by Daniel A. Graubert, MD
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 CT scans and MRIs 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 MRIs 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 has 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 EKGs.
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 e-mail 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.
I was inspired by an item in the Journal of the American Medical Asociation 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.
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.
Daniel Graubert is an anesthesiologist who blogs at Fathers and Doctors.
Submit a guest post and be heard.
Related posts:
- Are doctors finding the physical exam useless and obsolete?
- What the United States health care system can learn from Mexico
- Will patients or doctors be the biggest obstacle impeding health care reform?
- Old-school doctors
- What doctors can learn from patients in the health care reform debate
- How should doctors handle the difficult patient?
- Primary care doctors face burnout, and how that affects health reform
{ 7 comments }
I’ve always envied the President of the United States because…… once a year (at least) he gets a full physical exam at Walter Reed Hospital! I’ve never had what would be termed a “full physical exam.” No one has ever taken a full physical history of me. When you make a doctor appointment you’re always asked why you need the appointment. Then, when you see the doctor, the focus of the appointment is all that is addressed. Even now, my current doctor does this. She is caring and knowledgeable, but there is only so much time allotted to an appointment and so that’s all that is addressed.
I doubt that this is going to change. Doctors do not have time to sit and talk with a patient for hours. And, even if they did, my memory is not as great as it used to be! But I still envy the President…
Nice to see this kind of accountability. If you look at maternity care in particular, we see all sorts of “snake oil” being sold to women. Continuous fetal monitoring, taking the baby before he gets “too big,” cesarean for almost any reason or none at all – these practices set up the expectation of improved outcomes, yet maternity care in the US is failing miserably at improving the lot of women and babies. So, yes, we need to stop relying on technology that holds false promise and the physician community has got to it’s part and stop clinging to the “trial lawyer made me do it” mentality.
Wait, do anesthesiologists do histories and physical examinations? It’s a valid message; we need to get back to basics.
But why is it coming from an anesthesiologist?
Anesthesiologists are doctors and went to medical school where they are taught to do a history and physical, and yes, anesthesiologists do histories and physicals. As a matter of fact, probably more thoroughly than most primary care docs since we are not focusing on a specific problem. We pick up murmurs, melanomas, bruits, etc. with regularity. I was often told by patients that I did the most thorough H&P they’d ever had.
@Melgirl … Charmingly naive.
@Doc99 …typically condescending. Feel free to cling to your wailing and gnashing of teeth over the Tort threat. I get it. It’s awful. But increasingly, you will see a diminishing number of your patients willing to lay down for sub-optimal care for the sake of CYA medicine.
where are all these patients going, considering that suboptimal CYA medicine is pretty much the only available option? abroad?
Comments on this entry are closed.