Abraham Verghese, the Stanford physician and writer, has a beautiful piece in the New York Times that’s worth unpacking a bit.
He starts off by marveling about the performance of IBM’s Watson supercomputer on Jeopardy, and thinking about how such a machine could change medicine:
THE other day as I walked through a wing of my hospital, it occurred to me that Watson, I.B.M.’s supercomputer, would be more at home here than he was on “Jeopardy!” Perhaps it’s good, I thought, that his next challenge, with the aid of the Columbia University Medical Center and the University of Maryland School of Medicine, will be to learn to diagnose illnesses and treat patients.
via Treat the Patient, not the CT Scan – NYTimes.com.
Verghese doesn’t shortchange the potential power of the computer one iota, envisioning a world where Watson-like machine might pick up side effects in ways that human doctors would not.
For example, Watson might recognize that the kidney failure in our patient is linked to kidney failure in a patient in Buffalo and another in San Antonio; all three patients, he might inform me, were taking a “natural” weight loss supplement that contained a Chinese herb, aristolochia, that has been associated with more than 100 cases of kidney failure.
via Treat the Patient, not the CT Scan – NYTimes.com.
But he also describes doctors being glued to their computers “like piglets at a sow’s teats,” and worries that this is both causing misdiagnosis and damaging the doctor-patient relationship. the “iPatient,” he writes, is replacing the real one.
Verghese first complaint is that being overly dependent on machines leads patients to get too much radiation from CT scans and also leads physicians to miss things they should have notice. One example is a woman who had been to doctors several times. the physicians missed tumors that were large enough to feel in a physical exam.
But his second worry is that, by not going through the ritual of a physical examination, doctors are depriving patients and their families of something that makes them feel better.
After introducing myself to the patient and to her daughter, I did a thorough but quick neurologic exam. I put the patient through her paces: mental status, cranial nerves, motor and sensory function, used my reflex hammer and pointed out interesting things along the way to my interns and students. I then said to the daughter that her mother seemed back to normal. to our surprise, the daughter seemed comforted, and now had no objection to her mother’s return to the nursing home.
via Treat the Patient, not the CT Scan – NYTimes.com.
This is one of the great quandaries, it seems to me, in medicine. a lot of doctoring could probably be improved by better use of computers, or of algorithms and checklists. Applying better techn0logy and evidence is important.
These kinds of improvements also have the benefit of improving the worst care. a lot of the best doctors are probably already combining the kinds of things computers do well with a very human capacity for creative thinking.
But there’s another part of medical care that seems detached from this kind of evidence collection and deduction. It has to do with how the doctor uses his senses, and how he interacts with a patient on an emotional level. For some ailments, such as pain, stomach problems, or depression, every word choice, intonation, and body movement might be a potential treatment. they are not treatments whose effectiveness anyone knows how to measure.
The closest I’ve seen anyone come has been the research into the placebo effect done by Ted Kaptchuk at Harvard University. He studied traditional Chinese medicine and has worked at figuring out how the way doctors interact with patients helps them feel better. my favorite of his experiments compared waiting, fake acupuncture, and fake acupuncture with warm, caring talk from the physician as treatments for irritable bowel syndrome.
In a trial of 262 patients with severe IBS, 62% of those who received the fake treatment got better, according to results published in the British Medical Journal. by comparison, only 28% of a control group of patients put on a waiting list saw their symptoms improve markedly. a third group who got the fake acupuncture, but without any warm talk, showed in-between results: 44% improved.
The result, says Kaptchuk, shows just how much the expectation of a cure–and the rituals associated with medical treatment–can improve real-world symptoms. “our own will, imagination and belief can modulate the course of illness,”
via The Nothing Cure – Forbes.com.
Orac, a physician-blogger I usually admire, dismissed Kaptchuk’s most recent study, which showed patients benefiting from a sugar pill when they knew it was fake, as not showing high quality evidence and deceiving patients. (See: More dubious statements about placebo effects.) I think he missed Kaptchuk’s cleverest idea — that the placebo effect might be a way to capture the effect of ritual in medicine.
Kaptchuk’s studies still suffer from many failings, most importantly that they are all being done by one researcher. It’s always hard to know how to trust a result when it hasn’t really been independently verified.
Still, I wonder if there are rigorous ways to establish the power of medical rituals, and to figure out how to teach doctors how to best perform them. One of my favorite medical stories is of the effort to improve how quickly patients who have had heart attacks have their arteries cleared with the angioplasty devices made by Johnson & Johnson, Boston Scientific, and Medtronic. the key was not just establishing that there was a problem, but figuring out what the best doctors did differently, and teaching that difference to doctors. I wonder if there’s some way to do something similar with the ritual of the medical exam.