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Tuesday, December 30, 2008

The Medical Matrix,the iPatient and does anyone remember the physical exam?

The December 25, 2008 issue of NEJM has a brilliant Perspective written by Dr. A. Verghese entitled "Culture Shock-Patient as Icon, Icon as Patient".

Dr. Verghese, a professor at Stanford Medical School, writes about the world of the computer screen patient or as he puts it so well- speaking of the world of internal medicine training- the iPatient.

"The patient is still at the center but more as an icon for another entity clothed in binary garments,the "iPatient".

He explains that after the ER docs work up or perhaps define the patient the " interns meet a fully formed iPatient long before seeing the real patient." Quoting the semanticist Alfred Korzbski, Verghese reminds us that the "map is not the territory".

The reality or virtual reality of the iconic patients may overwhelm the person from whom the iPatient is constructed. The CT report or lab test may not be correlated with the history or physical exam as neither may be done as the reality of the full developed iPatient arrives "on the ward".

"If one eschews the skilled and repeated examination of the real patients, then simple diagnosis are overlooked, while tests, consultations and procedures that might not be needed are ordered."

He speaks of two approaches, the traditional way where in the body is the text and the new way or the expedient or Ipatient way. The first approach is a needed remedy for the development of "chartomas"-which are disease labels that become the iTruth by "being cut and pasted into every note".

This is a great commentary and Dr. Verghese tells us that at Stanford an effort is underway to revise and strengthen bedside skills. Good for them. My medicine chief during training, George Burch, preached that if you are uncertain or uneasy as to what is going on clinically go back talk to the patient again and examine him again. When the house staff receives a patient fully iDefined patient, they may never know if that are uncertain or not and they probably would have no reason to be uneasy, but the patient may.

HL Mencken,National Health Coverage Council and Public Choice Theory

Recently, Dr. Donald J. Boudreaux in a commentary in his column,"Eonomics in Many Lessons", featured some quotes from one of my all time favoties, H.L. Mencken. Mencken's comments suggests that he understood the core thoughts illuminated by Tullock and Buchanan in their writings that informed us of what has become known as Public Choice Theory.

Mencken said:

"the survival into our enlightened age of a concept hatched in the black days of absolutism the concept, to wit, that government is something that is superior to and quite distinct from all other human institutions ... a transcendental organism composed of aloof and impersonal powers, devoid wholly of self-interest and not to be measured by merely human standards."

Mencken struck the key note of the ideas behind Public Choice Theory, namely that public officials-elected,civil service or appointed- act, at least in part in their own interests. These people, members of the same species as those not in government employment, tend to be motivated by salaries and other perks,lust for power and prestige and easy of managing their bureaucracy.The ideal from our eight grade civics class of a selfless public official wisely acting for the good of society is seldom achieved.

With that in mind, the"independent Health Coverage Counsel" proposed in Max Baucus's health reform plan should scare the heck out you.See here for one critique of that plan.
The danger of placing the power to make economic decisions in the hands of a governmental or quasi-governmental organizations should be obvious to all.

In fact, it scares me so much that I awoke from my blogging hiatus.