The Tools of Doctors, and a Price for Patients

The Tools of Doctors, and a Price for Patients

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By ABIGAIL ZUGER, M.D.
Published: October 26, 2009

A stethoscope amplifies inaudible heart and lung sounds in a very satisfying way. If, however, the owner of the organs under evaluation decides to make a comment during the exam, what results is a painfully loud, unintelligible blast of noise directly into the doctor’s head.

It was during such an interruption almost 30 years ago that Dr. Richard Baron, a Philadelphia internist, grumbled at his patient: “Shhhh. I can’t hear you while I’m listening.” The phrase has undoubtedly been said by many, but Dr. Baron was the one with the wit to stop and laugh (and reflect at length in a classic medical article), realizing that he had enunciated in pure koan form probably the single greatest tension in modern medical practice.

Against the siren song of all those beautiful instruments and machines, whatever the patient has to say is sometimes just an annoying interruption. Medical technology is addictive; it is exclusionary and expensive, and it begets versions of itself like the sorcerer’s brooms. It complicates everything, and yet from X-ray and M.R.I. to the stratosphere of gene analysis, only a simpleton would opt to fly without it.

Dr. Stanley Joel Reiser, a physician, historian and medical ethicist now at George Washington University, has been ruminating on these matters in scholarly circles for years. His latest collection of essays escapes the ivory tower and resonates precisely with today’s headlines. Anyone with more than a passing interest in our present health care logjam will be intrigued and enlightened by Dr. Reiser’s painstaking retracing of its origins.

He begins with the stethoscope, the greatest medical hit of 1816. “Before stethoscopes, the coin of evaluation was words — the doctor learned about an illness from the patient’s story.”

Then, suddenly, the doctor was paying attention to something else. Patients were suspicious, they were cowed, and they were impressed. Soon they were demanding the stethoscope’s attentions on all occasions, even though what they felt and reported was now somewhat less important than the sounds coming through the tube. And so a new device had fundamentally changed the phenomenon of illness — a pattern that was to hold remarkably consistent for future innovations.

Technology distances doctors from patients. It creates a compelling alternative reality composed of facts that may or may not be accurate (note all the false alarms created by spurious X-ray findings and aberrant blood tests). It incites considerable public backlash (shortly after X-rays were developed, stores in London were selling X-ray-proof underwear to preserve genital privacy). Then wild enthusiasm takes over (as exemplified by those X-ray shoe-sizing machines of the 1940s).

Medical professionals tend to be the opposite: first enthusiastic and then less so, as the limitations and drawbacks of the toys become clear. At a 1960 medical conference unveiling a new Teflon shunt for long-term kidney dialysis, the audience of doctors and scientists actually rose and cheered. But soon enough they were faced with the painful task of allocating what proved to be an extremely limited resource.

In Seattle, the job of deciding who would live on dialysis and who would die of kidney failure fell to a seven-member committee of laypeople dubbed, in a 1962 article in Life magazine, “the life-or-death committee.” Sound familiar? Only after the 1972 decision to extend Medicare to dialysis patients were these decisions no longer necessary.

A different dilemma followed the development of the automated respirator, which can substitute not only for the lungs but also for the breathing center of the brain. The big problem soon became not so much when to use a respirator as when to turn it off. It was the respirator that touched off the medical, political and religious dialogue on the definition of death, a debate that continues.

Technology may spawn elevated philosophical discussion, but it also has mundane needs. It needs a home — hence the morphing of the hospital from a sad rest home to its present gleaming industrial self. It needs expertise — hence the evolution of the medical sub-sub-specialist and the slow demise of the generalist. It needs regulation — injudicious use can be, in the words of 17th-century midwives describing the new technology of forceps delivery, “extraordinary violence in desperate occasions.”

And of course, technology needs to be paid for, bringing us directly to the honking horns of today’s stalemate, with all movement stymied by the conflicting needs and mandates of machines we cannot do without.

If Dr. Reiser takes the bird’s-eye view of technology — the helicopter traffic report, as it were — then a roadside view is provided by Dr. Robert Marion, a veteran medical writer and practicing geneticist. In the last few decades, Dr. Marion has seen his field grow from a small backwater of pediatrics to a force with the potential to drive all of medicine.

That potential is still largely unrealized: the essays that make up Dr. Marion’s latest well-told collection are about diagnosis rather than treatment, as genetic screening identifies aberrant genes and missing proteins both before and after sick children are born. A few do well despite significant handicaps; most suffer a tragic downhill course. When the human genome starts to inform clinical practice, that pattern will certainly change.

Dr. Marion can almost taste the difference. “What a great time it is to be in this field!” he enthuses. Time will tell how that enthusiasm survives.

http://www.nytimes.com/2009/10/27/health/27books.html