Five Patients Read online

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  RESPIRATORY SYSTEM

  PT. NOTES COUGH OF SEVERAL MONTHS DURATION, WHICH OCCURS DAILY. DENIES SPUTUM PRODUCTION, DENIES HEMOPTYSIS. NOTES NO DYSPNEA. HAS HAD HAY FEVER. HAS HAD NO KNOWN CONTACT

  WITH TUBERCULOSIS. LAST CHEST X RAY -2 YRS AGO.

  CARDIOVASCULAR SYSTEM

  PT. NOTES CHEST PAIN OCCURRING LESS THAN ONCE A MONTH, LOCATED "ON BOTH SIDES," WHICH RADIATES TO NEITHER ARM NOR NECK. PAIN IS NOT AFFECTED BY DEEP BREATHING, IS NOT ASSOCIATED WITH EATING, EMOTION, OR EXERCISE. PAIN IS NOT RELIEVED BY RESTING. PT. NOTES PALPITATIONS ON RARE OCCASIONS. DENIES ORTHOPNEA. DENIES PEDAL EDEMA, DENIES LEG PAINS, DENIES VARICOSE VEINS, DENIES PERIPHERAL REACTION TO COLD. CARDIAC MEDICATIONS: NONE. HAS BEEN TOLD BY MD OF NO COMMON CARDIAC DISEASE. NO ECG IN PAST 2 YRS.

  This is only half the total report. Analysis of gastrointestinal musculoskeletal, genito-urinary, hematologic, endocrine, dermatologic, and neurological systems followed. This particular computer program draws no conclusions about diagnosis; it only summarizes answers to its own questions, and it does not cross-check itself. Thus, while the computer was told the patient took digitalis, it later accepted the conflicting statement that the patient took no cardiac medications.

  This program, which was devised at the MGH, is a rather simple example of the way that computers can and almost certainly will be used in the future. But it is the least sophisticated of the medical-history programs available; more complex ones already exist.

  When Mrs. Thompson arrived at the MGH emergency ward, which had been expecting her, she was taken down to the EW X-ray department. In doing so, she passed a door near the front of the EW which is unmarked, without a label. Over the door is a lighted sign that says, incongruously, "On Air. "

  Dr. Murphy was behind that door, sitting in a corner of a small room, surrounded by equipment. Directly in front of him was a camera and a large TV screen, on which he watches the Logan patients. Built into his desk were two other screens: one, a small monitor of the larger screen, the other, a monitor that showed him his own image being transmitted to the patient. This second monitor allowed him to check his own facial expressions, the lighting in the room, and so on.

  To his right was a panel of buttons that controlled the various remote cameras-two in the examining room and one in the laboratory. The examining-room remote camera is operated by a joystick: by pushing the stick right or left, up or down, the camera moves accordingly. In addition, there are buttons for focusing and zoom control.

  Before going out to check on Mrs. Thompson, Dr. Murphy continued a study of Tele-Diagnosis

  capability: reading a series of 120 chest X rays that are set up for him at Logan. He planned to read these by TV and later reread them in person, to compare the accuracy and consistency of his diagnosis.

  The nurse at Logan set up the next X ray.

  "Whats this one?"

  "Jay-nineteen," the nurse said, reading off the code number.

  "Okay. " He moved the joystick and touched the buttons. The camera tracked around the X ray, examining the ribs, then scanning the lung fields. "Wait a minute. " He zoomed in to look closely at the right-upper lobe; he watched the little monitor, because resolution was better, but by glancing up at the large screen, he could also get a magnified view. "No. Well, on second thought. . . " He zoomed back for an over-all view. He zoomed in on another part of the upper lobe. "Looks like a small cavitation there. . . " He zoomed back, touching the buttons. He turned to the joystick, panned across the rest of the lung field, occasionally pausing to look at suspicious areas. "Nothing else, not really. . . " He finished his scan, and returned to the right-upper lobe. "Yes, theres cavitation. Id have to call it moderately advanced tuberculosis. Next, please. "

  He was working with considerable rapidity.

  "You get to be pretty good at this," he said. "At first, it all seems clumsy, but as you get more accustomed to the equipment, you move faster. " The average time for a patient interview and exanimation by Tele-Diagnosis is now twelve minutes, less than half the average figure a year ago.

  "What Im doing now," he said, "is really just a test of our capability. It has no immediate practical use, because we cant take X rays at Logan-thats one of the main reasons we brought Mrs. Thompson into the hospital. But its important to know if X rays can be read at a distance with accuracy. Our impression is that you can read them as well on TV as you can in person. "

  "Jay-twenty," the nurse said, putting up another film.

  Murphy began his scan. "Ah. Whats this? Looks like a rib fracture. . . "

  One can argue that for the past twenty years technology has defined the hospital, has made it what it is today. That is, once a range of expensive, complex therapeutic and diagnostic machinery became available, the hospital assumed the role of providing a central location for such equipment. This was inevitable: private practitioners and even large group practices could not afford to buy such equipment, nor maintain it, nor pay the personnel to operate it. Only the hospital could do this. It was the only institution in existence that could possibly absorb the expense. Other possible institutions, such as nursing homes, were wholly inadequate.

  Furthermore, because the hospital was already oriented toward acute care of critically ill patients, the technology that it absorbed was precisely that

  which helped in this area. Monitoring machines and life-support equipment are clear examples. Thus technology reinforced an already existing trend.

  Now, however, the pressures and forces acting upon the hospital are social and of a nature that is changing the meaning of technology within the hospital. As C. P. Snow has said, "We have been letting technology run us as if we had no judgment of our own. " But such judgment is now required, and one can argue that in the next twenty years the hospital will define technology. That is, it will create a demand for new technological applications- and in certain ways will itself produce the new technology.

  By doing this, the hospital will be extending its newest and most striking trend, which is to foster innovation, later to be picked up by other, nonac-ademic institutions. The absurd end-point of such a trend would be for the hospital to direct personally the diagnosis and therapy of a patient who never enters the hospital. Absurd as it may be, it is already happening in the case of many patients treated at Logan Airport. It will happen more often, in other ways, in the future.

  Of the almost limitless spectrum of potential technological advance, we can concentrate here on two areas of imminent advance, television and computers. One ought to say that they have been imminent for a long time; a decade ago one heard that computers were about to revolutionize medicine, and one still hears it today. It obviously hasnt happened yet. Indeed, neither television nor the computer has made much difference yet to routine hospital functioning. Television is employed on occasion for student teaching; it is used in a small way for dispatching blood samples and other items; it has some application in X-ray technology, in terms of image-intensification systems. Computers remain primarily the plaything of researchers. At the MGH there is now a computer program to help in running the clinical chemistry lab, and a computer to help in billing and patient record-keeping, but the computer and television as direct aids in patient care have not made their appearance.

  In contrast, the Tele-Diagnosis system at Logan Airport uses computers and TV in direct confrontation with the patient. The system is expensive and in some ways primitive. Also, its present thrust is diagnostic; therapy, the steps following diagnosis, will still be directly carried out by a doctor, nurse, or the patient himself. There are no machines to do this, unless one stretches the definition to include renal-dialysis machines, exercise machines, and the like.

  In general, diagnostic automation appears much closer than therapeutic automation-and is much more readily acceptable to physicians. Consider, then, diagnostic automation first.

  The first and most striking feature of the Logan system is that diagnosis can occur at a distan
ce. The doctors stethoscope is three miles long. But, oddly, that diagnosis at a distance is very old and has some humorous elements. Beginning around

  a. d. 900, for example, the practice of uroscopy, or "water casting," came into vogue. It was felt that the amount of information obtainable from inspection of urine was unlimited. The urine of a sick man was often sent many miles to be examined by a prominent physician.

  David Riesman cites a typical medieval interpretation of urine:

  The urine is pale pink, thick above, thin below, becoming gray or dark toward the surface. The grayness and obscurity is caused by overheating of the material. The symptoms are these: pain in the head, especially in the temples, sourness of the breath, pains in the back from bile descending to the loins and kidneys, with paroxysms every day or every second day, usually coming on after dinner time.

  In medieval literature there are many discussions of the hazards to the physician of uroscopy; even in those days, diagnosis at a distance had its risks. The Spanish physician Arnold of Villanova, who lived in the thirteenth century, wrote:

  With regard to urines, we must consider the precautions to protect ourselves against people who wish to deceive us. The very first shall consist in finding out whether the urine be of man or of another animal or another fluid.

  The second precaution is with regard to the individual who brings the urine. You must look at him sharply and keep your eyes straight on him or on his face; and if he wishes to deceive you he will start laughing, or the color of his face will change, and then you must curse him forever and in all eternity.

  The third precaution is also with regard to the individual who brings the urine, whether man or woman, for you must see whether he or she is pale, and after you have ascertained that this is the individuals urine, say to him: "Verily, this urine resembles you," and talk about the pallor, because immediately you will hear all about his illness. . .

  The fourth precaution is with regard to sex. An old woman wants to have your opinion. You inquire whose urine it is, and the old woman will say to you: "Dont you know it?" Then look at her in a certain way from the corner of your eye, and ask: "What relation is it of yours?" And if she is not too crooked, she will say that the patient is a male or female relation, or something from which you can distinguish the sex. . . Or ask what the patient used to do when he was in good health, and from the patients doing you can recognize or deduce the sex. . .

  The list continues through nineteen precautions, all designed to enable the physician to pry information from the person bringing the urine, and to prevent deception. Arnold was not above a little deception himself, however:

  You may not find anything about the case. Then say that he has an obstruction of the liver, and particularly use the word, obstruction, because they do not understand what it means, and it helps greatly that a term is not understood by the people.

  The modern counterpart of this medieval guessing game over urine is the telephone conversation between physician and patient. For years after the telephone became common, physicians resisted making telephone diagnoses, and they still frown on them. But every practicing doctor now spends a substantial part of his day talking to patients on the phone, and he is resigned to making a large number of decisions, some of them uneasily, by

  phone.

  Closed-circuit television, while far from the ideal of a personal examination, is vastly superior to the telephone alone, and in many cases it is surprisingly adequate. This does not mean that future patients will all be seen by closed-circuit television, with neither doctor nor patient leaving home. What it does mean is that television will probably work in certain very special applications. One of these is the Logan application-providing a doctor to a clinic during low-use periods. Another obvious use would be specialist consultations. A hospital or clinic that needs a neurologist only a few times a year cannot afford to staff one. Nor could it find one, even if it could afford it. Television is perfectly suited to such consultation.

  At the same time, a system such as that at Logan makes possible a routine physical examination, but goes no further-and there are suggestions that technology will ultimately change the very nature of physical examination. Here the historical trend is clear.

  Consider the innovations in physical diagnosis. In the nineteenth century, there were three of great importance-the stethoscope, the blood-pressure cuff, and the thermometer. Each of these is really nothing more than a precise way to determine what can be inaccurately determined by other means. Thus the thermometer is superior to the hand on the forehead; the stethoscope superior to the ear against the chest [For the purposes of this argument, I will ignore the fact that the stethoscope really initiated auscultation as a useful examination procedure. In truth, ears were not pressed against the chest with much regularity before Laennec invented the stethoscope and described auscultation. ]; and the blood-pressure cuff superior to a finger compressing the artery to test its pressure.

  Now, the first two advances of the twentieth century were quite different: the X ray and electrocardiogram provided new information not obtainable by physical contact. No amount of squeezing and touching the patient will tell you anything directly about the electrical currents in his heart. You may deduce this information from other findings, but you cannot extract it directly. Similarly, X rays represent a new kind of vision, providing a new kind of information.

  At the present time a variety of examination procedures are being tested. These include ther-mography, ultraviolet light, ultrasonic sound, as well as mapping electrical currents in the skin. Except for thermography, these all represent "new" sensory information for the doctor.

  Thus the initial trend was to measure the patient more exactly, and later, to measure the patient in new ways. The first approach has been to find new sorts of measurements and new sensory information. But a second approach, now in its infancy, concerns translation of old information into new forms. The computer will be helpful here in a number of ways, in producing what is called "derivative information. "