Though I am currently a second year student at University of Vermont, I actually started medical school back in the ’80s in an ancient and venerable school in England, granted the royal seal by Henry VIII. Even just twenty-five or so years ago, the nurses still wore uniforms not significantly different from that worn by Florence Nightingale herself, and they kept their heads bowed and eyes demurely averted on ward rounds. I remember that there was never any doubt that “Doctor knew best” and that his word (and I use ‘his’ advisedly) was beyond question or reproach. He would make his pronouncement and the ‘angels’ would do his bidding.
After a tortuous journey, I am back in medical school, many years and several thousand miles removed, and I am struck by how different the view of care is now. “Patient-centered care”: doctor as steward but at the helm of an integrated team, encompassing many disciplines and with a goal of understanding the patient’s viewpoint as the target of primary designation.
My peculiar, somewhat unique history makes me view things rather differently from most medical students. It makes me very conscious that things are transient, not immutable. What we believe to be true of good practice today may be the focus of ridicule to another generation. So as good stewards we need to be looking for those things that are eternally true and fostering them in our ever-evolving ideas. The practice of medicine will continue to change beyond all possible recognition from where it is now, but that is not new; it has always been the case. If we look carefully to the past, it may help us to understand our future, because some things that were true in Hippocrates’ day still hold true now, and these are the ones that are likely to continue to be true in the coming centuries as well. Perhaps for this reason I am repeatedly drawn back to a wonderful quotation from William Osler: “It is better to know the patient that has the disease than the disease the patient has.” I believe that this is one truth that is unlikely to change.
We, as a species, are at a time of unprecedented transformation. We are preparing ourselves for a future that no one fully grasps and the world in which we will practice medicine is something of a mystery to us. All that we can confidently say is that it will be different from the one we see around us now. Yet we are educating ourselves largely as we did a hundred years ago. Technology is advancing at exponential speed, and we seem hell-bent on coming up with cleverer and cleverer ways to use the number crunching power that so enchants us. There is a significant risk in this, however. The more we believe that a patient can be reduced to a series of aliquots of data, the more inevitable it is that the digital, silicon-based life forms we are creating will make us obsolete in the care of ourselves and our fellows. We also seem blind to the fact that we will become irrelevant if we compete with them at things they were specifically designed to do better than us, rather than use and embrace them as differentially functioning partners. Is it in anyone’s best interest for us to be focusing our attention on skills that will inevitably be done far better by a laptop?
I anthropomorphize the computer in order to illustrate one of our historical Achilles’ heels: failing to appropriately value the input from sources outside our own cerebra. We frequently give too much weight to shiny new ideas and are blind to the enduring simple power that comes from observation of that which is all around us. It was certainly true of our openness to receive input from the nursing staff in the past, indeed it is probably still true to a significant extent. I think it will become an increasing source of friction as we head into the 21st century and beyond and see computers get better and better at integrating complex information and consequently value human input less and less.
On a population basis, you see, computers are always going to do better than us at predicting outcomes. They have bigger numbers to run and can be constantly updating their database. Indeed, if we were to set up the system well, there could easily be a time where every primary care practitioner in every State of the Union is adding information moment by moment throughout their patient visits, alerting us to changing patterns of everything from infectious disease outbreaks to how much weight loss is associated with a specific intervention practice. Our role is not to try to assimilate all this data ourselves. It lies in providing a steadying hand to guide something that is inevitably protean and ungraspable. Let us, rather, look to the things that are representative of our real skill, the things that do not change with time or technology and which are not threatened by the vast computational power of electricity and gated potentials that encroaches all around.
At the heart of everything in medicine is the doctor patient interview and this is the one place that will remain challenging for computers to supercede their poor primate programmers. Here is the most important intersection in medical practice, the point at which we have to decide, “Is the person in front of me like everyone else or not?” What we must always be asking ourselves is, “Why is this person NOT the statistical average of the population? Why should I NOT to do what the computer says to do?” Because these are the moments when we transform medicine. This is when we add to the care of our patients and truly work in partnership with technology, making best use of all it has to offer without losing all that we have to contribute.
In order to do this we need as much information as possible about the individual in front of us. Not the lab tests; not the CAT scans. The personal history, the personal story. I think there are three big questions that eternally hover over the patient-health worker interaction. The first two questions are beguilingly simple: Who are you and what do you want? I was an actor for 20 years and I am acutely aware of the enormity of those questions. Plumbing the depths of a character for an answer to those two questions has been the essence of art for as long as our species has told stories to each other. Can we get anywhere near an answer in a 15 minute encounter? Of course not, but we have multiple inputs from people who spend many hours with them: nurses, physical therapist, social workers, chaplains, the list goes on. Each is a human interaction that will reveal a different detail to those that are sensitive enough to see. The lab tests will tell the computer the sum of the parts, but the body language and the light in the eyes will tell a story that is much deeper. Life is complex and the practice of medicine no less so. Our true skill is in this interpretation so that we will know how to evaluate the gambler’s odds that the computer serves up to aid us.
Then, and only then, after we have come as close as we reasonably can to an understanding of who someone is and what they want, can we honestly ask the third and perhaps most difficult question, both for them and for us: “Can I help?” Because that involves doing what is best for them, not what is best for us and that may be a difficult place for us to see as well as a difficult place for us to go. To truly be stewards, we must strive to attain that knowledge and we need as many collaborators on that journey as we can muster. Hence, it behooves us to try to hold in the forefront of our minds the ideas that medicine is a team effort and that our number one job is to advocate for the patient. The one standing in front of us, not the one that is the total amalgam of the population he or she belongs to. If we keep that as our focus we will be in a good position to keep everything in the practice of medicine shipshape.