Monthly Archives: August 2011

The clinical arts made clear

For years I have been whinging on about the overuse of medical technologies, in my writing, teaching, speaking (occasionally stooping so low as to corner a hapless victim at some dull cocktail party who’s made the mistake of innocently asking me what I do/am working on). And finally, the Archives of Internal Medicine has backed me up with a new, elegantly designed study from a group of physicians in Israel.

(Oh North America, why do you ignore the nuanced questions? Why is it that American and Canadian researchers confine themselves to reductionist questions like Pax2-dependent transcription activation and other such unpronounceable minutae, leaving the critique and analysis to the Israelis and Finns and Norwegians and Dutch and so on?)

Then again, it is not just researchers but us on this large continent, we who believe in high tech and guidelines, rules and benchmarks. We has seen the enemy and he is us, to coin a phrase. Our cultural template, our social world, our beliefs and values predispose us to believing in the power or science and technology; we love our smartphones so medical technologies – those lovely acronyms like MRI, CT and PET – must also be the royal road to answers. So we push push the doctor to send us for “tests” so we too can receive our god-given right to radiation.

What we inevitably forget (or just don’t know) is that what medical technologies measure are, at best, only pale imitations at best of the complexities of disease and illness.

When I remind students – seniors, undergraduates, their ages don’t matter – that “an MRI or CT scan can’t tell if that lump is benign; it’s a person, a human being who makes that determination” I can see that shock in their faces.  Because the seem to have forgotten that it is a fallible human being, prone to errors and fatigue and over- and lack of confidence who figures out the test, not the computer/technology.  And people can miss things, over- or under-report; people can exaggerate a problem because they’ve been sued or are in a hurry to get home and get to their child’s soccer game.  (Came as a shock to you too, didn’t it? You kind of thought technology trumped clinical judgement as well.)

Back to the Israeli study done by Liza Paley, MD along with physician colleagues Zornitzki, Cohen, Fredman, Kozak, and Schattner. They examined newly admitted patients to the emerg for 53 days, checking to see if the various tests and scans and so on ultimately aided in the final diagnosis. Sure enough, and wonderfully confirming my own cranky comments, they found that “more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool”. In other words, with only a handful of old, cheap lab tests (which were found to be “crucial”) plus a detailed history and decent clinical skills, you could narrow down the diagnosis and figure out how to treat the patient.

In fact, up to 90 percent of correct diagnoses were the result of history, exam plus some basic blood work (hematology and chemistry, urinalysis, EEG chest x-ray – which, I would remind you, contains anywhere from a tenth to 1/400th of the radiation of a CT scan.

These are not the tests we associate with medical high tech though. These are old tech, based on boring old 20th century research. No genetic tests, no cool monitors or flashy gadgets.

“Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation,” wrote the authors  in the Archives.

Of course our complicity in all this, particularly in community medicine, was a not a part of this study; neither was our belief, our faith in the power of the technology; superhuman, infinitely superior to the biological brain and, of course, infallible. Stemming from our belief that disease somehow has an independent reality – that it is the “other”, evinced by our metaphors (“killing” the cancer, “fighting the disease) and attitudes – that is observable through “scientific” means, ergo technology.

In fact disease and illness are nothing of the sort. A manifestation of human frailty, highly individual and affected by everything about us and around us: who we are, who we were, our personal and family history; our lives and fears; our environment and social biases – all the many stresses and strains we’ve been exposed to, from what we ingested to what we’ve invested. Ultimately, what matters isn’t that label, that diagnosis, however much it might provide us with comfort, but the care we receive.

And that, boys and girls, is the art of medicine without which the science hasn’t got a chance.