The danger of digital medicine

Sometimes I worry about where technology is leading the healthcare profession.

It is not just the distraction of white screens and electronic health records. These are bad, terrible, in fact. The concern I have runs deeper than just monopolistic EHRs.

We, and I mean we as in the caregivers, are losing touch with the basics. I see it everyday, especially, but not exclusively, in the younger generation of nurse and doctor. The collective loss of fundamentals is happening so slowly and steadily that no one seems to notice. Indolent is what we say in medical-speak.

Here is what I mean.

What makes the practice of medicine work well is not at all complicated. It starts with a story. What is a person’s story? A BNP level, a set of shadows on an ultrasound, a white count, a rhythm strip with squiggles, these are not stories.

I begin almost every new patient visit with words like this: “What is bothering you most…I want to know what you say, not your doctors.”

When I do this, it is as if magic occurs. I met with a clinician a month ago at the Heart Rhythm Society meeting in San Francisco. He told me something that I’ll never forget about the patient encounter:

I can almost always tell within a few minutes of meeting an (AF) patient what the correct treatment will be. It’s as if God himself speaks, and tells me the right course for that patient.

I know that sounds like hyperbole, and maybe it is, a little. But what it highlights is the power of observing people, their faces, their clothes, their families, their reading material. You simply cannot know the correct course for a person from a chart, an x-ray or an ultrasound.

As a consultant, I see people for abnormal heart rhythms. But often, the heart rhythm is not what is bothering them. Often it is that their body hurts, or they can’t sleep, or they are unsteady, or they can’t remember things.

You see the trouble? A doctor is tasked with treating the person in front of them, not his ECG, or low ejection fraction.

This is what is getting lost.

As the healthcare machine increasingly embraces mobile sensors, digital records, and binary quality metrics, what used to be the care of people has tragically become the treatment of aberrations of 1s and 0s.

There is more.

It is not just loss of the human narrative; it is also the loss of the human touch, the act of the physical exam. I was recently made fun of on Twitter for suggesting that the treatment of congestive heart failure aided by an invasive monitor stuck into a pulmonary artery would prove no better than a doctor’s observation. The believers in all-things-tech laughed me off the social platform.

But that is BS. And such a defeatist approach to fundamentals is what I am talking about. Consider the case of CHF.

When fluid builds up in the body, patients, especially educated ones, will tell a story of increased breathlessness, swelling or a fullness in the abdomen. They know; and they will tell you if prompted and listened to. The physical findings (observations) of CHF are also quite reproducible. These are not complex findings mind you, rather, they are simple things such as a scale reading a higher weight, distension of neck veins, crackling of breath sounds, a palpably full abdomen, and swelling of the legs. There is also the appearance of the person from the door. We call this the “general appearance.” And it is everything, except quantifiable.

Good doctoring is not rocket science. But it is also not digital. It is not on a white screen. It is not numbers from a pulmonary artery. And it does not come quickly. It requires seeing patients alongside mentors over years.

What worries me is that we are taking our eyes and ears off people. We are distracted, perhaps intoxicated, by the 1s and 0s.

This is not to say that technology and computers can’t help us. Of course they can. But no machine, not even an Apple product, can replace looking and listening to the person we are trying to help. Machines and sensors do not tell stories.

Perhaps the next generation of smart people will figure out a way to keep the fundamentals of medical practice and let technology aid us rather than distract and intoxicate us.

My tiny nudge is to remember the first rule of getting out of a hole: stop digging.

JMM

Comments

  1. Nanci Cartwright says

    Thank you Dr. John. I work for a health research company. I am also a person with lone afib. I have been arguing your point with colleagues for some time and am thrilled that you’ve stated how I feel (from a patient’s perspective) so eloquently from a doctor’s perspective. I only wish I lived close enough to be one of your patients.

  2. Jay SJchloss says

    As one of the folks who “made fun” of you for “suggesting that the treatment of congestive heart failure aided by an invasive monitor stuck into a pulmonary artery would prove no better than a doctor’s observation,” let me point you to a reference:

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60101-3/fulltext

    In this randomized trial conducted in 64 US centers, wireless hemodynamic PA monitoring was used as an adjunct to clinical care from heart failure center care. Using best practices in both groups, the hemodynamic monitoring group saw a 39% drop in hospitalizations.

    Recognize, both groups in this trial got the kind of care you advocate in your piece. Adding a hemodynamic sensor was complementary to good clinical care. No one is implying that this is a substitute for bedside evaluation by clinicians.

    That’s the data. If you wish to challenge, it might be better to do this with a close read of the study in the FDA submission which is also available at
    http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystemDevicesPanel/UCM284021.pdf

    I understand and agree with your concerns that the importance of basic clinical skills is being lost. That’s not a reason, though, to shoot down evidence based advances that have the potential to help patients and save money.

    Jay

    • Kenneth Grauer says

      @ Jay – I think there is truth on both sides. I don’t think Dr. John was negating the potential for advanced modalities used appropriately in the “right hands” to help in addition to skillful clinical exam with attention to patient needs and desires. He after all, does spend his days in the EP lab with the most sophisticated of evaluative tools. And I think you are fully acknowledging that advanced modalities when used by certain clinicians have a tendency to be overused with resultant loss of personal touch and bedside exam. The obvious goal that I think we all agree on is integrated use of personal touch, skillful bedside exam and if/when needed in addition – appropriate use of advanced modalities to augment the clinical picture. I think Dr. John’s lament is that such integrated use is not what is being taught to the current generation of clinicians …

    • Dr John says

      Jay…I almost chose another example, other than the pulmonary artery monitor. Really. I’m thinking to myself, “oh John, this is going to rile up Jay and Suneet.” Maybe that’s why I left it. Grin.

      I don’t disagree with your point. It is true; in selected patients, who are implanted by selected doctors, there may be some incremental benefit to these sorts of advanced technologies. The key words are selected and incremental. I have no doubt, you and Suneet, and others, would use this technology wisely. It’s what Dr Dave said, tech must NOT be used as a substitute for listening. But the marketing machine does not want wise use of their device in selected patients by selected doctors; they want paradigm shifts.

      And the real world often gives it to them.

      Look at the roll out of dronedarone. Look at the first year of dabiagtran. I still see patients on two non-statin lipid drugs. I see elders passing out because of their ACE inhibitor. I see asymptomatic patients referred for AF ablation. I see ICU doctors who abdicate their responsibility to stop delivering futile death-prolonging care.

      Doctors are here to care for people not just deliver treatments. The list of nonsense-due-to-loss-of-fundamentals is a long one.

      My concerns are less with which monitor/tech but all the monitors/tech. They are not the root cause of our not seeing people, but they foster it. And so does the marketing of such technology.

      Thanks for engaging.

      • Jay Schloss says

        John,

        I figured you knew what you were doing. I just wish you hadn’t picked on CHF as your example. This is a huge public and personal health problem and premier heart failure teams still haven’t found the optimal way to deliver CHF care in a cost efficient manner. You and I both know that bedside evaluation of volume status is extremely difficult even for “master clinicians.” You and I also both know that even the best clinicians cannot assess volume status over the phone. I really do believe that solutions for CHF will required a tech component. Your post explicitly criticized this monitor against the evidence and send the wrong message.

        I share your concerns about the marketing machine behind this technology. When the marketing machine kicks in on Cardiomems, you know I’ll be among the first to criticize anything inappropriate. You may have seen mine and others’ criticisms of the European marketing of Medtronic Renal Denervation: https://storify.com/EJSMD/renal-denervation-marketing . My concerns on this matter have gone directly to the CEO of the company and it looks like our voices have been heard.

        Let’s be careful to time and direct our criticism appropriately, lest we look like Luddites.

        Jay

      • Ken Grauer, MD says

        Jay – I hear your concern loud and clear, and as I previously stated – I think there is truth in both viewpoints that you and John expressed. But the population in need of “technical” volume status assessment on a day-to-day basis is a distinct minority of what primary care clinicians are seeing in out-patient offices. In my capacity as a primary care clinician with interest and expertise in cardiology matters – I routinely included brief discussion of volume status assessment by a skilled cardiologist in the 3 times/year AAFP National Board Review talks I gave on Heart Failure (as well as other cardiology topics) for a decade (to an annual audience of ~ 2,000 family physicians studying for AAFP Board Recertification). That said – my experience in the primary care arena both nationally and locally in my teaching overview of family medicine residents in and out of the hospital – provided me with the distinct impression that while selected use of volume status by an experienced cardiologist was invaluable in the ongoing care of certain patients – that in the vast majority of patients in- and out- of the hospital – attention to simple, nontechnical factors (sequential body weight, carefully elicited historical information, physical exam at the bedside) were all that were needed for guidance in appropriate management. Please note intentional exclusion of serial BNP values – that for the majority of patients add little. In my personal panel of patients that I myself cared for in my faculty primary care practice over the 30 years I was on faculty – the overwhelming majority of my patients did not need ongoing volume assessment for control. I did care for patients who on occasion needed and benefited tremendously from referral to the University to a “Heart Failure Center” – clearly beyond the expertise of simple clinical (less technical) management. Of course there were many patients I cared for with ischemic or valvular heart disease or persistent AFib who needed referral to Cardiology for optimal management of those disorders that exacerbated their heart failure. But for the day-by-day management of heart failure seen in a primary care office – technical modalities beyond chest X-ray, Echo and ECG were rarely needed to know IF I myself (as a primary care clinician) could effectively manage the patient – OR – if there was some aspect of management that could be improved if I referred the patient. Of course, as John said – I cannot “prove” that I am “correct” (and not self-perpetuating my own glorified fantasies of “successful management”) – but many of these patients I followed for many years, over which time regular office visits with nontechnically-aided management controlled symptoms to their satisfaction and without deterioration suggesting need for referral. So – I agree, technical modalities HAVE their place – but better attention to simple stuff works surprisingly well in a majority of cases in an ambulatory population when the primary care clinician is interested in and comfortable with heart failure management issues. I believe attention to “simple stuff” clued me in to knowing when referral was needed for additional modalities and cardiology attention without inappropriate delay in the vast majority of cases. And in many such cases for which referral to Cardiology IS clearly indicated – joint management by primary care + cardiology can be optimized by frequent visits with primary care provider (who may make adjustments via “simple stuff” – and who has access to contacting Cardiology at any time if needed prior to less frequently scheduled visits with the referral cardiologist).

  3. Sergio Pinski says

    How does the clinician you quote know that the atrial fibrillation treatment he chooses is the “correct” one? Could it be a self-fulfilling prophecy? Can a “correct” treatment result in a bad outcome? If so, what went wrong? We all have our biases. I think master clinicians incorporate more variables, including softer and subtler ones not captured by conventional charting, in their decision-making. Are we sure their decisions are better.? I would like to think that is the case but I have no proof.

    • Dr John says

      SP…I struggled also with using that quote. I thought about your point. Namely that all of doctoring involves bias, and, it was quite paternalistic.

      Another aspect of master clinicians is an hyper-acute awareness of our own biases. I would estimate that almost every grand plan I devise for/with a patient, especially ones that involves invasive or expensive technology, brings me pangs of doubt. Was this the right course? It’s sort of a paradox. As my experience grows, I seem to have more not less doubt.

      Finally, I do think our decisions are better–though never perfect. And yes, there will never be any proof, because that sort of thing, the essence of quality doctoring, will never be shown on a spreadsheet.

  4. David Albert says

    John, you may be surprised to know that I agree with you. The CardioMEMs studies did show a decrease in hospitalizations but no decrease in mortality. My smartphone ECG is only a tool that is a small part of patient assessment and management. Physicians must make intelligent use of CardioMEMs and AliveCor and the myriad digital technologies to improve care but they are NOT a substitute for listening. Time is increasingly the most precious resource in medicine and we must objectively evaluate if these new digital tools are really “time dilatory”. They are not panaceas, they are only tools. The physicians must use those tools wisely (something we have always done in the past) to build the house that is quality patient care.

  5. jane says

    You mention the basic signs of CHF. When my husband was hospitalized for CHF and an atrial flutter, for which he was cardioverted with TEE, he continued to have nocturnal spells of breathing problems, which on the [thanks, teaching hospital!] telemetry showed up as bradycardia, and to complain of breathlessness and feelings of fullness in the abdomen. He got a chest x-ray and abdominal ultrasound – those could be billed – but was told that they “didn’t show fluid” so they did not try an increased Lasix dose until days later … only the day after he had, under rather brutal coercion, signed a consent form to have a pacemaker implanted. Over the weekend with an adequate Lasix dose, he lost sixteen pounds in two days and funny thing, his “permanent, inherent [nighttime-only] bradycardia” vanished. On the Monday, when he was to have surgery, the doctors never showed up all day so they could not be questioned. They went ahead and crammed the pacemaker into him anyway, against my advice … and they did it wrong, which is another horror story. Turns out there’s a phenomenon in CHF called “paroxysmal nocturnal dyspnoea”, which apparently certain MDs haven’t heard of any more than I had. I hope nobody reading this whose family member is having an acute exacerbation of CHF will ever let them consent to the implantation of a permanent device without an independent second opinion and, if at all possible, trying better drug dosing first.

  6. Joe says

    I know you’re also an observer of problems with education, so I’ll offer these observations.

    Many technologists are disturbed by the proliferation of gadgets in schools, particularly among younger children. By jumping straight into the virtual without first mastering the physical, their brains don’t master the kind of observation and thinking that lays foundations for future learning. I’ll go so far as to say that an iPad should never darken the door of an elementary classroom.

    I took my kids to the public library yesterday. The computer banks rows packed with kids doing who knows what. Every seat was taken and there was a line of kids waiting for an open computer. The juvenile book section was practically empty. This is progress?

    Ironically, I think the real future of medical devices is in the hands of people who are not (and shouldn’t be) trained by traditional means. In other words, med gadgets should be much more useful for informed patients than they are for physicians.

    • Dr John says

      Thanks Joe. I do think the problems besetting education parallel those of medicine. Teachers and doctors, students and patients, share similar challenges, including, the bloated and growing bureaucracy governing over both.

  7. Doctorsh says

    DrJ

    In one post you argue that we are too reliant on technology, which EMr’s are a large focus.

    In another post you argue that the VA system is working and they have had an EMR system for years, which ends up being what the VA system treats, as opposed to the individual patients.

    Your thoughts are pretty eclectic and I do not see the coherence.

    I am third party free in my office, yet in use an emr. But the emr is not used for EBM or MU, or for any third party. It is used solely for my note taking and so that I can share the chart with my patients.

    So I ask that when you write these posts, you try to see where it seems you are advocating for one side in one post and the other in the next, when it may be I possible to merge the two in the system that is emerging.

    • Dr John says

      I do not think I said the VA was working. I said the VA was truth. Triage was truth. And that to take care of many there is little room for excesses of the few, like there is an every American city: while the suburbs bask in overtreatment in their posh hospitals, the underprivileged struggle to get basic care.

      And this current post was not just about EHRs. It was about a generation of caregivers that seem to see tests, Xrays, charts, diseases, rather than people. Yes, the EMR fosters that, but I believe it is a deeper problem than just EHR.

      • DoctorSH says

        DrJ

        Your post was not about the suburbs vs the inner cities so I will avoid that debate, for now.

        It is not just about a generation of doctors that love to order tests.

        Our patients are demanding these tests fueled by wants over needs, fueled by a third party system that pays for the tests with patients only paying a small portion if any,

        It’s about the legal system coercing doctors to order more tests.

        It’s about a society in general that wants, wants, and wants more than ever before.

        So yes, doctors have a part in this, but not without many partners.

  8. Kenneth Grauer says

    Dr. John – The more I read your Blog – the more I wonder if you weren’t really a Family Physician Educator in your previous life …. I’m sure your wife’s medical insights serve as total complement to your own. Your perspective and viewpoints are a joy to read. Keep up the GREAT work! – :)

    • Dr John says

      Thanks Ken. Glad to see you are back from a little hiatus.

      The more I take care of AF, and the more I learn from Prash Sanders and his team in Adelaide, the more I realize that EP doctors need to have an eye on primary care. That’s 1) because the body is all connected, and 2) the majority of AF is clearly a disease of lifestyle.

      • Kenneth Grauer says

        HI John. I continue to read each of your Blogs (and frequently share them with my non-physician wife – who equally enjoys your perspective). I don’t always comment. Keep up the GREAT work!

  9. Lisa says

    Dr. John:
    I see my EP for maybe 5 minutes two times a year. I don’t think that he’d notice a difference in me if something was wrong. I honestly don’t think he remembers who I am from visit to visit. If it weren’t for the readouts from interrogating my ICD I don’t think he’d have a clue. I could tell him that I have had more palpitations and fainted more times in the last 4 years than I have in the entire rest of my life, but what would be the point? The trigger isn’t something he treats. The trigger is treated by my nephrologist and endocrinologist. My primary doctor is going to notice the signs of worsening CHF long before anyone else with. I can walk into his office and he can tell if something is wrong by looking at me, which is one of the reasons I trust him.

    • Dr John says

      Yours is a telling comment. Thanks for sharing. Dr Mark Josephson (Beth Israel, Boston) is one of the grandfathers of EP. He has often proclaimed that we are not proceduralists, we are doctors.

  10. Coleen says

    Bravo! As a physician who has been in practice for over 20 years, I have seen technology taking over the exam room. While I like using an EHR, I will not allow it in the exam room with me. I want to interact with my patients, not a tablet.

  11. Rob says

    Very good article and I agree with the points Dr. Mandrola makes. Even after being a CIO for many years in my career, I feel the industry, followed by the Gov’t (CMS) has swung the needle too far in the “technology for technology’s sake” direction.

    Of course I see value in things like an EHR, but it should be a tool for healthcare providers, not the other way around. There needs to be a happy medium between treating the patient as a human being, and accurately capturing that treatment electronically.

  12. aminer says

    Dr. John,

    Who is this clinician’s name who said

    “I can almost always tell within a few minutes of meeting an (AF) patient what the correct treatment will be. It’s as if God himself speaks, and tells me the right course for that patient”?

    You live too far away from me for me to see you, but maybe this guy lives closer to me. I’m looking for a good EP.