I have spent the last week getting “pre-oped” before I undergo bilateral hip replacements at St. Luke’s. The nurses, doctors, and technicians who have taken care of me have been magnificent—as they have always been. My criticism of Luke’s has always been about its management and the Board of Directors who remain, according to many employees, more concerned with the process of revenue and margins than they do with patient care. Once again, thank you to all the caregivers.
During part of my workup, I underwent a study of my carotid arteries looking for any obstruction to blood flow. The Doppler and blood flow study was completed using several pieces of equipment. One piece of equipment was the size of a home refrigerator, and the technician told me it cost over several hundred thousand dollars. The tech also used a handheld doppler the size of a pencil attached to an amplifier that allowed anyone listening to hear for disturbances in blood flow. When I was a resident early in my career and when I performed vascular surgery all we had was the aforementioned pencil size piezoelectric transducer and the microphone/amplifier. Together they cost less than $50.
In the hands of an experienced vascular surgeon, the handheld pencil transducer gave one 95% of the information that the hundreds of thousands of dollars machine could give. Here is my point that applies to many areas of our lives. The more experience one has, the less one has to rely on technology. This also applies when comparing vascular and laparoscopic surgery where the rules of exposure, traction and counter traction, and “seeing what you are cutting” apply equally. The skill of manipulating the scope takes longer to develop, but once that piece of the puzzle is completed operations become easier and less operator-dependent because of the technology.
Like with newer applications of Artificial Technologies (AI) mechanical tools like (ECG) have used artificial techniques and laboratory tests like blood counts and chemistry analysis that had to rely on handheld microscopy and flame bench chemistry analytic techniques, a Coulter Counter or a mass spectrometer that used to take a room now sits on a bench or can be carried around in a briefcase or a doctor’s bag.
This caused me to think about how vulnerable and sloppy technology has made us in solving problems requiring deductive reasoning. In times past physicians had to rely on their hands, ears, and eyes and perform a physical examination of patients. Now they get back tranches of information piecemeal at a time from “MY CHART” Organizing and coalescing information becomes the new skill that must be deployed, much of the time even before the physician sees the patient. Deductive reasoning—general to specific, is replaced with computer-generated algorithms and probability graphs. Observational skills and common sense take a backseat to technology and statistics.
When we begin to treat patients or treat customers, or even if politicians treat their constituents with a “one size fits all mentality”, without regard to the patient or individual history or unique circumstances, we automatically are placed in situations where the communal code replaces individuality and identity. This is precisely the logic that allowed for Public Health “experts” who looked only at what was happening during the “political pseudo pandemic” using “data” and who spent little if any time at the bedside, and then were allowed to make decisions that lacked any deductive analysis or common sense.
So, my (ECG) results showed up on the St. Luke’s MYCHART yesterday showing “sinus bradycardia—abnormal (ECG)”. I have always been a runner until my hips gave out so now, I try to swim one mile a day five days a week. At home, my heart rate has always been 50-60bpm for fifty years. I retrieved an old (ECG) from a predeployment physical I underwent 42 years ago. It said, “sinus bradycardia—abnormal (ECG)”
In the first instance, I saw a friend of mine who was a cardiologist who used to run with me. He wrote down on the consult normal (ECG)—Elite athlete—he was a close friend and I asked him for the addendum so I could show my wife! Because of the latter (ECG) it has been recommended that I undergo a cardiac echo and a radioisotope perfusion study. Maybe if the cardiologist was my friend or not an employee of the hospital trying to “maximize revenue and margins” for administrators prior to contract wage negotiations, common sense, and clinical judgment may have been all that was needed. Or maybe if malpractice litigation was not at the back of every physician’s mind, then the whole process could have been streamlined.
One last point. When I was a medical student and resident the house staff always “pre-oped” patients before major surgery by making sure they could walk up 4 flights of steps, and blow into a straw with a mechanical resistor that we carried around in our shirt pockets, that would measure their forced expiratory volume. At THE Ohio State, a hospital administrator approached the chief of surgery asking if those tests performed by residents could be billed for and patients were given an invoice for services. We all laughed. I bet there is actually a code for those procedures today! In fact, I bet there is a robot (AI) that will do those same procedures and bill several thousand dollars.
Technology has allowed us to make great strides with great speed in medicine and surgery. We should embrace and leverage any advantage it can give us to help take better care of patients and have better outcomes. We should never minimize the importance of common sense, clinical judgment, or “use the data out of context”.