Recently in Culture / Media Category
Ten years ago this month, my wife and I left our youngest son with Grandma at home in El Paso, Texas and we flew to Manhattan to attend the party to inaugurate TALK magazine. I'd agreed to be one of the writers for Tina Brown's new magazine--I'd previously written for her at the New Yorker.
Ferries ran the 1000 or so invitees over to the Statue of Liberty--the island off the island. I felt as if I were in a dream, walking around in the dusk, brushing past the likes of Salman Rushdie and Madonna. Sylvia ran into a chatty Dr. Ruth in the restroom and then it seemed we kept running into Dr. Ruth --she was everywhere on the island just as she seemed to always be on TV those days.
The New York Times reports today on the ten year anniversary of that party, but titles it "An Omen No One Saw" and how we were all "unaware of the sharks circling".
I don't think that's a fair assessment. Looking across and seeing the twin towers standing, could anyone have predicted how the world would change? Or how magazines would fare over the next decade?
Here is how I see that surreal event: as an example of Tina's daring and inventiveness. I've pointed to her career when advising students and others. I say, be bold, be creative, reinvent yourself and dare to reshape the world around you, and most of all be willing to risk failure. Tina's latest venture, The Daily Beast, is like nothing else out there, and she brings to it all her skills in media, in recruiting new talent. But what it does best of all is showcase her own writing--in all the talk about Tina Brown, people don't always appreciate the brilliant writer behind the brilliant organizer.
So Tina, thanks for the memory of a hell of a party. I'm sitting here this morning, looking out of the window and drinking coffee. I am wondering what else is cooking in the mind of Tina Brown. It is commute time here in California, but near noon in Manhattan. She's already ahead of us.
(Photo credit: http://www.flickr.com/photos/patrioux/145381211)
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It's a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions--a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending's note, blood tests, imaging studies, nurses' notes, consultants' notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
"the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it."
Simon anticipated by 40 years the issue I've been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns' generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone's signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn't be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I've felt that my time at our patients' bedsides, examining them (because only the exam can tell you if there is pain and if it's better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam's words --poverty of attention-- which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap--time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient's data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It's the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he'll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let's see what he reports. I have no doubt we will both learn something.
I began my internship in 1980 at a Veterans Administration hospital in Johnson City Tennessee--the Mountain Home VA. To this day I don't think I have seen a more beautiful campus with quaint brick buildings, lush lawns, dogwood lining the main avenue, and white southern mansions in which the doctors lived.
But most beautiful and poignant was the cemetery, just to the right of the main entrance. Established in 1903 as a tribute to this corner of the "Volunteer" state that had contributed 30,000 volunteer soldiers to the Union, it was maintained beautifully. I would walk through that cemetery with reverence, the pages of history becoming more real when I read the names on headstones of men who had died in the civil war and every war since.
There was a plaque in the cemetery bearing these lines without attribution:
ON FAME'S ETERNAL CAMPING-GROUND
THEIR SILENT TENTS ARE SPREAD
AND GLORY GUARDS WITH SOLEMN ROUND
THE BIVOUAC OF THE DEAD.
I returned some years later as a specialist to work at that VA and I lived in one of the grand antebellum houses (or maybe they were post bellum--but they fit my idea of what antebellum looks like). I loved the old open wards, which, even though they were outmoded and needed to be replaced by semi-private rooms, seemed to recreate for the patients the intimacy, the camaraderie and the supportive environment of a barracks. I could often get from the patient in the next bed the low down on his neighbor's progress through the night.
My patients in those first days of my internship were largely World War II veterans, in their late fifties and sixties at the time. I recall the generosity of their spirit to us young physicians, and the stories they traded of service in North Africa, or the Pacific theater, or landing at Normandy. I wonder now how many of them are still with us--so much time has passed.
Tonight while writing this piece, I reached for my first book (which I have rarely gone back to because I immediately want to change things); it was the true story of AIDS arriving in that idyllic corner of east Tennessee.
Read MoreI love medical riddles. (I don't mean the "Why-did-the-doctor-give-up-his-practice?" --"Because-he-lost-his-patien-ce!" kind of riddle). I mean the kind that one wrestles with, the kind that is instructive, a teacher's tool, a way to make the student reason, formulate hypotheses, go to the book, research and eliminate possibilities . . . and come to the answer. Such riddles have a hallowed place in medicine--I remember these riddles only because I was asked them as a student and I learned something in trying to solve them.
So I'll often ask a medical student or resident, "Why do we say, 'Beware of the patient with a glass eye and a big liver?'"
If the student were to reason this out, the steps ideally might go something like this:
I wonder why the patient had a glass eye in the first place.
I suppose it could be trauma . . . could be a malignancy.
At this juncture the student might look up malignancies that occur in the eye and that justify removing an eye.
A melanoma in the eye is a common reason to remove an eye. (Or used to be--it has changed a bit with new treatment).
Now . . . how might I connect this to a big liver?
Hmmm. If melanoma metastasized to the liver, then they probably would never have taken the eye out in the first place and replaced it with a prosthetic eye.
At this point the student might look in a textbook or in UpToDate and find that ocular melanoma is famous for recurring years later with distant metastases. When it does return it often presents with new tumors in the liver. Bingo!
Ideally that's how a student would reason. If however the student were to decide to "google" the question by typing in "glass eye and big liver" as I just did, the first hit is NEJM: Solution to a Medical Mystery, which gives the answer to a photoquiz the New England Journal of Medicine put in its pages in 1997, showing an elderly lady with one eye that was clearly yellow with jaundice and the other which was pearly white. (The latter had to be a glass eye because there is no earthly reason for jaundice in just one eye. And she was jaundiced because she had melanoma metastases in the liver.) A total of 928 readers had the correct answer. No surprise I suppose because it's an old riddle.
If the Journal were to repeat the photoquiz with a similar patient in the years to come, Google would lead the readers right to the answer.
Which is why when I offered a new riddle to my students last week while we were rounding, I emphatically added, "Don't Google!" Nothing at all against Google--we're proud of Google at Stanford, and indeed my kid brother works there. But the point of the riddle is to search your brain, not Google. To reason and to come to the answer for the right reasons . . not just to come to the answer.
In case you're curious, the riddle I gave my students and which they are supposed to report on this week is:
A man walks into a bar, offers to keep his head completely submerged in a bucket of water for twenty minutes and if he doesnt he will buy drinks all around and if he does the patrons must stand him a round of drinks. He does and so they do. The question is how did he do it?
A clue? No hidden tracheostomy, and yes it's a medical condition that allows him to do this. And remember, don't google this riddle!
Abraham Verghese
