is often beneficial, but has often led us down the wrong path.  For example, when advanced imaging techniques such as "CAT" scans and MRI's became available, we were able to see the inside of large numbers of patients but we didn't know what was really normal.  One thing we found in quite a few people was a small growth on their adrenal gland.  Many of these patients were subject to operations and it ultimately turned out that the growths were harmless.

This is one of the problems with undergoing medical tests.  You have to deal with the results.  Sometimes the results are incorrect, leading to further testing and treatments.  Sometimes the results are correct, different than normal, but still harmless.  An example of this would be the "bulging discs" seen on so many MRI's of the spines of patients with back pain.  It seems logical to assume cause and effect in a patient with back pain and a spine abnormality, yet it turns out that bulging discs are a common finding and usually not associated with pain.

We have certainly improved our treatment in many areas of medicine, but it has come at a price, both in cost and in quality of care.  Too many people can't be seen quickly.  Our attempt to provide care for everyone gas created problems.  We have lower level people doing higher level functions, and they simply can't do them as well.  This ranges from blood drawing to EKG's.  A controversial area is the autonomy given to caregivers that have less formal training than physicians, such as midwives, nurse anesthetists, and nurse practitioners.  The overload of patients has led us to treat by email or video, an idea which is hard to accept when one learned that the basis of quality treatment is a good history and physical exam, neither of which can be done electronically. 

Physicians had it good for a long time, and really didn't take care of the field.  Now there is conflict between physicians and the AMA, and a new voice has arisen at Sermo
Unfortunately Sermo does not have a section for non-physicians, although I think it would be a good idea.

This post was inspired by an item in the Journal of the American Medical Asociation (JAMA) from December 24, 1955 by G.W. Pickering M.D..  It reads as follows:

Machine Age Overtakes Medicine-
As year succeeds year, some new physical or chemical technic and some new and elaborate machine are applied to the study of disease; great claims are always made for the precision of the answers yielded by these technics and machines.  One of the greatest struggles that a practicing doctor has is to keep up-to-date with advances of this kind.  No sooner has he mastered one than another is upon him.  Moreover, the machines or technics are often so complex that he cannot understand them.  He has to take what they tell him on trust...There is a growing tendency for doctors to rely on the information given by such technics and machines in preference to the information which they gain themselves from the history and physical signs.  I am extremely doubtful if this is in the interests of good doctoring, and for three reasons.  First, the errors and limitations of these new technics are not at first appreciated...Second, a thorough clinical examination, which will be carried out only by doctors who appreciate its worth, is the best method of establishing that spirit of mutual understanding and good will which is the core of the doctor-patient relationship.  Finally, to rely on data, the nature of which one does not understand, is the first step in losing intellectual honesty.  The doctor is particularly vulnerable to a loss of this kind, since so much of therapeutics is based on suggestion.  And the loss naturally leaves him and his patient poorer.

I think there was a lot of wisdom and foresight in this 1955 article.  Technology has advanced medicine without doubt, but a good history and physical exam remain the basis of good care.  The explosion of medical technology has introduced many useless and expensive technologies as well as pure snake oil, in addition to the useful technology.  Marketing directly to patients has made it more difficult for physicians to practice good medicine and avoid the use of treatments that look wonderful on television but are not in the patient's interest. 

We have a lot of work to do, but I think that physicians still have the best interests of their patients in mind and are the only ones who can fix what has broken, even if we played a role in breaking it.

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