Friday, September 21, 2012

Does All the New Technology in Medicine Really Translate to Innovation and Improved Care ?

Airstrip Technologies offers remote, virtual real-time access to patients' medical data, with software tailored to individual specialties. Software versions are available for critical care, cardiology, obstetrics/gynecology, imaging, and laboratory. Airstrip Cardiology, for example, gives remote access to telemetry strips, EKG data, pulse oximetry, end tidal CO2 monitoring, and arterial pressure monitoring. The software reduces delays in making time-critical decisions when the physician is not present. Users can also access bedside monitoring data, including heart rate, respiratory rate, temperature, and blood pressure, as well as invasive monitoring measurements. Image courtesy of Airstrip Technologies.

    As you might guess, I do a huge amount of continuing medical education. Some of it is in symposia or groups,and involves some travel, and an increasing percentage of it is on the internet with an exam afterward, prior to credit being given.  I say I do this in order to keep my RN license in a variety of US states, but I suspect that I would do this level of work even if it were not required, simply to help to guide my own family and for my own intellectual curiosity.
        This week something came to me through one of the companies I use for medical education. Dr. Eric Topol, Director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape Genomic Medicine and, has written a series of articles which had their origins in a book he had written.  The series is called, " The Creative Destruction of Medicine".   His series begins on a fairly simple assertion that many physicians have discomfort in the digital age of medicine.  Many physicians were trained in times in which a patient, who might be bright in his own field, comes to him for advice on a particular health problem. The patient often knows very little about his issue, and even depends upon the physician in order to know what to call it. Then, not only are treatment decisions made but even the education the patient is given about his condition is chosen by the physician. Voila ! The patient is managed.   The internet has changed the landscape of medicine in many ways.  Now, with increasing frequency, a patient comes to a physician bringing symptoms and conclusions he read about on the internet. The patient may come in saying, "I have joint pain.  Do I have lupus, fibromyalgia, or Lyme Disease.  Is it even worth getting a Lyme titer because they are often falsely negative ?"    These are a lot of conclusions drawn, and it can take time to explain why none of these are our starting point with this patient.  In the clinic where I have most recently worked, patients come in being very sure of their diagnoses, and having misunderstood a great deal about what they read on the internet.  They don't understand enough about basic anatomy and physiology and pathophysiology for the information on the internet to make any real sense to them. Of course, in addition, no one can be objective about their own symptoms from inside their own body. Physicians and nurses alike have made this same mistake.   Getting a diagnosis from your physician and then seeking some information about your condition afterward is probably best.
         The internet has brought a huge amount of medical information to the general public and this often does not allay their fears. Most people live more happily not knowing how many things have and can go wrong in a human body. Sometimes, less time should be spent reading about medical disorders and pathophysiology and more time needs to be spent simply living the life.
      In some regards, an electronic medical record can save lives.  The rheumatologist who orders a certain drug, doesn't always consult with the cardiologist who orders something else which is not only incompatible but dangerous. You may not be seeing a cardiologist when the rheumatologist ordered the original drug. An electronic medical record in the same health system can help to identify these types of problems.  In addition, those with a serious chronic medical issue can stay in touch with their physician weekly.  My son see his physician every three months or so following a lightning strike, however he is in e-mail contact with him every week or two.
       The next article written by Dr. Topol talked about a number of devices which have a potential to change the way we follow patients. He told the story of having done an EKG on a patient on an airplane, with his iphone using peripherals and a certain ap. Ge diagnosed the person's anterior wall MI (heart attack) and the person was successfully  released from the plane onto an ambulance for excellent care. He talked about the continuous glucose monitor. (I have news for him. I've used that on my juvenile diabetic daughter, and it's not the panacea people might think.)
         On the one hand, appointments, prescription refills, and quick communication should become easier.  On the other, patients may come to the physician needing more information and correction of misconceptions gathered from the internet assessment of symptoms. This might take more time.  This also may lead to more people having a better understanding of what a physician really does.  People may actually figure out who does their continuing education, and who isn't doing it.
        Now it's my turn to weigh in.  In the early 1980s, I graduated as a Registered Nurse, and we were prepared to do the job. Our units were staffed adequately unless a disaster was occurring. Our patients were cared for properly and for the most part, did well.   In the late eighties and nineties, in critical care, we began doing things procedurally that had been the venue of physicians, and we found that nursing was evolving and that this was legal. While I was working in critical care, and in semi-management, I found that the staffing to other types of units was dwindling.   When I talked to other RNs in other hospitals, I found that my own hospital was staffed better than most.  As the technology to care for our patients improved and its availability increased, the quality of the candidates in both nursing and in medicine decreased. Nursing aides and assistants were used to do procedures which ten years prior would have legally only been the venue of registered nurses. This was not due to a true unavailability of nurses, but an unwillingness and financial inability of many hospitals to hire more of them.  The job of being a Registered Nurse in many settings became so difficult and so unpleasant that many nurses leave the profession as soon as they can line up another gig. You can see why I later taught medical subjects as a college instructor.   It is my opinion that technology and medical "toys" cannot compensate for decreasing the numbers of properly trained nurses and physicians in hospitals with the time to really do the job. 
It looks to me that the technology might have changed the practice of medicine and the practice of nursing in order to compensate for sub-optimal staffing levels hospitals adopted to keep up with diminished reimbursements and a heavy burden of illegals who will never be able to pay them.
To my way of thinking, the practice of medicine might be more interesting and more fun with these toys, but won't necessarily result in good care.  We need to remember that a good physician, a good history and a good physical exam will produce the most accurate diagnosis and then, the best plan for treatment.  In the hospital, a Registered Nurse with adequate time to check her patients, provide them with intravenous blood, treatments, chemotherapy etc. and watch their responses to such will result in the best patient outcomes. The toys each of them use aren't going to change that.


Gorges Smythe said...

I think it's like the new phones that folks are crazy to get, a person only has the time to use so much technology properly.

JaneofVirginia said...

I think you are absolutely right Gorges. I like technology generally, but I think we have to pick and choose what parts of it benefit us, and what parts of the technology world don't enrich our lives and simply suck up our time. I was happiest with a very basic cell phone. The one I have now has a number of features I don't need or use that came free with my plan.

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