Medicine needs to get back to hands-on basics, rather than focusing on technology

There is plenty to criticize in our bungling trek toward health reform. Leaders on the right, left and at 1600 Pennsylvania Avenue have sidestepped the crucial conversation of controlling the cost of care, in favor of partisan rhetoric about “death panels” and “rationing care.” Worse, the entire focus of reform has centered on spending billions of dollars on technology solutions that will only make marginal changes in the cost and quality of care Americans get.

I want to refocus the debate on what matters most: relationships. Let’s reinvest in the sitting down with, listening to, empathizing with and touching patients.

America has the most advanced healthcare system in the world. But in our haste to research, develop and invest in high-tech medicine, we have lost sight of the very basics of good doctoring. The first things we learn in medical school are: ask, listen and touch. Doctors do not do enough of this any more.

As has been made painfully clear, most doctors are rewarded for doing all manner of procedures. This is true from the earliest moments of our career . As a resident, even when faced with the most basic medical problems, I was grilled by my attending when I didn’t order the full battery of tests, or contact all the specialists available to consult on a patient. Thus, over-testing and over-treating becomes a knee-jerk response from the get go.

This is how doctors practice medicine today. Some of us do it this way because it’s how we get paid. Some of us refer our patients to specialists because we don’t have time to sit down with them ourselves. Some of us rely on tests and procedures because we’re fearful of malpractice lawsuits. And most of us have just lost sight of the most powerful tools in the doctor’s arsenal: our hands and our minds.

I’ll illustrate this with an example. Once while still a medical student, author Dr. Sandeep Jauhar evaluated a man with chest pain whose lab tests and EKG suggested he was having a heart attack. The patient was admitted to the ICU. Hours later, the patient was in severe pain and his blood pressure had dropped. The resident in charge ordered another EKG and prepared to intubate and place a central line in the patient.

In the midst of this, Jauhar took the patient’s blood pressure. For reasons then unclear to him, the resident instructed Jauhar to repeat the exercise — on the patient’s other arm. Jauhar tried, but above the din of beeping monitors and barking doctors, he couldn’t hear the pulsing sounds through his stethoscope. Jauhar “shrugged and let it go.”

Sometime in the night, the patient underwent a CT scan. The next morning Jauhar learned his patient hadn’t suffered a heart attack, after all. Instead, it was an aortic dissection – a tear in the wall of his aorta, leading to severe internal bleeding. Worse, with the time lost to the misdiagnosis, the dissection was now inoperable. The patient died later that day.

I use this example because the diagnosis ultimately confirmed by a $1,000 high-tech CT scan would have been evident from the low-tech hands-on procedure Jauhar shrugged-off. A discrepancy in blood pressures between the right and left arm is a classic indicator of aortic dissection, and easily distinguishes the condition from a heart attack.

Consider that a blood pressure cuff costs just a few dollars, compared with the hundreds of thousands of dollars in sophisticated ICU and ER equipment that the medical team employed trying to solve the riddle of the patient’s condition. These same high tech tests and procedures also led the medical team down the wrong path. So much for the certainty we believe technology gives us.

If Jauhar had employed the basics of physical exam might the patient have lived? Possibly. In my own recent experience, I saw a young boy whose mother told me he seemed to be clumsier than other children his age. She had mentioned this to previous doctors, as well. When I examined him, I noted very brisk reflexes and an unusual flapping motion in his feet. This is called ankle clonus. I referred the mother to a pediatric neurologist. I learned shortly thereafter that her son wasn’t just clumsy. He has cerebral palsy. This is a diagnosis that must be made clinically; oftentimes an MRI or a CT scan cannot detect CP because there are no discrete visible findings. The happy ending is that physical and occupational therapy can ameliorate the boy’s symptoms.

My point is that not all of the system’s ills can be solved with high technology – nor should they be. If you believe that reforming health care is essential for our country’s future – and if you’re at all mindful of our fiscal state — then you’ve got to be open to other strategies besides throwing billions of dollars at the problem.

We can start by leveraging the basics. For doctors like me, this means re-learning value of the patient history and the head to toe physical exam. It means weaning ourselves off our dependence on technology, tests and procedures.

In a better system, doctors won’t be rewarded for doing everything. Instead, they will be rewarded for doing the right things. They’ll use their heads and hands to decide how to spend our healthcare dollars – and I can promise you they’ll spend less of them in the process.

This is how we could do it. This is how we should do it. Simply by re-prioritizing medicine’s hands-on basics we can make great strides toward improving healthcare, without spending a dime on more technology.

Rahul K. Parikh is a pediatrician and a writer.  He can be reached at his self-titled site, Dr. Rahul K. Parikh.

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  • Erica

    I think all doctors can benefit from spending time treating people in third world countries where high priced diagnostic technology isn’t available to re-hone their “touch” skills.

  • Marcus Tan

    I completely agree with the sentiment of this post. However, it must not be forgotten that any test or technology is merely a tool.

    The author’s example of the missed aortic dissection is poignant but even had the clinical signs been recognised for what they were a CT would have still been required. Few major and serious diagnoses nowadays are made by clinical history and examination alone, particularly if the treatment is invasive or potentially harmful to the patient. There is usually a need for some confirmation using technology of some sort, be it a blood test or diagnostic imaging.

    I believe getting back to basics only allows us to focus on what needs to be ordered as far as confirmatory tools go rather than the lazy ordering of the blanket battery of tests hoping to find the right diagnosis. There have been many a case of harm to patients from the discovery of otherwise benign “incidentalomas”.

    I vote for both better clinical skills AND better technology!

  • zoe

    I am truly shocked by how many M-3 med students come to my office for a primary care rotation with little or no interest in physical diagnosis. Their reliance on technology is so high and they are mirroring what all the specialists at university are teaching them–make your differential, and then order tests. Physical exams are taught as unreliable and of questionable value, and as shown above, this lack of confidence is so high that a significant physical finding is ignored even when found.

  • Dr Robert Schertzer

    Good article reminding us of the basics of clinical care and rational use of technology. Yes, we do need to make clinical accumen the focus of our patient care but also use technology to confirm certain findings and, in my field of glaucoma, help with analyzing for subtle changes over time to provide timely interventions.

  • Steve Parker, M.D.

    Rahul, the polititians WILL NOT listen to you. Their minds are made up already. Unfortunate.

    Most doctors don’t even listen for murmurs anymore.


  • Doctorr Forall

    I have wonderful doctors but it seems that some of their staff members don’t communicate with them much! Does anyone else seem to have this problem?

  • jsmith

    The author is correct of course, but he’s swimming against the tide. Good luck with that. America is a country of mass techno-delusion.
    Some technology is great–CTs and MRIs and antibiotics comes to mind–when used appropriately. Some not so great.
    My favorite recent example of medical techo-idiocy is the vaunted Electronic Health Record. Rarely helpful, usually useless, frequently worse than useless, yet coming soon to a practice near you.

  • Jenga

    I agree with Marcus. It would not have eliminated the need for the CT. I don’t know a single CVT surgeon that would open someone’s chest based on a BP reading and I hope I don’t meet one. It might have saved the guy, but that is a big if. On a side note, the correct treatment would have been vastly more expensive. Surgery ain’t cheap which kind of goes against the gist of the article.

  • Doc99

    Damn …. You’re right of course. But I was actually holding out for Leonard McCoy’s Tricorder. Physical diagnosis, how quaint!

  • Anonymous

    If the blood pressure was off in the other arm, won’t the surgeon get a CT scan to confirm the extent of the dissection, before taking the patient to the OR?

  • Paul MD

    McCoy also had that cool salt shaker that he would wave over the chest to cure whatever it was that ailed ya. Next to the tricorder (circa 1968 RCA transistor radio), its what I’m talk’n bout.

  • Alchemipedia

    The art of diagnosis is essentially an iterative process involving the generation of hypotheses (differential diagnoses) which are then tested through further history taking, further examination and selected relevant investigations. The medical hypothes(is)es are then either refuted or tentatively supported by the facts, with further iteration occurring. The most useful initial tools still remain the history and examination.

    In health care systems with limited resources, the requesting of routine batteries of tests leads to increased costs and delays in diagnosis and appropriate management. Using the example of a CT scanner, if the capacity is 30 scans per day, and 20 of those are unnecessary then there will be delays in obtaining appropriate diagnoses for those patients where the CT is really needed.

    Limited medical resources are real issues in most health care systems, including amongst the uninsured in the US.

    At least historically, it was felt that when doctors from Commonwealth countries went to the US for postgraduate fellowships then their clinical examination skills deteriorated. The culture of using tests as a replacement for a careful history and examination is likely partly to blame for this.

  • H

    1. Doctor uses technology to diagnose instead of hands on examination.
    2. Doctor’s hands on examination skills deterioate.
    3. Patient becomes accustomed to technology for diagnosis.
    4. Doctor does hands on examination to make diagnosis.
    5. Patient feels uncomfortable with diagnosis and prefers technology to make diagnosis.
    6. Doctor orders technology because patient will complain or sue if diagnosis is wrong.
    7. Doctor grumbles that patients are the driving force behind unnecessary testing.
    8. Lawmakers don’t see the value of hands on examination and continue to provide more funding for technology.
    9. Doctors continue to rely on technology.
    10. Patients continue to insist on technology.
    11. Health care is expensive.

  • Tex Bryant

    As a patient I expect my healthcare to come from the experience of the physician aided by whatever technology he/she deems best. My primary care physician only relies on blood work for my physical. His experience and judgement supply the rest. My urologist yearly uses my PSA results but relies primarily on the rectal exam and his previous year’s notes. Whether his notes are electronic or not does not matter to me as long as he can access them quickly. I do however believe that it would be best if the results of my exams by my PCP and urologist were linked electronically. Thus, knowledge and wisdom sprinkled with some judicious use of technology seems best to me.

    Looking from another perspective, one can see that technology has made a major impact on other business for the better. Take for instance, the office computer. For years, according to the Wall Street Journal, it did not improve the productivity of the average office. Today, however, it does make a big impact. I am sure that for healthcare there will be a gradual improvement in care with technology correctly used (as a support mechanism for the knowledgeable physician).

  • Betty

    Interesting article. I just finished reading a book called “Time to Care” by Norman Makous, M.D. In his over sixty years in medical practice he has seen the phenomenal growth in the technologically effective methods used today. However, he believes that what has been lost is the very important and effective aspect of medicine that originates in the personal relationship between the doctor and patient. Professionals will find the case studies very valuable for application to their own medical training and continuing education.

  • stress management

    I agree with the opinion of this post…

    I personally believe getting back to basics only allows us to focus on what needs to be ordered as far as confirmatory tools go rather than the lazy ordering of the blanket battery of tests hoping to find the right diagnosis.

    Nice article by the way, reminding me of the basics of clinical care and rational use of technology..