My medical school at the University of Utah developed a clever computer program in the late 80s that was meant to both educate medical students and assist in the treatment of patients. 

For several years the tech geeks at the school had collected an immense database of information from all the patient admissions at the hospital—presenting symptoms, exam findings, tests, and final diagnoses.  They took all this data and crunched it into a program that provided a statistical snapshot of all the clinical syndromes seen by our university hospital over several years and then created a user-friendly interface that allowed us new trainees to learn from all this experience.  With this program I was able to enter the term “chest pain” and quickly learn what the ultimate diagnosis was for all the thousands of patients who had reported chest pain as part of their initial symptom constellation (e.g. 12% heart attack, 6% pulmonary embolus, 46% esophageal reflux, 18% chest wall pain, etc.).

Even cooler was the function that allowed us to enter several symptoms and findings and the computer would spit out the most likely diagnosis.  Mind you, this was not based on some sort of theoretical textbook list of syndromes, but rather on the real-world experience of our patients and our doctors at our hospital.  I’d type in “abdominal pain, nausea, and elevated blood lipase” and the computer would tell me that this patient was 91% likely to have acute pancreatitis.

As far as a computerized training tool this program was unsurpassed.  It could tap its database to create a fictionalized patient and problem list, then quiz us on what testing and therapy we’d recommend.  Patient X with foot pain and history of diabetes, heart disease, and schizophrenia shows up with a fever.  What’s your next test?  What’s the most likely diagnosis?

As medical students, we couldn’t help but be a little intimidated by a computer program that seemed a million times smarter than we were.  It seemed to us that the rapidly advancing technology, if left to evolve down this Orwellian path, would soon be able to diagnose and treat patients with precision and reliability that we humans could only dream of.   It was a little deflating to think that we would suffer through a decade of schooling and countless thousands in loans only to find that we are all being replaced by computers.

Well, that was 1989 and in the 21 intervening years I’ve managed to find employment as a doctor and have not yet been replaced by a robot.  Despite the fact that we have more evidence-based models of care (algorithms based on large population studies that help take the variability out of medical care) than we’ve ever had, human doctors—despite all their flaws and imperfections—are still an integral part of modern healthcare.

You wouldn’t think this should be the case.  In a world where complex software at sites like Amazon and Pandora can predict your tastes better than you can, where Google can access trillion pieces of information in fractions of a second, where all details of everyone’s medical history will potentially be available for data mining, and where computers can trounce the grandmasters in chess, someone could come up with a computer program that would out-doctor even the best of doctors (is there an app for that?).  How is it that our system continues to rely on the imperfect judgement of doctors to treat us?

The answer, I would suggest, is what we commonly know as the “art of medicine.”  Most of you have heard this phrase before, but do you know what it actually means?

I don’t either.  Look it up in a dictionary and you’ll come up empty.  Wikipedia, one of my favorite resources, has no separate entry for the art of medicine.  One of the few on-line essays I found dealing with the subject employed vague platitudes to define this concept: “Mastery. Individuality. Humanity. Morality.”

I would attempt to define “the art of medicine” a little more specifically.

In much of modern medicine there are pretty clearly established practice patterns that lead to reliable results.  A good example of this is our treatment of acute appendicitis.  Ever wonder why there aren’t a half dozen competing treatment strategies for appendicitis?  Come down with leukemia and you’ll be presented with at least a couple of options for therapy (different types of chemotherapy, bone marrow transplant, alternative medicines, etc.), but get an infected appendix and you pretty much get an immediate trip to the operating room.  The simple reason you don’t get many options with appendicitis is that the established therapy works so well—it’s curative in all but rare cases.  The rate of cure for most leukemias is low, thus there are many different ways to produce a relatively poor outcome.  If we had a pill that cured leukemia in nearly all cases, all other alternatives would quickly vanish.

The treatment of appendicitis is so straightforward (the diagnosis, by the way, is murkier) that even the simplest computer program would churn out the correct recommendation every time.  One plus one equals two.  At that point all you need is a pair of hands to dig the offending tissue out of the abdomen.

But what happens when one plus one doesn’t equal two?  What happens when there is no cure, or when the intended cure doesn’t produce the results you hope for, or when a cure is available but the patient’s condition precludes its application?  I maintain that the art of medicine is very simply defined as what you do when things don’t go how they’re supposed to—when one plus one adds up to something else.

The art of medicine is what you lean on when you have to explain to family members why the surgery you just performed on their loved one didn’t produce the beneficial results you had hoped for, or, even worse, resulted in an adverse outcome or complication.

The art of medicine guides you in dealing with an emotionally fragile patient who needs a procedure or treatment that you know will be beyond their ability to cope.

The art of medicine dictates how you break the news to a worried waiting room that their ill family member has just passed away; or how to cautiously guide families to the acceptance of impending demise in a patient about whom they clearly have denial; or how to comfort a surviving spouse when he or she asks you if they should have done more to save the person they’d been married to for 50 years.

The art of medicine is knowing when to stop asking questions during an office visit and just let the patient speak what’s on his or her mind.  It’s knowing when the agenda you have for your interaction has to take a back seat to something that may be very unimportant to you but critical in the mind of your patient.

The art of medicine is how you handle the patient who returns faithfully to your office seeking relief of her symptoms but who just can’t bring herself to remain compliant with the medications you prescribe to treat her condition.  Or how you handle the patient with an easily treatable illness who simply refuses therapy.

The art of medicine is choosing a course of therapy based as much on an understanding of the character and personality of the patient as on knowledge the disease process itself.

I could go on for page after page but I think you get the picture.  To a computer program—even the most clever ones—one plus one will always be two and the treatment of medical problems will remain nothing more than a function of odds, statistics, and search engines.  This may be satisfactory for appendicitis and a handful of other problems, but for most of what we do as doctors the math is never quite so simple.

The art of medicine—the art of dealing with the unanticipated, unwanted, and less-than-optimal—can’t be programmed into a computer and, for that matter, can’t be taught in medical school.  It’s what clinicians develop after years of experience, application and sometimes failure of science, mistakes, introspection, and learned humility.

Those sorts of skills will be in high demand forever.  And until they can program robots to do all that I’ll probably be able to keep my job.

Just last week I saw a full-page ad in the newspaper for a series of medical screening tests—EKG, echocardiogram, aortic ultrasound, and the like (all interpreted by “certified doctors”)—that a person could arrange for oneself or a loved one.  We newspaper readers were told we could arrange to have these tests performed without a doctor’s order as long as we’re willing to pay for them ourselves.  We could choose à la carte from a menu of screening tests or order a group of them as a package (Do you have a relative who died from a brain aneurysm?  Purchase peace of mind with the vascular package, including EKG, carotid ultrasound, echocardiogram and abdominal ultrasound!).  They even had testimonials from lucky survivors whose lives were saved by early, proactive testing.

The purveyors of these roving imaging clinics are looking for people with no particular symptoms but who are anxious about the possibility of occult disease lurking inside their bodies—the “ticking time bomb.”  Insurance companies don’t typically sport for most of these tests unless your doctor thinks you have symptoms to warrant them.

Should you sign up for testing?  Seems like a bargain, don’t you think?  A few hundred bucks and you get either peace of mind or early detection that could save your life.  Before you call the 1-800 number let’s look more closely at one of these tests.

The carotid Doppler ultrasound (CDUS) is a study that is meant to detect blockage in the arteries of the neck that provide blood flow to the brain.  High-grade carotid artery stenosis (CAS) is a risk factor for stroke and we know that CDUS is a critical part of the evaluation in patients who’ve suffered a stroke or transient ischemic attack (TIA, or “mini-stroke”).

But what about people like you and me who have no weakness, numbness or slurred speech?  To further tease out whether this is a useful test for those of us who are asymptomatic I’ll need to guide you through the complex web of population statistics, and to do that without inducing irreversible narcolepsy I’ll need to use a simple analogy.

Let’s say you’re the ruler of a country with a small population, a thousand of whom are over the age of 65.  This group of geriatric citizens is very lucky in that they are not burdened with more than the average collection of health woes: some with hypertension, others with diabetes, a few smokers.  None of them have had a stroke or any symptoms suggestive of carotid vascular disease.

Your country struck it rich with the discovery of some valuable mineral that the world just can’t live without.  You are now so wealthy that your citizens don’t pay taxes and all their municipal needs are provided painlessly.  Needless to say, your nation has also constructed the most comprehensive healthcare plan imaginable with state funding for every procedure, test and therapy that modern medicine can devise.

You, as the benevolent ruler that you are, want no one to suffer a stroke, and when you hear that you can test the carotid arteries with CDUS you jump at the opportunity (all costs be damned!).  You beam with pride as you announce that all one thousand citizens will undergo CDUS to screen for possible carotid vascular narrowing.

How many lives do you save through your magnanimous efforts?

I did a little research on the subject and have pulled some fairly reliable data on which I base my estimates.  Out of a thousand asymptomatic people over the age of 65 in the United States only 1% (ten patients) will have CAS that is significant (defined as narrowing of greater than 70% vessel diameter).  This sets the stage for our experiment in disease screening—we will be looking for 10 patients with disease among 1000 people we screen.

Now, using the wizardry of my higher math skills (adding, subtracting, pushing buttons on a calculator) I conclude that CDUS on these thousand people will produce a negative (normal) result in 892 patients and a positive (abnormal) result in the other 108*.

“Wait!” you say, “there are only 10 people in this population with carotid blockage.  How can we have an abnormal test in 108 people?”

It’s fairly well established that CDUS is not a perfect test.  It tends to over-diagnose some people and under-diagnose others.  A false positive result arises when the CDUS suggests blockage that isn’t really there, and a false negative means that the CDUS failed to detect blockage in an individual with significant narrowing.  We quantify the diagnostic accuracy of any test by using the concepts of sensitivity and specificity (please see a previous post for more fun with sensitivity and specificity, concepts which have bedeviled medical students for ages) and can translate them into more useful parameters by incorporating what we know about the prevalence of CAS in the population.

In our group, where patients with CAS make up only 1%, the CDUS will produce far more false positives (99, to be exact) than true positives (9).  And, since CDUS is such an imperfect modality, all 108 of our patients with abnormal studies will need further testing to determine who really has meaningful CAS.  The next test would be either an MRI or invasive carotid angiography.

Carotid angiography is the “gold standard” study that provides the definitive answer.  The problem with this method is that it is invasive and fraught with about a 1% risk of stroke (as well as other less dangerous problems).  If we do carotid angiography on all 108 patients we will leave one of them with a potentially debilitating stroke.

MRI is nice because it is noninvasive.  Its only drawback is that it, like CDUS, can produce false positive results, albeit less frequently.  Using MRI in our 108 patients will result in some of them going on to surgery who don’t really need it.

Once we’ve narrowed down our 108 CDUS-positive patients to only the 9 who have real CAS (not 10, by the way, because we missed one with true CAS), we have to ask ourselves “What then?”  Do we send them all to surgery?  Carotid endarterectomy (CEA) is a good, time-tested procedure, but even in the best of scenarios it is accompanied by significant stroke in 3% of patients.  The benefit of CEA in patients with asymptomatic CAS is not clearly proven and is reserved mainly for younger, healthier candidates with good life expectancy (see American Heart Association guidelines).

So, in summary, for our 1000 asymptomatic test subjects we will have correctly detected CAS in 9 of the 10 with this problem, but at a cost of 1 disabling stroke (presuming the use of angiography as the follow-up test).  We will have failed to detect true CAS in only one individual.  Those going on to CEA surgery will face a 3% risk of stroke at the time of the procedure.

“But,” you counter, “we’ve prevented strokes in 9 patients.  Surely that’s worth something.”  Not true.  A patient over the age of 65 with high-grade CAS but who has no symptoms still has only an 11% risk of stroke over the next 5 years.  Eleven percent of 9 is exactly one—you prevented one stroke over 5 years and you caused one through your testing.  Net score: zero.

As you can see, the utility of screening for CAS in asymptomatic people is far from proven.  The U.S. Preventive Services Task Force—which recommends against such screening—calculates that we would need to screen 8696 people to prevent one disabling stroke.  And although you, as the ruler of a fabulously wealthy nation, wouldn’t care about the financial burden of such a screening effort, you’d have to recognize that the cost of such screening and follow-up testing would be astronomical.

Now back to real life.  Do you get yourself screened or not?  Still hard to say.  It’s one thing to talk in terms of “populations” and another to discuss you personally.  If you’re at high risk for CAS (smoker, high blood pressure, high cholesterol, etc.) your chance of CAS and stroke might be considerably higher than the population average of 1%.  In that case it may be worth your money and time to get screened (it goes without saying that you need to aggressively treat your risk factors as well).

If, on the other hand, you’re a healthy but anxious middle-aged adult with few risk factors, and don’t happen to be the ruler of a small, independently wealthy nation, you could probably find better ways to spend your money.

*Sensitivity and specificity for CDUS is documented in many studies to be right around 90%.  For those of you who question the results I’ve come up with I encourage you to dust off your medical statistics textbooks and run the numbers for yourself.  The high number of false positives is a weakness of all screening tests when applied to a population with low disease prevalence.

I recently read a book called Better by Atul Gawande, a practicing surgeon who authors books, essays, and is a previous National Book Award finalist.  In Better Dr. Gawande strings together a series of essays detailing ways in which clinicians have made big changes in medical quality by launching small initiatives: a cystic fibrosis clinic that made dramatic improvement in success by encouraging parents to play an active role in the treatment of their ill children; third world surgeons who have made do with limited resources but who’ve managed to create remarkable breakthroughs in surgical technique; army doctors who pushed surgical care closer and closer to the battlefield to cut down on deaths among wounded soldiers.

Almost as an aside Dr. Gawande includes in his postscript some recommendations for other doctors who want to improve their medical care.  One suggestion related to our interactions with patients:

“Ours is a job of talking to strangers.  Why not learn something about them?

“On the surface, this seems easy enough.  Then your new patient arrives.  You still have three others to see and two pages to return, and the hour is getting late.  In that instant, all you want is to proceed with the matter at hand.  Where’s the pain, the lump, whatever the trouble is?  How long has it been there?  Does anything make it better or worse?  What are the person’s past medical problems?  Everyone knows the drill.

“But consider, at an appropriate point, taking a moment with your patient.  Make yourself ask an unscripted question: ‘Where did you grow up?’  Or: ‘What made you move to Boston?’  Even: ‘Did you watch last night’s Red Sox game?’  You don’t have to come up with a deep or important question, just one that lets you make a human connection. 

“If you ask a question, the machine begins to feel less like a machine.”

I like this advice. 

People spend their whole lives establishing their identity: an accountant, a mother, a nurse, a military officer, a truck driver.  A lifetime of accomplishments—whether big or small, momentous or simple—come together to make up a person’s self-image, and it’s generally something they, their family, and their friends recognize and take pride in.

Place that person in a hospital and he or she immediately becomes nothing more than a series of numbers and problems.  A retired schoolteacher, married for decades, who volunteers for her church and can bake a prize-winning pie suddenly becomes the 72-year-old female in room 734 with a UTI, HTN, GERD, and fever.  The retired bank president who is a decorated veteran and father of six is distilled down to a medical record number and billable diagnostic codes.

As a cardiologist I am under no strict obligation to dig any further than a patient’s past medical history, medication and allergy list, and chief complaint.  But if I do that I miss out on what makes a patient more than just a complex series of organs, tissues, and diseases.  Furthermore, I think I owe it to my patients to express as much interest in them as people as I do in them as patients.

Ask your patients what they did (or do) for a living and what they enjoyed about it.  Find out what they do to spend their spare time or if they have any vacations planned for the near future.  Ask about family or pets, what books they read, if they’ve ever traveled overseas.  Learn where they were born or raised, what their parents did for a living, or if they played sports in high school.

Of course it’s not always possible to spend much time ruminating on non-medical issues—we’re all a lot more rushed in clinic than we’d like to be—but in asking one or two of these questions we can at least scratch the surface and find out more than just a list of medical acronyms.

Plus, you might be pleasantly surprised by what you learn.

Just last week I consulted on a gentleman with shortness of breath.  On the surface his case was relatively uncomplicated and as an individual he seemed like any other elderly patient.  In his previously dictated admission note he was described simply as “retired,” but as I questioned him further I learned that he was a professional photographer and learned his trade while serving in the military.  Years ago, as an enlisted army man, he was trained as a staff photographer with a specialty in assessment of intelligence and surveillance imaging.  He was later pulled for special duty as the military photographer attached to the Lyndon Johnson administration and spent a year traveling with the president and his wife.  Lady Bird became quite fond of him and volunteered to intervene when my patient was told he was being deployed on a tour to Viet Nam.  He declined the offer and proceeded overseas.


Another patient of mine recently made the local news for her unusual fitness at a ripe old age.  Mary Skaggs (I use her story with her permission) just turned ninety this week and as I was visiting with her a few weeks ago I asked her to give me an idea on how she spends her time.  She proceeded to list the many things she does on a daily basis—cleaning, walking, spending time with friends, etc—but I had to interrupt her when she said “splits.”  What do you mean by splits? I had to ask.  In a flash she dropped to the floor of the exam room and proceeded to perform a series of splits for which even a stubborn East German judge would give a perfect 10.  Once done she rose to her feet and shuffled out with her cane.  It reminded me of the scene in Star Wars: Attack of the Clones where Yoda hobbles in to face the bad guy, cane in hand, then erupts into a Jackie Chan display of aerial kung fu.

With further probing I discovered that another patient of mine, whom I’ve seen for years, was a bomber pilot in WWII who was shot down, taken prisoner, and escaped to make his way to freedom across occupied France.  One elderly female patient was a nurse at a mobile surgical unit in the Korean War (a little less entertaining than the TV series, she tells me).  Another patient, well into her eighties, spends her time volunteering her services as a driver for other geriatric patients who need trips to doctors’ offices, pharmacies, and grocery stores.

The more we learn about our patients the better care we’ll be able to provide.  And the more we show an interest in what makes them unique the more they’ll trust us when we have to make hard recommendations.

Eventually, like everyone else, I’ll be someone’s patient.  When that time arrives I’d rather not be just the “72-year-old arthritic male here for an annual prostate exam.”  I’d prefer “72-year-old irascible semi-retired doctor with a wife who looks 20 years younger, a daughter who never got in trouble (even during her teen years), and two knees that suffered from way too many years of running and biking (but who keeps plodding along) who is reluctantly here for his annual prostate exam.”

It is estimated that 98,000 Americans die each year from preventable medical errors, according to a 2004 publication of the HealthGrades Quality Study, which called the issue of medical mistakes the “elephant in the room.”

“Medical errors seem to be the elephant in the room that no one wants to acknowledge or talk about.  The lack of recognition and acknowledgement of the seriousness and urgency of the problem fosters a culture of denial and complacency.  Also, our culture has typically viewed medical errors as a failure of people rather than systems, which prevents reporting and consequent analysis and solutions to prevent it from recurring.”

It was this report that prompted junior senators Hillary Clinton and Barack Obama in 2005 to jointly introduce a bill that would provide legal protection to physicians who voluntarily and expeditiously disclose medical errors to patients and families.  Five years earlier another Clinton, during his last year in office, announced an effort to curb deaths from medical errors by putting pressure on hospitals and clinics that receive federal funding to introduce policies to mandate mistake reporting and improve quality.

Despite these efforts, and many others, harmful medical mistakes still occur.  One such episode was the highly publicized tragedy involving the newborn twins of actor Dennis Quaid.  The two children received heparin, a blood thinner, at a dose one thousand times stronger than indicated for their small size.  Thankfully, they survived.  The staff at Cedars-Sinai readily admitted their mistake and placed the blame on “human error,” stating that they had safe processes already in place but that they were simply not followed.

More recently, Mr. Quaid, a private airplane pilot spoke at the National Press Club about the ordeal and compared the way we handle medical errors to the scrutiny applied to aviation tragedies:

“The airline industry doesn't have much choice,” Quaid noted in an interview Monday after speaking at a National Press Club luncheon. "When a crash happens, it's so public," he said. "No one is going to fly on their airplanes unless they have that trust."

But when a mistake occurs in a hospital, the public might never hear about it. Although an estimated 100,000 Americans die each year because of medical errors, their deaths are scattered over thousands of hospitals, "where people die anyway," Quaid said. "It doesn't get the same type of attention."

Mr. Quaid has a valid point.  Medical misadventures deserve greater scrutiny and the entire medical system needs to have mechanisms in place to allow us to tease out the root causes of error and correct them.  But he’s also viewing the problem a little simplistically when comparing the world of medical care to the aviation industry.

It is fair to compare a medical error (and its resultant harm) to an aviation mishap and suggest that medical mistakes be vigorously investigated.  But if we take the metaphor a step or two further it becomes clear that this analogy has only very limited utility.  In order for Mr. Quaid’s comparison to be truly valid we’d need to change the way we think about airplanes as such:

• Our country would have 300 million airplanes, all flying each and every day, with new models coming off the line and old models being retired around the clock.
  
• Each airplane, while essentially similar from the outside, would have a unique set of internal design, wiring, construction, and aeronautical characteristics.  No one set of blueprints would apply to all planes.
• The pilots and owners would be free to maintain the aircraft any way they’d like.  Most would neglect routine maintenance and would launch the airframe into flying conditions that are clearly damaging.  While some would use clean fuel, oil, and lubricants, most pilots would dump filthy petroleum into the gas tank and try to get by on cheap and filthy grease—then be surprised when the engine runs poorly.
  
• Older planes would gradually lose power over time, their moving parts would rust, and their flight controls would short-circuit and fail.  Navigation would freeze up, rudders would break, and landing gear would become unstable.  All this would be considered routine and no amount of equipment upgrades could slow the inexorable decay.  Still, they’d be expected to fly daily.
  
• Every single airplane would eventually crash.  Some would crash after many years in service and others would go down early in their lifespan due to some design or construction flaw.  For some, the crash would be expected; for others, a sudden plummet from the sky and fiery explosion on the ground would catch all by surprise.  No aircraft would be simply mothballed or retained in a museum, and there would be no option for a failing airplane to not fly.
  
• Aircraft would fail in a nearly infinite number of different ways—enough to fill textbook after textbook—and there’d have to be teams of highly specialized technicians to sort out the different system failures.

Now imagine the Federal Aviation Administration trying to deal with a world where airplanes are more like human bodies and aircraft crashes are as common as hospital deaths.

On the whole I agree with Mr. Quaid’s concerns and I’m glad he’s taken up the issue of medical errors as his cause célèbre.  To his credit, Mr. Quaid has assumed the banner of hospital errors and, among other things, is producing the documentary "Chasing Zero: Winning the War on Healthcare Harm" that will air on the Discovery Channel on April 24.

But in order to correct the problem we need to first understand the complexity of the issue.  No mechanical creation (even one as intricate as an airplane) will ever be as complicated, convoluted, and confusing as the failing human body. The multifaceted care that doctors, nurses, and hospitals are called upon to provide is staggering when it’s broken down into its individual parts.  During the course of one moderately complicated hospital admission the doctors and nurses cumulatively make hundreds of decisions and there are a thousand different critical steps where errors can occur.  With all the moving pieces it sometimes surprises me that more mistakes are not made and for this I credit the training of the staff and the detailed policies of the hospitals.

While we continually take steps to cut the rate of medical mistakes in a world where healthcare will always be more nuanced than aircraft maintenance, it pays to bear in mind that our progress will be slow and methodical.  Because, in the end, we’re still just fallible doctors and nurses trying to care for what is still the most complicated machine on earth.