Are we relying too much on gadgetry to improve ourselves?

Apple announced the company is working on a new app, called Health, that allows a user to store in one place all aspects of their health data, from heart rate to blood sugar levels, cholesterol measures and calories burned. The Health app, Apple says, will enable an exercise app to determine the number of calories you consume a day — and, in turn, how hard you have to exercise to burn off all that food.

Coupled with Apple’s rumored-to-be-released-this-fall iWatch wearable computer, the software represents another incursion of technology into our lives, raising the question: Are we relying too much on gadgetry to improve ourselves?

In considering the answer it’s useful to examine a profession at the forefront of incorporating technology into everyday work — doctors. Key figures in medicine today believe physicians are paying too much attention to their iPads and not enough to their actual patients — so much so that it’s hurting docs’ ability to do their jobs.

Take the remarkable essay in the New York Review of Books by Dr. Arnold Relman, the 90-year-old former editor of the New England Journal of Medicine, who was hospitalized last year after breaking his neck in a fall. The experience provided him with new insights into the way today’s doctors do their jobs.

“Attention to the masses of data generated by laboratory and imaging studies has shifted [doctors’] focus away from the patient,” Relman notes. “Doctors now spend more time with their computers than at the bedside.”

Consequently, Relman and many other physicians believe that some physicians are losing all the old skills that used to be critical to making a quick and accurate diagnosis. These skills tend to be part of the physical exam, the part of an appointment that sees a doctor using touch, sight and all the other senses to learn about what’s ailing the patient — flashing lights into the pupils, watching the way a patient walks, pushing and tapping on the abdomen and listening to the chest with a stethoscope. Skills the legendary physician William Osler called “inspection, palpation, percussion and auscultation.”

A physical exam can be fast and accurate, and the tests are cheap, since they tend to use only the most basic elements of technology. And, as I discovered when I practiced medicine earlier this year in remote parts of Kenya, these analogue diagnostic techniques are particularly valuable when electricity supply is unreliable.

But these methods require intimate contact with patients, which can be uncomfortable for doctors who are more accustomed to interacting with computer screens. They also require physicians to use their own senses, to trust their judgments, and to engage in messy probabilities rather than the relative certainty provided by computer algorithms.

“If you come to our hospital missing a finger,” said Abraham Verghese, a faculty member at Stanford Medical School, in a recent feature about this phenomenon in the Washington Post, “no one will believe you until we get a CT scan, an MRI and an orthopedic consult.”

Medical educators such as Verghese and others are pushing back against the trend. At Baltimore’s Johns Hopkins Children’s Center, pediatric cardiologist W. Reid Thompson has set up Murmurlab, a website that hosts more than a thousand recordings of heart beats, to better train physicians on the ability to use stethoscopes rather than echocardiograms to tell the difference between an innocent and life-threatening heart murmur.

For his part, Stanford’s Verghese has compiled a list of low-tech physical examinations that every med school student should learn. Verghese’s list is called the Stanford 25, and it includes things such as testing a patient’s pupil for its response to light, which can reveal neurological damage, and observing the way a patient walks, which can assist in the diagnosis of Parkinson’s and many other maladies.

I wonder whether the non-medical world should adopt the concept of the Stanford 25. What are the skills that everyday people should know how to do without smartphones or tablet computers? My own, non-medical version of the Stanford 25 would include being able to add, subtract and multiply without a calculator app. So would retaining the ability to navigate a city with a paper map, rather than just Google Maps.

During the summer, at a time when all of us will be trying to spend as much time as possible outdoors with friends and family, disconnected from the Web, it strikes me that all of us, not just doctors, have a duty to exercise the most important computer we have at our disposal — our own brains —  so that we don’t lose the ability to function on our own.

James Aw is medical director, Medcan Clinic.  This article originally appeared in the National Post

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  • W. X. Wall

    You make 2 different points in this article:

    1) Do patients use too much technology? If it’s to calorie count every day, then I would say yes. Focusing on calorie counts on your iphone is a way to avoid focusing on eating healthy and yet another way to develop a previously non-existent neurosis that someone else will happily sell you an app to treat.

    OTOH, there are some great uses for consumer technology (e.g. diabetes, CHF, arrythmia monitoring, etc.) that I think actually can improve health in a significant way. I’m not sure this is what Apple is focused on.

    2) Do physicians use too much technology? No. Aside from the EMR which was forced on (most of) us against our will, other technologies such as improved imaging and labs are helpful. Every old doctor (Dr. Relman included, apparently) likes to talk about the hoary old days when they could diagnose anything with a stethoscope and their two hands. What they never talk about is how accurate they truly were. In medicine, diagnostic accuracy vs. cost is an exponential function. That is, as you asymptotically approach 100% accuracy, each increase you want costs much more (in money, testing, effort, etc.). It’s easy to get to 50% accuracy. That’s flipping a coin. Getting to 75% accuracy probably requires a history. Add a physical exam, maybe 90% accuracy. A few basic labs or simple stuff like Xray / EKG -> 95%. Expensive, common stuff like MRIs, -> 99%. Exotic, hard-to-find, ungodly expensive stuff -> 99.9%. And these days, with increased liability, no one will accept an uncertain diagnosis.

    I loved how my old-time cardiology professors used to go on and on about the fine art of listening to a murmur. But quite frankly, an echo done by an average tech would pretty much blow away any of my professors’ stethoscope skills in terms of accuracy. In today’s medicolegal climate, Dr. Thompson (of murmurlab) is kidding himself if he thinks anyone with even a hint of a murmur isn’t getting an echo (not just for legal reasons: an echo is safe, and will provide a far better diagnosis than a simple auscultation). Knowing this, is it really necessary to teach murmurs beyond learning how to tell if there is one?

    In my residency (neurosurgery), we were always blasted by our semi-retired, emeritus professors about how in the old days, they could diagnose a brain tumor by sitting with a patient for an hour and doing a detailed neuro exam. Their skills were truly extraordinary (My emeritus chairman once spent an hour discussing everything that could be gleaned from a bicep reflex; I actually enjoyed it :-), and indeed, one of the things I *like* about neuro is exactly that everything is so precise, it’s truly possible to localize to within a few millimeters in the brainstem with just an H&P.

    But to get closer than a few millimeters…? Now you need an MRI with stereotactic intra-op navigation. The old-timers who like to wax eloquent about the beauty of the neuro exam (which I’d wholeheartedly agree with) never mention that in their day, “exploratory” craniotomies (where you’d open up half the skull and just start pressing around the brain until you felt something hard, then start taking brain / tumor until the samples you send to the pathologist keep coming back normal and you finally decide you’re done) were routine.

    Nowadays, an “exploratory craniotomy” would land you in the courtroom. Instead, you get an MRI, feed it into a stereotactic system that allows you to make a small incision with an optimized trajectory, take out the entire tumor, and have the patient out of the hospital in a few days.

    That’s progress worth paying for, and something only possible with increased use of technology.

    • Acountrydoctorwrites

      Good points, but possibly more relevant in specialty care. When a patient in primary care has nonspecific symptoms, like shortness of breath, we need doctors with enough clinical exam skills to notice pallor, prolonged exploratory phase, JVD, irregularly irregular pulse, tachycardia and all the other clues that help us decide what tests to order first.

    • HJ

      The old-timers also fail to mention the cost of the exam. How much does an hour with a neurosurgeon cost?

  • SteveCaley

    Machines make for machine medicine. Sorry.

  • meyati

    I used to remember a dozen phone numbers, now I look at my cell phone and it doesn’t text or have apps-don’t want any and press a button. A young nurse looked me the other day when I looked up my ER contact’s number-She asked me if I was having memory problems. I asked her what her best friend’s number was-she looked at me- and I asked “do you know your best friend’s number is or do you speed dial?” She quit asking me about my memory–she probably just finished a course in detecting dementia. We’re all going down hill in the mental smart department including logic.

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