Just a few weeks ago, I attended another talk here at UT titled “A Doctor’s Touch” by Dr. Abraham Verghese, the Professor for the Theory and Practice of Medicine at Stanford University Medical School and Senior Associate Chair of the Department of Internal Medicine. This time last year, I attended the “World in 2030” talk by Dr. Michio Kaku here at UT, for which I wrote an article titled “The Digitization of Medicine.” The article focused on Dr. Michio Kaku’s predictions for the near future, where the role of the doctor will become obsolete, and robots and gadgets will take over the discipline of medicine.
Although both talks addressed the growing influence of technology in the medical field, Dr. Verghese’s talk emphasizes that the ritual of patient-physician relationship must never fade, which seems to serve as a rebuttal to Dr. Michio Kaku’s idea of the future of medicine. The following section serves to discover yet another facet of the future of medicine.
In today’s clinic setting, if you walk in to the doctor’s office with a foot injury, one of the first things you’ll have done is a CAT scan. Technology has replaced much of the communication and background information from the patient-physician complex that is critical to making simple diagnoses. Many patients, as Dr. Verghese confirms, express that they face a decreasing level of interaction with doctors, and this can make their trip to the clinic or hospital uncomfortable. Some doctors have been observed to make little eye contact or seem to display no apparent concern for their patient. Verghese argues that when doctors jump straight to ordering tests instead of sitting down and performing the proper physical exam, they are not only overlooking simple issues that can be treated preventatively, they are losing a ritual. This ritual is the art of the physical exam, and the human hand and its ability to touch, comfort, and diagnose will be the most important innovation in medicine for the next 10 years.
A proper and thorough physical exam develops the vital trust in the patient-physician relationship. In one case, a 40 year old woman entered the ER, had a heart attack, and was taken back to look for blood clots in the lung with a CAT scan. The scan showed no clots, but discovered large tumors in her breasts. What’s even more astounding is that her records showed that she had been to four to five other hospitals and no one had taken the opportunity to examine her breast mass and intercede at an earlier stage of development. So what are we missing in healthcare today?
Is Sherlock Holmes what we’re missing in healthcare today? You may be surprised to learn that Sir Arthur Conan Doyle’s concept of the mystery connoisseur, Sherlock Holmes, was inspired by Dr. Joseph Bell, a respected surgeon and lecturer. Sir Arthur Conan Doyle was a student of Dr. Bell’s during the late nineteenth century in Edinburgh, Scotland. To think that medicine and mystery have parallels is certainly a curious thought, so what could they possibly have in common?
Dr. Bell could look at a man’s hand and tell his trade, examine a man’s face and discern if he was a drinker. In dealing with so many people, Dr. Bell became exceptional at using clues to figure out the patient’s background and to assign a diagnosis. In addition to his experience and observational skills, he knew how to ask the right questions. Below is an excerpt of Sir Arthur Conan Doyle’s description of Dr. Bell’s examination of a woman mentioned in Dr. Verghese’s talk.
Picture Bell in the center of a room full of medical students, as a woman walks in with a child:
Woman: "Good Morning." Bell: “What sort of crossing did you have on the ferry from Burntisland?" Woman: "It was good." Bell: "What did you do with the other child?" Woman: "I left him with my sister at Leith." Bell: "And did you take the shortcut down Inverleith Row to get here to the infirmary?" Woman: "I did." Bell: "Would you still be working at the linoleum factory?" Woman: "I am."
In that moment, Bell turned to his students:
"You see, when she said, 'Good morning,' I picked up her Fife accent. And the nearest ferry crossing from Fife is from Burntisland. And so she must have taken the ferry over. You notice that the coat she's carrying is too small for the child who is with her, and therefore, she started out the journey with two children, but dropped one off along the way. You notice the clay on the soles of her feet. Such red clay is not found within a hundred miles of Edinburgh, except in the botanical gardens. And therefore, she took a short cut down Inverleith Row to arrive here. And finally, she has a dermatitis on the fingers of her right hand, a dermatitis that is unique to the linoleum factory workers in Burntisland."
With the background information checked, Dr. Bell proceeded with the physical exam, in which he would disrobe the patient and use the power of touch to diagnose, comfort, and heal. This is the sacred art of reaching diagnoses by means of asking clear-cut questions and administering a thorough physical exam. Making a diagnosis is in many ways like solving a mystery. So thank you Sherlock, but more importantly, thank you, Dr. Joseph Bell.
Percussion, the Stethoscope, and The Doctor
Percussion, a practice developed by Leopold Auenbrugger in the late eighteenth century, is a method of diagnosis in which areas of the body are tapped with the finger to determine the condition of internal organs via resonance. Auenbrugger conceived of the method early on by watching his father tap the sides of wine caskets to gauge how much wine was left. He carried this observation with him when he began practicing as a physician, tapping on the chests of patients to listen for fluid congestion in the lungs. This was a new, exciting invention for physicians to have a chance to “look” inside the body.
Not long after this discovery came the invention of the stethoscope, which was developed by Laennec. According to Dr. Verghese, the story goes that Laennec was walking on the street and found two boys playing with a stick, one scratching one end of the stick and the other listening on the other side. This event could very well have been the inspiration for the device we have grown to know as one of the emblems of medicine. Curiosity and observation contribute largely to the development of these critical devices – devices that allowed physicians of the past to peer into the body non-invasively. They were measures which required a delicate and comforting touch to develop the trust necessary for the patient-physician relationship.
The selected image depicts the famous painting titled The Doctor by Luke Fildes in 1891. In the lecture, Dr. Verghese relays the story of Fildes’ son’s death at the age of nine on Christmas Eve. Fildes was so inspired by the doctor who stayed at his son’s bedside for nights that he gave life to this painting, which portrays his vision for the doctor of the future: a humane doctor equipped with the ability to empathize, think, and touch to transform the patient.
Medical school admissions officers are now, more than ever, looking for qualities such as integrity, teamwork, cultural competence, resilience, and adaptability in their upcoming applicants. These are qualities that make up the character of the doctor envisioned by Luke Fildes. These are qualities that will promise a future of doctors intent on helping others and restoring the human touch back to medicine. Stanford Medicine 25 is an initiative of the Stanford School of Medicine to restore the culture of bedside medicine with 25 types of examinations that should be conducted for assessing diagnoses. You can read more about the top 25 links and any of the other sources I used to compile this article in the list below.
Sources: Dr. Verghese’s TED Talk- https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch Stanford Medicine 25- http://stanfordmedicine25.stanford.edu/index.html The 25 Physical Exams- http://stanfordmedicine25.stanford.edu/the25/ Sherlock Holmes- http://www.sherlockian-sherlock.com/dr-joseph-bell-the-real-sherlock-holmes.php The Doctor Painting Image- http://adelgadono.files.wordpress.com/2009/06/pediatra-de-cabecera1.jpg