Book worms, imperialist nostalgia and the "Stanford 25"

By New Year's Eve I will have finished another spell on the wards as attending physician overseeing a wonderful team of interns, residents and students; our team has been admitting patients every fourth night. The experience always leaves me in awe and reaffirms my faith in internal medicine.

I've become better at the EMR--electronic medical record--and grateful that the days of hunting all over the hospital floor for the missing patient chart are over. So also with trooping down to radiology and trying to get a file clerk to find a particular x-ray, which too often had been checked out by another team. I'm so glad we don't do that anymore. Now, from any computer, including my home computer, I can call up CAT scans, MRIs, lab results for my patients. The only thing I resent about the EMR is that it is a time sink and it's in direct competition with time we should spend with patients.

I so appreciate these advances. The other day I felt compelled to describe to a student how "in the old days" (and at another institution) we would go down to medical records in a basement dungeon and hunt down the old charts, which might run to several volumes. Those thick stacks of paper held together by rubber-bands were dust laden, often fenestrated with book worm tracks, and sure to trigger some wheezing if you were predisposed. (I was.) My student listened to me with fascination, almost as if I were describing something romantic and desirable. I hastened to say it wasn't something I'd want to do again.

Two days ago a Stanford colleague in anthropology introduced me to the term, "imperialist nostalgia": romanticizing the past while choosing not to remember the particular injustices of that period. An example might be a colonialist recalling the wonderful days in a hill-station bungalow, while forgetting the slavery or apartheid that might have made that possible.

"Imperialist nostalgia" is a great term, and for me its a cautionary one. I 'm keeping it in mind as I make this very short list of things I like about the way we practice medicine now:

  • terrific ability to look inside the body, to probe, see, reconstruct
  • incredibly efficient ways that we can store and access data
  • much less shuttling between the radiology file room, the medical records room and the patient room
  • quick access to information about disease--everyone seems to carry a peripheral brain (a PDA loaded with ePocrates or Skyscape or the like) so knowledge has become democratic and instantly available at the point of care
  • great choices in therapy for the treatment of so many diseases that just twenty years ago would have had a different outcome (rheumatoid arthritis is a great example).
  • pretty good data to tell us what works best - "evidence-based medicine" (I can't believe I am touting the term, having railed against its zealots for some time. The fact is that I am all for evidence as long as its well applied and applied to the right patient.)

But here is what I bemoan, and this isn't "imperialist nostalgia":

  • I regret that more and more we seem to distrust our eyes (and almost all of dermatology for example relies on observation, as do a myriad of other diagnoses); we distrust our ears (and the tale the patient might tell us if we only listen long enough) and we distrust our senses. We are putting far too much emphasis on "test results" to tell us what to do next.
  • We see too little of our radiology colleagues because we don't go down there as much as we used to. It's a loss--it was great to show them a CAT scan or MRI and give them the clinical context, and then hear their opinion.
  • I miss the nurses' station with the chart racks which used to be the social center of each floor of the hospital. Since you can write your note from anywhere (including from Starbucks), we we wind up "talking" to each other through the medical record. We don't develop relationships that are good for coordinated patient care.
  • I bemoan the fact that the art of bedside diagnosis is in danger of extinction. The people who invented these skills (beginning a hundred and fifty or more years ago) had to wait for an autopsy to reconcile what they saw or felt or heard on the outside of the body with what was actually going on inside. Now, we can make those correlations in real time; it should have made us superb at the bedside. Instead I worry we will get to a point where if you are missing a finger and show up in a hospital, no one will believe you till they get an MRI, CAT scan and an orthopedic consult.
  • Technique at the bedside is rarely emphasized, never really tested in board-certifying exams (at least in my field of internal medicine), and there are a diminishing number of people who will be able to teach it as time goes on.

Speaking of technique, we've been promulgating the "Stanford 25:" twenty-five technique-dependent bedside maneuvers that we want to make sure all our trainees learn and which we'll teach and then watch them perform at the bedside. The thought is that perfecting those 25 skills will give confidence and stimulate the desire to learn more of those skills (See our recent paper, "In Praise of the Physical Examination" in the British Medical Journal, listing the Stanford 25.)

The analogy for me would be skills for which boy scouts earn badges; those skills hardly equip you for all the exigencies of life. But they do make you appreciate that technique is important, as is repetition. It's not enough to read about a slip knot or a bow line or an anchor bend (and by the way, check out "Animated Knots by Grog"-- a lovely site ); you still have to pull that rope out and practice, practice, practice.

That's no nostalgia, that's a fact.