By ROBERT WACHTER

In last week’s NEJM, physician-author Abraham Verghese paints a disturbing picture
of a medical world in which technology has morphed from tool to object,
the patient relegated to a supporting role. To me, Abraham has nailed
the diagnosis but not the treatment.

I had the distinct pleasure of getting to know Abraham when we both served on the board of the ABIM (actually I came to know his work 15 years earlier, when I reviewed his bestselling book, My Own Country, for the NEJM). Abraham is a romantic and a traditionalist, and in last week’s New England Journal
piece he poignantly lays out a problem he has fretted about for years:
namely, that information technology is dehumanizing the practice of
medicine. Describing rounds with his ward team at Stanford, his new
academic home (he was recently recruited there from the UT-San
Antonio), he recalls:

When I stroked a patient’s
palm and caused a twitch of the mentalis muscle under the chin — the
palmomental reflex — it was as if I were performing magic. Still, the
demands of charting in the electronic medical record (EMR), moving
patients through the system, and respecting work-hour limits led
residents to spend an astonishing amount of time in front of the
monitor; the EMR was their portal to consultative teams, the pharmacy,
the laboratory, and radiology. It was meant to serve them, but at times
the opposite seemed true.

Although the presence of
such a portal doesn’t sound like a bad thing to me (it beats the hell
out of the pager and the old Easter egg hunt looking for lab results
and consultants’ notes), his observations about the impact of IT on the
physician-patient relationship are salient and powerful. In
characteristically limpid prose, he decries this “new way” of
medicine:



The patient is still at the center, but
more as an icon for another entity clothed in binary garments: the
"iPatient." … The iPatient’s blood counts and emanations are tracked
and trended like a Dow Jones Index, and pop-up flags remind caregivers
to feed or bleed. iPatients are handily discussed (or "card-flipped")
in the bunker [the team’s charting room], while the real patients keep
the beds warm and ensure that the folders bearing their names stay
alive on the computer.

Although Abraham advances
the usual pragmatic arguments about unnecessary testing and missed
diagnoses, he is clearly troubled by something much deeper, more
fundamental, for both doctor and patient. Regarding the latter,

Patients
recognize how the perfunctory bedside visit, the stethoscope placement,
through clothing, on the sternum like the blessing of a potentate’s
scepter, differs from a skilled, hands-on exam. Rituals are about
transformation, and when performed well, this ritual, at a minimum,
suggests attentiveness and inspires confidence in the physician. It
strengthens the patient–physician relationship…

And for physicians,

…what
is tragic about tending to the iPatient is that it can’t begin to
compare with the joy, excitement, intellectual pleasure, pride,
disappointment, and lessons in humility that trainees might experience
by learning from the real patient’s body examined at the bedside. When
residents don’t witness the bedside-sleuth aspect of our discipline —
its underlying romance and passion — they may come to view internal
medicine as a trade practiced before a computer screen.

I’ve written (here and here)
about how computerization “de-tethers” us from the need to visit the
radiology department, the ward, and the patient’s bedside. And I too am
concerned that our physical exam skills may be entering a death spiral
– underemphasized by trainees who have never learned them and
supervisors who can no longer teach them. (Let’s be honest – many of
our physical exams are now perfunctory performances in a Theater of the
Absurd whose audience is comprised of coders and insurers.) That can’t
be good.

Yet by arguing that the physical exam will save us from
what I’ll call “iPatient-itis,” I believe Abraham has focused on the
wrong finding. Metaphorically, the patient does have a Boutonniere deformity, but the source of the fever is sepsis, not rheumatoid arthritis.

Years ago – well before electronic records and CPOE – one study
showed that internists’ fundoscopic exam skills were sufficiently poor
(~50% error rate) that their observations were no longer useful. I’d
wager that the same is true of most of the findings that Abraham
nostalgically cites, such as Roth spots, subcutaneous neurofibromas,
and the palmomental reflex. Remember that Physicians of Yore learned to
elicit and interpret these findings during eras in which they spent 100
hours a week in the hospital, the average patient stayed for 3 weeks
after an MI, and they had few data to review and analyze other than
that culled from their physical exam and a handful of rudimental lab
and radiology studies. It seems to me that with everything today’s
residents and students need to do and learn, the chances that we can
revive the painstaking Oslerian physical exam are zilch, akin to the
chance that we can resurrect the study of Latin in medical school.

Even if we could
create a new generation of expert physical examiners, would it be worth
the time and trouble? I doubt it. When I was a medical student, I spent
a couple of months at London’s Brompton Hospital, the UK’s premier lung
disease specialty hospital. Brompton physicians lavished attention on
the chest exam – elegantly listening for whispered pectoriloquy and
egophany, percussing for dullness, and palpating for asymmetric chest
excursions. Such exams often took 10 minutes. Ever the spoil-sport,
around Minute 8, I found myself wondering why we just didn’t get a
chest radiograph. Not because the ritual wasn’t engrossing – and yes,
even “magical” at times – but because at some point, all of this
elegance has to be weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.

This
is where my argument diverges from Abraham’s. In my zeal to bring
physicians back into the patient’s room, I’d place 20% of the emphasis
on performing and interpreting a good, thorough physical examination,
and 80% on teaching and promoting superb communication skills –
eliciting the history, describing prognosis, discussing alternative
treatments, determining the patient’s attitudes about end of life care,
and apologizing for medical errors, to cite but a few examples. These
are teachable skills that will never go out of style, skills whose
value won’t be supplanted by PET scan results and graphs of trended
ANCA levels. And, to me at least, they highlight the patient-as-person
and physician-as-humanist more than sticking a tuning fork on a
forehead ever could.

Don’t get me wrong. Like my dear friend
Abraham, I too am terribly bothered by the “iPatient”. But Abraham sees
the physical examination as the essential vehicle to promote a set of
core values – the physician-patient bond, the humanism of medicine, and
the central role of empathy – and keep our focus on real-, not on i-,
Patients. For the most part, I don’t.

(By the way, if somebody ever needs to stick a needle into my pleural space, please be sure they use ultrasound [performed by someone who knows what he or she is doing], not percussion, for guidance.)

Moreover,
by emphasizing the physical exam as the reason for leaving the “bunker”
to visit our patients, I’m afraid we risk having that reason
discredited. As laboratory and radiographic tests get better and
cheaper, the physical exam may compete poorly on the playing field
known as Evidence-Based Medicine. If our rationale for coming to the
patient’s bedside was to test for shifting dullness and a fluid wave,
what do we do when we discover that these are terrible tests for ascites?

On
one point, I’m sure that Abraham and I would speak as one: those of us
privileged to teach the next generation of physicians must relentlessly
promote human contact between doctors and patients. If we don’t, the
forces of technology will gradually erode this special relationship,
causing irreparable harm to both parties. 

So let’s ascultate
and palpate when it makes sense to do so. And as long as we’re doing
these things, we might as well try to do them well.

But I’d argue that the main reason to enter the room is to speak to the scared, ill human being in the bed.

And, more importantly, to listen.

****

A happy and healthy New Year to you and those you care about and for.