Medical Matters: Patients better served when bedside evaluation is linked to technology

How would you like if your medical consultations were conducted by a robot? Probably one with a smiling face, programmed to be appropriately empathetic, but nonetheless one working to fixed algorithms that would click in depending on your presenting complaint.

Leaving aside jokes about doctors with a wooden (metallic?) bedside manner, medicine may already be well on the way to such mechanistic consultations.

In his book, The Creative Destruction of Medicine: How the digital revolution will create better health care, Eric Topol, a former professor at the University of Michigan and Case Western Reserve University, and chief academic officer for Scripps Health, argues that the digital revolution can democratise the US medical system.

Topol writes about how the digital revolution can be used to change individual care and prevention, and even the economics of healthcare.

But there is an alternate view, expressed in a recent piece in the Journal of the American Medical Association (JAMA), that "medicine finds itself far from the bedside, seeking a way back".

Bedside teaching has been the bedrock of medical learning for centuries; in fact, medical schools in Ireland were at the vanguard of a style of teaching that revolved around real patients, with students being taught clinical examination and then being directly observed by their teachers as they practised these techniques and methods.

Instant diagnosis
Now, however, with the advent of accurate scanning techniques such as MRI, doctors may see the rigorous examination of the patient as superfluous, safe in the knowledge that the latest technology will make an instant diagnosis.

But as the Stanford Medical School JAMA authors say " technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty".

And delusions they may well be: despite all our advances, there is still not a single medical test that is 100 per cent accurate.

Even the most sophisticated report false positives – suggesting you have a particular abnormality when you do not. False negatives may be even more damaging, giving misplaced reassurance of a false “all-clear”.

It's not that a return to clinical methods will yield instant diagnostic accuracy; but because it is a painstaking process of inclusion rather than exclusion, it inherently acknowledges the reality of diagnostic uncertainty. Patients are arguably in a safer place when good bedside medicine is practised.

Rightly wary
But the modern patient is rightly wary of old-fashioned medical paternalism, so a return to the era of the bedside diagnostician must be a more democratic affair than it may have been in the past.

As John Launer points out in his essay The art of questioning, he remembers being taught the importance of asking the right questions.

For him, two of the most crucial questions, and ones that readily embrace the patient’s view, are: “What do you think you’ve got?” and “How can I persuade you otherwise?” – meaning is there a test we can do to put your mind at rest?

Clinical questioning is not primarily about pinning problems down but works better if used to redefine and resolve them through meaningful conversations between doctors and patients.

Interestingly, one of the four principles put forward by the Stanford authors to guide doctors on the road back to the bedside is to “critique and develop the evidence. It is a false strategy to pit the accuracy of bedside evaluation against that of technology”.

“The question is not whether physical examination alone is better than a chest X-ray at diagnosing pneumonia, but whether physicians who combine both approaches deliver better outcomes to their patients than had they used one approach alone.”

It’s a conclusion that’s hard to argue with. As a patient you could do worse than seek out doctors who are comfortable with this as their modus operandi. As for robots, you don’t really want one standing beside your bed struggling with the art of clinical questioning, now do you?

mhouston@irishtimes.com