“I’ve got a headache.”
“Google it.”
“OMG, it might be a brain tumor!”
Have you overheard or participated in a similar conversation?
Doctors cannot avoid Doctor Google: it makes patients happy to have a virtually unlimited amount of information just one click away, easier and faster to access than ever before. In turn, self-diagnosis annoys medical professionals.
As a medical student, I can see both points of view. Patients are often left hungry for a few more words, as the information they receive from doctors can be minimal at times. Where else should they turn for answers to their questions? Patients enjoy reading about a new diagnosis, a diagnostic test they are about to go through, or exchanging experiences with other patients online.
The information that patients access, however, often raises more questions than it answers. It takes a certain amount of background knowledge to be able to sift through all the facts and tell what is true and relevant and what is not.
Doctors do not have all the answers, but they do know how to ask the right questions. Non-medical professionals have difficulty determining what is and is not important. This makes doctor Google dangerous: lay people are lost in a sea of misinformation and frequently prioritize facts inappropriately, leading to an incorrect diagnosis. When people fancy themselves doctors, most medical professionals lose patience. Yes, Google always has answers; however, the answers are always multiple, and most patients cannot critically evaluate the information they find. This is why patients need doctors.
Does this mean that the internet is bad? Doctors and medical students use the Internet. Resisting the shift towards electronic data would be antiquated as well as pointless. Electronic resources help physicians in numerous ways. They are used, for example, to check for drug interactions, find new treatment protocols, and read about cutting-edge research.
Still, some doctors seem to fear knowledgeable patients. It is entirely possible that a patient will know more about his or her condition than a doctor. This is particularly common for patients diagnosed with rare conditions. This embarrasses some doctors. But why should it? In training, students and residents are taught that it is acceptable to tell a patient that you need to review the literature before making a treatment decision. Again, it is the ability to ask the correct questions and then find the answers that separates physicians from non-physicians.
While we should strive to provide our patients with as much information as we can, we shouldn’t limit their curiosity. In fact, directing patients to reputable web sites might be an appropriate answer to this multi-faceted dilemma.
Sometimes our strengths can also be our weaknesses and in OB-GYN, confidence can be taken as arrogance.
I eat 32 chips ahoy cookies I find
six months after I first opened them
in the back corner of my kitchen cabinet,
behind cans of beans and tuna.
That same day, my neighbor’s daughter texts me
a photo of red bumps under her pubic hairs.
A bag of trash is the only thing in my refrigerator;
no time to take it out and it would have made
my apartment smell like dead people.
The people who die in hospitals—you see it
in their skin—grey and dry—two days before
it happens. My chief tells me to notify the family
but there was no one who cared, so I write it up.
A new patient sleeps in the dead patient’s old bed.
Just as soon as the morgue people leave
the nurse’s assistant changes the sheets and
mops the floors in bleach.
Doctors skip lunch. I do too
to put off the depression that smacks me
when I stop propelling patients from bed,
to diagnostic test, to operating room and
start propelling white bread and meat-mush
from esophagus to anus.
In continuation of the Medical Commencement Archive, this Friday we are releasing a new commencement speech. Today’s commencement speech is titled Preserving the Nobility of Medicine. This commencement speech was given by Dr. Robert J. Alpern, a Northwestern University alumnus, to the students of the Northwestern University Feinberg School of Medicine. The esteemed Dr. Alpern is Ensign Professor of Medicine and Dean at Yale University School of Medicine. He also is President of the American Society of Nephrology, as well as a sitting Advisory Council Member of the National Institute of Diabetes and Digestive and Kidney Diseases.
Dr. Alpern took a moment for students to take a closer look at the value and weight of the two-lettered title: MD. He reflected upon the unique status given to physicians, and the reverence given to doctors from the community and from patients. Yet, at the same time the medical paradigm continues to evolve. Dr. Alpern astutely foresees a future where physicians must adapt to the growing roles in the medical team, changes in bureaucracy, and the changing expectations of patient’s for their treatment. Dr. Alpern also notes that these changes will influence the training and education of physicians. On top of our own desire to stifle the monsoon current of medical information during our education, there are legitimate concerns that the future medical student will receive but an abbreviated biochemistry course, or won’t need to take an MCAT, maybe even spend less time in medical school. Yet, Dr. Alpern urges one thing: to value the pursuit of scholarship. He reminds us that only with a strong foundation may a strong physician be built.
“We observe the patient and draw on our scientific understanding of how the body works and sometimes does not work, to develop a truth that we can implement as an action plan. We must know clinical guidelines and the most up-to-date treatment algorithms, but we must also be ready to identify clinical circumstances in which they do not apply.”
Dr. Alpern eloquently explains that, above all else, the pursuit of knowledge and scholarship is indeed the nobility of medicine. He reminds us to respect this pursuit in lieu of the changes we will see in our futures as physicians, such that “we do not return to the era of trade schools of medicine”. Dr. Alpern further mentions that, in addition to being a scholar, the physician must be compassionate, and that neither trait is mutually exclusive:
“I also want to make the point that an emphasis on science is not the antithesis of compassion, but it is rather the complement of compassion”.
At the end of his speech, Dr. Alpern concludes with this piece of wisdom:
“Do not be intimidated by the evolving healthcare system. Rather, as the next generation of physicians, you will define healthcare, and you must define it well.”
The role of physicians and scientists within the legal system is ever expanding. Medical and scientific personnel are frequently called upon to analyze evidence in a wide variety of legal cases, ranging from worker’s compensation claims to felony trials. The expertise of physicians and scientists is often so valuable that the result of cases hinge on their professional opinions. While the importance of medical involvement in the legal field is implicit, certain ethical issues do arise. This is especially true when physicians are on retainer or are compensated by certain parties in a legal dispute. The importance and intricacies of medical involvement in the legal process has inspired curiosity in me. What is the history of the use of expert witnesses in common law? Where do scientific and medical expert witnesses fit into our legal code? Most importantly, how are these witnesses used in current court proceedings, and what are the prospects for the future?
The Origin of Expert Witnesses
The origin of expert witnesses is in England. According to English law, the first expert witness was used in a 1782 case involving the silting up of Wells Harbor in Norfolk. In that case, renowned civil engineer John Smeaton testified, signifying the first use of an expert witness’ opinion in common law. In the United States, expert witnesses were codified into US law in 1975, under the Federal Rule of Evidence (FRE) 702. The FREs represented general rules passed by congress governing how evidence is presented in both civil and criminal cases.
Scientific and medical witnesses have greatly helped to shape the rules governing expert witnesses. Prior to FRE 702, rules for admissibility of scientific evidence were established in Frye v. United States (1923). In Frye, the question at hand concerned whether scientific evidence in the form of a systolic blood pressure deception test was admissible in court. The Frye ruling indicated that such evidence was admissible as long as the test or theory was “generally accepted” among a meaningful portion of the scientific community. To prove that something was “generally accepted,” parties often put a number of scientific experts on the stand to verify certain tests or theories. This rule for establishing the admissibility of scientific evidence is colloquially known as the Frye Test.
After the adoption of the FREs in 1975, they, along with the Frye Test, remained the seminal rules governing scientific expert witnesses. However, in 1993 a new case would open those rules up to interpretation and eventual amendment. In Daubert v. Merrell Dow Pharmaceuticals (1993), two citizens born with birth defects sued Merrell Dow Pharmaceuticals claiming that Dow’s drug Bendectin caused their conditions. Both opposing parties relied upon scientific expert witnesses to prove their claims. A district court ruled that the testimony from the citizens’ expert was inadmissible because the evidence came from methodologies, such as in vitro and in vivo studies, that were not “generally accepted” at the time.
After the Ninth Circuit Court upheld this decision, the citizens’ took their claim to the Supreme Court. The citizens’ reasoned that the Frye Test was no longer the governing standard for admissibility of scientific evidence as soon as FRE 702 was passed. The court agreed, reasoning that, since FRE 702 made no mention of “general acceptance,” the Frye Test was not to be applied in discerning the validity of scientific evidence.
The implications of the Daubert ruling were significant in amending the rules for the admissibility of scientific evidence given by experts. No longer was evidence only judged on its “general acceptance” among the scientific community. Under Daubert, scientific evidence can be admissible if it is “relevant to the task at hand” and “rest(s) on a reliable foundation.” In determining what makes up a “reliable foundation,” conclusions made from evidence must be based on sound scientific methodology. Sound scientific methodology rests in using proper scientific method, including empirical testing of evidence, peer review, proper controls, and determination of potential error rates. In order to prevent the presentation of “pseudoscience,” judges are given the power to be the final arbiter of any submitted scientific evidence. These guidelines outlined in the Daubert ruling were eventually added as amendments to FRE 702.
Understanding the history of expert witnesses allows us to determine how science and medicine shaped one aspect of the US legal code. In the next part of this series, I will provide an overview of current medical and scientific involvement in court proceedings. I will examine not only common case-types in which physicians testify, but also case types in which physicians are directly involved in. Check back soon!
Dr. Krugman is a respected educator and leader in the medical field. Dr. Krugman received his bachelor’s degree from Princeton University, and earned his medical degree at New York University School of Medicine. He went on to complete his residency in Pediatrics at the University of Colorado School of Medicine. He currently serves as the Vice Chancellor for Health Affairs for the University of Colorado, Denver, where he oversees all five hospitals of the university in addition to providing support for deans and faculty. Among many esteemed positions, Dr. Krugman has served as a member of the Institute of Medicine and the board of University of Colorado Hospital. Dr. Krugman is internationally recognized as an authority on child abuse prevention.
Dr. Krugman begins his speech by discussing his desire to hold the title of spouse of the President of the United States.
“I have watched for years as each Presidential spouse came to the White House, starting with Jacqueline Kennedy, and each took as a cause some area of public policy that instantly got attention and, over the next four to eight years had billions of dollars appropriated toward resolving the issue.” He goes on to discuss his future endeavors.
With a humble nature, Dr. Krugman comments on the common nature of forgetting commencement speeches. He focuses his speech on what he believes will be the single most important piece of advice that the novel physicians ought to remember,
“it is probably easier to learn the facts and the technical skills you will need to practice medicine than it is to learn how to balance lives that are relentlessly crammed with the demands of your families and friends, your patients, your supervising residents and attending physicians, your students…”
Take some time to read Dr. Krugman’s recommendations for maintaining balance alongside a career in medicine.
I love the way your quadriceps twitch beneath the table,
awakening your patella
and asking your damaged collateral ligaments if they are feeling any stronger today.
And I love how the curvature of your corneas focuses light just before it reaches your retina,
weakening your long-distance sight
and giving me another excuse to come closer.
I love the thickened areas of stratum corneum on your palms,
summoned from layers below each time you reach for a wrench,
and how they grip onto my epidermis each time you reach for my hand.
I love the way you manipulate your vocal cords and adjust the curve of your tongue
to effortlessly transform the air in your lungs into the sweetest “Good morning,”
and how your right lateral incisor proudly stands just a slight bit forward from the rest of your smile,
and how the collection of melanocytic nevi on your skin connects to form a crescent moon,
or an elephant, or train tracks,
depending on how the neurons in my brain direct my imagination that day.
I love the way your closed fist is pressed against the angle of your mandible,
supporting your head and all the vessels that travel through the delicate tunnels within your neck
that converge as they greet the heart I loved from day one.
This week, Dr. Georgette A. Dent, Associate Dean for Student Affairs at the University of North Carolina School of Medicine joins the list of spectacular commencement speeches in the Medical Commencement Archive.
Dr. Dent is an esteemed educator, writer, and innovator in the medical field. She received her Bachelor’s of Sciences from Duke University where she graduated magna cum laude. Dr. Dent went on to earn her M.D. from Duke University School of Medicine, where she also completed her residency in Anatomic and Clinical Pathology. Dr. Dent completed a fellowship in Hematopathology at the University of North Carolina School of Medicine, where she now serves and inspires students as the Associate Dean for Student Affairs. Among Dr. Dent’s many accomplishments, she has served as a member of the AAMC Electronic Residency Application System Advisory Committee, the Liaison Committee on Medical Education (LCME), and the American Society of Hematology Committee on Promoting Diversity.
“Going forward, when you have an “on” weekend, it will not mean you have a Monday exam, it will mean that you are on call.”
“The Five C’s”, provides a succinct and intimate view of the UNC SOM Class of 2014. Dr. Dent encourages her students to go forward as physicians while staying true to their caring natures, abilities to connect with others, competence, character, and engagement with cutting edge technology. Read Dr. Dent’s 2014 Commencement Speech at the University of North Carolina School of Medicine.
Ten years ago, the idea of going to Walmart for a primary care check up would have seemed completely foreign. Walmart, as the largest American employer, previously seemed to limit itself when it came to health care. Currently, it is branching out into the discount drug industry, owning roughly 100 retail clinics and working in conjunction with a few large hospitals. Now it appears that they’re ready to branch out with more clinics. Since they already have a number of clinics, it begs the question: why are many major television networks and newspapers only now showing alarm over the idea of Walmart becoming a serious contender in the healthcare market? There are several reasons: first, the clinics that Walmart are now endorsing are completely owned by them. Furthermore, they are being branded as “one stop shops” for primary care. Second, the new clinics are run solely by nurse practitioners and are open longer and later than their competitors (such as, private practice physicians), thus launching a full front assault on the family medicine practitioner. Thirdly, due to the reach of the company, its potential as a disruptive innovator and giant in the industry is unparalleled. Experts are now saying that Walmart can single handedly change healthcare as we know it.
What does this mean for us as medical students, soon to be working in the medical field? It seems to me that the greatest thing that Walmart is offering customers is choice. Rather than simply offering healthcare at a lower cost, they are offering customers a simpler way of dealing with their health concerns. They also seem to be veering away from the procedural based medicine that physicians seem to practice currently. Instead, patients are allowed to buy doctor visits in bulk— thus the “retail” if you will. Though this inevitably means more competition for contenders, it may also prove useful. With cheaper, more readily accessible primary care, emergency rooms will be less full with repeat offenders. People who would greatly benefit from primary intervention (those suffering from diabetes, obesity and high cholesterol) –those who typically slip under the radar due to lack of insurance – could get covered for a cheap cost. Finally, extraneous hospital costs would be cut down, allowing patients a certain amount of control over insurance and their insurance provider. With Walmart entering the industry, other companies will be forced to offer more competitive and reasonable rates.
Who knows, Walmart might be the thing to make healthcare equitable in this country.
Dr. Abraham Verghese, critically acclaimed author and widely respected clinician, is now featured in the Medical Commencement Archive. Dr. Verghese’s commitment to medical humanities, teaching, and the art of medicine is one that students have the pleasure and honor of learning from through various platforms.
In his speech, Timelessness in the Ever-Changing Medical Field, Dr. Verghese calls upon the Stanford University School of Medicine graduates to find the connection between their technology-laden careers and the careers of their predecessors.
“I hope that sense of history will make you conscious that when you are there with the patient, you are also participating in a timeless ritual. Rituals, like this one today, with all its ceremony and tradition are about transformation, about crossing a threshold — indeed the ritual of our graduation ceremony is self-evident. When you examine a patient, if you think about it, it is also a timeless ritual, a crossing of a threshold.”
In his speech, Dr. Verghese discusses the graduation speech boycotts of 2014, patients from his past, memories of medical school examinations, and opinions about medical licensing techniques. Dr. Verghese currently serves as Vice Chair for the Theory and Practice of Medicine at Stanford University, among many other appointments. Ending his speech, Dr. Verghese leaves the graduates with words that resemble a blessing:
“May you celebrate the rituals of medicine, recognizing their importance to both you and the patient. May you find courage to face your own personal trials by learning from your patients’ courage. May you minister to your patients even as they minister to you. When there is nothing more medically you can do for patients, remember it is just the beginning of everything you can do for your patients; you can still give them the best of you, which is your presence at their bedside. You can heal even when you cannot cure by that simple human act of being at the bedside — your presence. May you discover as generations before you have, the great happiness and satisfaction inherent in the practice of medicine, despite everything”
Interested in reading about Dr. Verghese’s work with infectious diseases? Check out My Own Country which features stories of the rise of AIDs in rural Tennessee. Interested in reading about mental health and creating balance within the medical field? Check out The Tennis Partner which explores the drug addiction and familial struggles of medical professionals. Fancy yourself a great fiction read in medical drama? Take a look through Cutting for Stone.
Further, Dr. Verghese writes on a variety of other interesting topics through New York Times, Newsweek, and Washington Post articles. Expounding upon the importance of the patient-physician relationship, Dr. Verghese has had a number of talks and interviews including TED talks.
A trip through my apartment is a serious lesson in buyer’s remorse. My iPad? What I thought would be a useful note taking and studying tool is more of a $500 YouTube and Netflix consumption machine. My spiffy dual monitor setup that I thought would amp up my productivity? Most of the time I forget to plug in my other monitor and spend my computing sessions staring at my 13” MacBook screen. In fact, that exact situation is occurring right now as I write this. My fancy Bluetooth speaker that I thought would be useful for jamming out when I had friends over? I’ve used it a handful of times, lost the charging cable so the thing won’t even turn on, and have absolutely no desire or intention to either find or buy a new cable.
You may be asking yourself what the point of that rant was, and I don’t blame you. What unifies all those examples is that they are situations when I either purchased or was given a new tech toy that I thought would be life changing, but instead turned out to be unnecessary or obsolete. What I’ve learned from years of accumulating new technology is that while everything comes with copious advertising and monstrous hype, few devices actually deliver as promised.
The medical field is no stranger to this. Hospital administrators and clinical program directors are people too, and they enjoy new toys just as much as the rest of us. Hospitals and universities try to justify their actions by citing journal articles and claiming that having “X” item allows them to remain “on the leading edge of Y specialty.” Let’s be honest, no one is being fooled here. Those new collections of surgical mallets aren’t any better at impacting components than the ones made 20 years ago.
The American Congress of Obstetricians and Gynecologists, in a March 2013 statement issued by President James T. Breeden, denounced the use of robotic surgical systems.4 Dr. Breeden claims, “There is not good data proving that robotic hysterectomy is even as good as – let alone better – than existing, and far less costly, minimally invasive procedures.”4 This speech came after studies published by researchers at Columbia University cast doubts about the perceived advantages of robotic surgical systems.2
These two examples only represent a few of the many opinions divulged about the topic of robotic surgical systems. The literature is rife with both positive and negative opinions, and it is up to hospital administrators and faculty to gauge the worth of these systems.
Why do so many hospital centers have this technology?
Implementation of these robotic surgical systems has occurred in major surgical centers in the US, France, Italy, Germany, Spain and many other places. If the literature is conflicting on the efficacy of these systems, why is implementation so widespread? I believe the answer is marketing. Top medical centers have a need to “keep up with the Jones’.” If one renowned medical center acquires certain technology, all of the other medical centers instinctively implement that technology as well to avoid a perception of inferiority. There is also a marketing aspect in terms of patient recruitment, as new technology and the promises of a “superior” surgical experience may lure prospective patients away from competing hospital systems. Whether or not the added income from patient recruitment offsets the initial and recurring costs of these systems is, to my knowledge, yet unknown.
My conclusion on this topic is that these surgical systems are akin to my iPad. They are good in theory, but their cost and relative utility make them a bad investment at the moment. However, this is not to say that these systems will never find justifiable use. With new innovation these systems may find a niche that makes them both efficacious and profitable. Just as a new app may breathe more life into my iPad, new research and better training with the robotic surgical systems may lead to advancements that will justify their implementation.
References 1.http://www.intuitivesurgical.com/ 2.http://online.wsj.com/news/articles/SB10001424127887323764804578314182573530720 3.Bochner, B. H., Sjoberg, D. D., & Laudone, V. P. (2014). A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med, 371(4),389-390. 4.http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-Robotic-Surgery
