Physician writer Sandeep Jauhar recounts his father’s experience, which illustrates this point.176 Dr. Jauhar’s father was taken to the hospital because of episodes of tingling in his left arm. Fearing a stroke, the neurologist who saw him ordered a CT scan of his brain, which was normal, and then an MRI of his head, which was also normal. Undaunted, the neurologist admitted the patient to the hospital and started him on blood thinning medicines. To be sure there wasn’t a blood clot in his heart that had broken off and gone to his brain, the patient had an echocardiogram, then an ultrasound of the artery in his neck, and a battery of other expensive tests, all of which were normal. After a while his symptoms got better and he was sent home with a bunch of medicines and a return appointment with the neurologist. Three days later the symptoms came back worse than ever. He was taken back to the ER and had another normal CT scan. Finally a nurse noticed that when she had the patient turn his head a certain way, it caused the tingling in his arm exactly as he had experienced it all along. Several doctors confirmed that observation making the diagnosis of a pinched nerve in his neck that was the explanation for his discomfort. Twenty thousand dollars’ worth of high-tech tests were all for naught while the carefully observed response to a simple physical maneuver nailed down the problem.
The good doctor knows from personal experience that physical findings can sometimes trump the technology. And the scans she does using only her ears, eyes, and hands are done in the privacy of an exam room without elaborate equipment. She trusts her senses but also recognizes their limitations, and so she uses all of the available technology where appropriate. But she has a hard and fast rule to always start with a careful physical examination. She might think of that as something like the rule of the gold stethoscope. And she might explain that to herself this way:
Learning the profession I chose is, I find, a process, not an event . . . the gift that keeps on giving as they say. Still, after all these years, I learn something every day, often from unlikely sources and when I least expect it. Experiences that seem small at the time stick with me. For example, every time I face a patient I’m reminded of the gold stethoscope, an icon etched into my brain as a symbol of the importance of a thorough physical exam. My old professor Dr. Samples was the stethoscope’s owner, and I learned from him the nuts and bolts of physical diagnosis. Not just how to do it, but also the value of the exercise. “Remember this gold stethoscope,” he would say, brandishing his shiny pride and joy. “Nothing you will do as a doctor is more valuable than observing, touching, and listening to your patient.” I remember those sessions like they were yesterday; apparently the lesson of the gold stethoscope is with me forever.
TO CONNECT WITH WHO YOU ARE
Even if she takes the time and trouble to do a complete and thorough physical exam and discovers nothing abnormal, the good doctor will still believe that the time and effort were well spent. You and your doctor need to get to know each other if you are to figure out how best to keep you healthy or get you well when the need arises. That means you have to form a relationship. Not unlike many relationships, this one has paradoxes—it is intimate but distant, revealing but secretive, caring but pragmatic. And the laying on of hands, the physical interaction of the doctor and the patient, is a critical part of the process. That is not only to see what’s happening inside, but also as a ritual that gives substance to this special doctor-patient connection.
Stanford physician and author Abraham Verghese says, “When one individual (a patient) seeks help from another individual, and confides in that other person, and then incredibly, disrobes and allows touch, that has all the trappings of a ritual . . . that is fundamental to the doctor-patient relationship.”177 The thoughtful doctor knows something about the importance of ritual, and each time she examines one of her fellow humans, she is impressed again with how important that experience is to a health care relationship that works right. That is, after all, why she chose medicine over more exclusively intellectual career possibilities; she wanted to do something to understand people and improve their lot. That is what she still finds most satisfying about her job. And that is why you want her to lay her hands on you. These might be some of this doctor’s private thoughts about rituals:
Another thing I think I’ve learned that I was not taught in med school is that there is more to the physical examination than discovering pathology. Patients show up in my office expecting something very concrete. They expect to sit with me and recount their medical history and then they expect to be asked to take off their clothes and to be touched by me. They expect those things because that is the drill, the ritual that is part and parcel of the patient-doctor encounter. When the ritual is done, this new patient and I are connected in a different way whether or not my exam reveals anything significant about their physical state. If it goes as it should, we’ve laid the groundwork for the kind of relationship that is essential if our collaboration is to help this patient to be as healthy and happy as possible.
This ritual thing is not magical, mystical, or sleight-of-hand. And, although it is ritual, it is not rote. I’m paying attention, not just going through the motions. A robot can’t do this! I see no conflict between holding to a time-honored effective ritual and my role as a clinical scientist practicing science-based medicine. We, both me and my patient, are people and people need rituals. Rituals christen us, marry us, usher us into adulthood, escort us from this mortal world into the great beyond. Connections with other people and, for the religious, even with God—marriage ceremonies, prayer, worship services, holy communion—are made more real by ritual. So when I dare to engage with another person in a sincere and very personal effort to deal with the care of their health, I am committed to bringing the best science that I can find to the task, but I will also lay my hands on that person. And both of us will benefit.
BECAUSE SHE IS A HEALER
The good doctor wants to see your disease cured, but she also wants to see your hurt healed; she knows that they are not necessarily the same thing. Some topical antibiotic cream and a bandage will hasten healing of a child’s skinned knee, but if delivered along with a hug from a loving parent it will work a lot better. And you haven’t grown out of your need for human touch when you hurt, although you may have some trouble admitting that even to yourself. You don’t need to admit the need for touch to a caring doctor. She senses the need and lays an empathetic hand on your shoulder or takes your hand in hers at the times when those gestures are exactly what you need. She has a box of tissues handy if your tears need drying. This doctor really does feel for you and the laying on of hands is her way of sharing your experience and helping you to bear the pain, whatever its source. You don’t have to do this alone is the message. Your doctor is there for the duration and committed to getting you back to physical health and also back to the pleasures of a happy and healthy life. She is a curer but also a healer.
The good doctor is not a shaman, magician, or faith healer. Her faith is in the scientific basis of medical practice, and science is the bedrock of what she does. She does not feel that the laying on of hands transfers to you some mystical energy that summons out the evil humors of disease and pain. But that doesn’t mean that the healing effects of human touch are not real. Even if she can’t explain in detail the chain of physiological and biochemical events that connect the human touch with healing, she has no trouble believing that those connections exist. There is so much about the theory and practice of medicine that is unexplained. After all, that is this doctor’s reason for being and why you want her as your partner in caring for your health. She might say something like this about curing and healing:
It took me a while to realize that many times my job is not done when my patient’s disease or injury is cured. There wasn’t much in my formal education to clue me in to the reality that human maladies have multiple dimensions and that if I am to be the doctor I aspire to be I’ve got to do more than prescribe an effective antibiotic or get my pat
ient on the right dose of heart failure medicines. Those things might cure the immediate medical problem but leave the patient unhealed. And my job is not done unless the patient is healed as well as cured. Of course, if things work perfectly, the two happen together, but I can’t trust that to chance. If I don’t pay attention to those other dimensions of illness, my patient and I may well win the battle but lose the war.
So now I, perhaps belatedly, consider myself a healer. I’ve learned, mostly by trial and error, that a healing relationship with a patient involves a lot of touching, both real physical touching and the more figurative gentle bumping together of emotional boundaries. Sincere, caring, empathetic touches of a human hand, sometimes as apparently trivial as a pat on the shoulder or a handshake, can be healing gestures. Touching can make a difference.
It takes a doctor some time and experience to realize the full potential of touch in the care of her patients. Her path to that point is littered with people who were cured but not healed or who, if healed, did it without her help. The good doctor often thinks about what she could have done or been for those patients but didn’t or wasn’t for lack of understanding . . . or time. Time still threatens her role as healer.
Writer Malcolm Gladwell says, “What doctors and patients need is more time, not more technology.”178 But why must it be one or the other? There is an array of powerful technologies and many more to come that will expand a doctor’s access to information, her ability to measure critical structures and functions of the human body, and her capacity to make sense of it all in the unique context of you. If the interface of humans and machines works as it should, won’t that give your doctor and you more face time as well as the other benefits of the technology?
Efforts to delegate health care completely to gadgets and computers imply a kind of assembly line medicine with homogenized care and rigid time commitments. Those may be useful tools for management, but they do not work in medical practice because every single patient a doctor sees is different. Humans are not produced on an assembly line! Health care at its most effective is a collaborative effort between you and your doctor, and it requires a special relationship between those two real people. That kind of relationship takes time and attention . . . and the laying on of hands.
“Hippocrates and the Laying on of Hands,” The International Center for Reiki Training, December 28, 2001, https://www.reiki.org/articles/hippocrates-and-laying-hands
Richard Knox, “The Fading Art of the Physical Exam,” NPR Morning Edition, September 20, 2010, http://www.npr.org/templates/story/story.php?storyId=129931999.
Sandeep Jauhar, “The Decline of the Physical Exam in Modern Medicine,” Pacific Standard, July 2, 2014, https://psmag.com/the-decline-of-the-physical-exam-in-modern-medicine-ba64c8d8bd4b#.irdubkcv1.
Richard Knox, “The Fading Art of the Physical Exam,” NPR Morning Edition, September 20, 2010, http://www.npr.org/templates/story/story.php?storyId=129931999.
Eric Topol, “Malcolm Gladwell: Future Docs Need More Time, Not Technology,” Medscape, August 15, 2015, http://www.medscape.com/viewarticle/847711.
PART V
Fears and Hopes for the New Medicine
CHAPTER 16
The Fear of a Tyranny of Experts and Sensors
I worry that we could become tyrannized by a combination of experts and sensors that have no close relationship to our priorities . . . I think it’s about this deeper connection we all have to something important.
—ATUL GAWANDE179
A tyranny of experts?
There are two groups of experts who, for different reasons, might be seen as threats to the whole health care system: medical experts and experts in the business of medicine.
MEDICAL EXPERTS
The good doctor bases her decisions about your care on evidence based guidelines developed by the experts as they apply to you. However, she knows that occasionally those guidelines morph, even in well-intended systems, into rigid protocols with unintended consequences; she stays alert to those exceptions.
Here’s an example. In a hospital where a certain general surgeon practiced, the evidence based guideline that antibiotics given intravenously to prevent infection around the time of surgery (prophylaxis) should be begun within an hour of the operation and discontinued twenty-four hours after the procedure was written into the standard orders as a quality assurance protocol.180 This surgeon had a patient with acute inflammation of the gallbladder show up at the hospital at 2:00 a.m. The doctor admitted the patient and gave admission orders that included beginning intravenous antibiotics immediately. The antibiotics were meant to treat an infection that was likely already present—therapy, not prophylaxis. The next morning, the surgeon got the patient on the OR schedule and the nurse asked if he wanted to start antibiotics before surgery. When he replied that the patient had been receiving antibiotics for the past eight hours, since being admitted, the nurse shook her head and said no, that the night nurse had delayed starting the antibiotics until within an hour of surgery, like the quality assurance protocol said. Bad medicine. Embedding decisions dictated by the experts’ evidence-based guidelines into the system as a protocol that can take an important decision out of the hands of the responsible doctors risks a practice that the experts never intended. “A foolish consistency,” Ralph Waldo Emerson wrote, “is the hobgoblin of little minds.”181 Thinking people, including the good doctor, are rather fond of Mr. Emerson.
At least since early in the twentieth century, most doctors practicing in the United States have tried to base their care of patients on the best available evidence. Up until the last thirty plus years, each physician was responsible for digging up whatever evidence he or she could find, blending that with his or her personal experience and deciding for a specific patient how to proceed. As one would guess, this resulted in widely disparate practices, depending on how vigorously the doctor dug for the evidence and how the evidence was interpreted in the context of a doctor’s clinical experience and the patient at hand.
Recognizing this disparity and believing that a broader and more rigorous analysis of evidence and its implications made widely available would improve care, a formal program of evidence-based medicine began in the 1960s, and evolved over the following three decades.182 The fully developed program has a lot of structure. There are specific rules for valuing evidence. The available evidence weighted for its scientific rigor is then used by experts to develop practice guidelines. Whole organizations spend their time searching the literature and generating documents that guide doctors in what to do in many clinical situations. The National Guideline Clearinghouse maintains a database of guidelines meant to influence practice in the clinic.183 That database addresses well over a thousand specific clinical situations.
Complaining about the habitual tendency of his economic advisors to equivocate (on the one hand . . . but then on the other . . .), President Harry Truman longed for a one-handed economist.184 Does evidence-based medicine threaten to neutralize our good doctor by amputating the other hand, creating an illusion of certainty that the facts don’t support and so minimizing the role of the doctor’s clinical judgment? There are some people who think so; evidenced based medicine has been maligned as “inconsistent with modern science, theoretically unsound, impractical and erroneous in its application,”185 “a simplistic cookbook approach, an excuse for not thinking” that contributes to “the debasement of physicians as ‘providers.’”
The good doctor knows better than that. She does not confuse evidence-based guidelines with inflexible instructions for how to take care of you; she is thoroughly aware of and comfortable with the uncertainties. But she always starts with the available evidence.
How about the teaching of medicine? Do the medical experts threaten to “tyrannize” the process of training doctors? Evidence based medicine is the touchstone of much of current medical education. Round on
any ward in an academic medical center on any day and you are virtually certain to hear the term more than once. Does that mean that the intellectual part of medicine is on the road to complete automation, needing doctors only to operate the computer, recite the edicts of the experts, and write prescriptions?
The good doctor knew better than that even when she was a medical student, and her experience practicing medicine continues to impress her with the need to deal with human ambiguity as she goes about trying to translate the available evidence into actual care of real people. She was fortunate to have teachers and role models during her long period of education and training who not only knew what they were doing and why but also cared deeply for the human beings for whom they were doing it. She learned some things from those teachers.
Does our good doctor practice evidence-based medicine? She surely does, but the way she does it won’t please anyone looking to eliminate the ambiguities. She pays close attention to the numbers, but she isn’t driven by them; she doesn’t practice exclusively digital medicine. She has great respect for science carefully done and properly interpreted, but, like Atul Gawande, the good doctor knows “that nothing is ever completely settled, that all knowledge is just probable knowledge.”186 She knows that medical conclusions, even at their most solid, are often inexact and so she doesn’t always strictly toe the “experts’” line. This doctor is okay with ambiguity and that figures into her decisions. Her brand of evidence-based medicine requires not only knowing but understanding the evidence in the full context of what is and what is not known and in the specific context of you as a unique person. She is not the experts’ doctor. She is your doctor! If you fit with what the experts predict, that is just fine. If you don’t, then “experts” be damned!
The Good Doctor Page 16