Dr Alvin Rajkomar was doing rounds with his team at the University of California,San Francisco Medical Center when he came upon a puzzling case: a frail,elderly patient with a dangerously low sodium level.
As a third-year resident in internal medicine,Dr Rajkomar was the senior member of the team,and the others looked to him for guidance. An infusion of saline was the answer,but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain swelling,seizures or even death.
Dr Rajkomar had been on call for 24 hours and was exhausted,but the clinical uncertainty was like a shot of adrenaline, he said. He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his iPhone.
With a tap on an app called MedCalc,he had enough answers within a minute to start the saline at precisely the right rate.
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The history of medicine is defined by advances born of bioscience. But never before has it been driven to this degree by digital technology.
The proliferation of gadgets,apps and Web-based information has given clinicians especially young ones like Dr Rajkomar (28) a black bag of new tools: new ways to diagnose symptoms and treat patients,to obtain and share information,to think about what it means to be a doctor or a patient.
And it has created something of a generational divide. Older doctors admire,even envy,their young colleagues ease with new technology. But they worry that the human connections that lie at the core of medical practice are at risk of being lost.
Dr Paul A Heineken (66),a primary care physician,is a revered figure at the San Francisco VA Medical Center. He is part of a generation that shared longstanding assumptions about the way medicine is practised: Physicians are the unambiguous source of medical knowledge; notes and orders are written in paper records while standing at the nurses station; and X-rays are film placed on light boxes and viewed over a radiologists shoulder.
One recent morning,while leading trainees through the hospitals wards,Dr. Heineken faced the delicate task of every teacher of medicine using the gravely ill to impart knowledge.
The team arrived at the room of a 90-year-old World War II veteran who was dying a ghost of a man,his face etched with pain,the veins in his neck protruding from the pressure of his failing heart.
Dr Heineken apologised for the intrusion,and the patient forced a smile. The doctor knelt at the bedside to perform the time-honoured tradition of percussing the heart. Do it like this, he said,placing his left hand over the mans heart,and tapping its middle finger with the middle finger of his right.
One by one,each trainee took a turn. An X-ray or echocardiogram would do the job more accurately. But Dr Heineken wanted the students to experience discovering an enlarged heart in a physical exam.
I tell them that their first reflex should be to look at the patient,not the computer, Dr Heineken said. And he tells the team to return to each patients bedside at days end. I say,’Dont go to a computer; go back to the room,sit down and listen to them. And dont look like youre in a hurry.
One reason for this,Dr Heineken said,is to adjust treatment recommendations based on the patients own priorities. Any difficult clinical decision is made easier after discussing it with the patient, he said.
It is not that he opposes digital technology; Dr Heineken has been using the Department of Veterans Affairs computerised patient record system since it was introduced 15 years ago. Still,his cellphone is an old flip model,and his experience with text messaging is limited.
Thirty-eight years and a technological revolution separate Dr Heineken from Dr Rajkomar.
In 2009,Dr Rajkomar was in his third year of medical school at Columbia. He was among the first in the hospital to use an iPhone as a clinical tool. Every time you looked something up youd get scolded, he said. At that point,people believed that if you had your phone out you werent working.
Along with MedCalc,the clinical calculator,Dr Rajkomars phone has ePocrates,an app for looking up drug dosages and interactions; and Qx Calculate,which he uses to create risk profiles for his patients. His favorite technology is his electronic stethoscope,which amplifies heart sounds while cancelling out ambient noise.
Not that he is indiscriminate in his use of technology. When he decided the electronic health record was taking too long to load on his iPad,he went back to taking notes by hand,on paper. But he is experimenting with writing by hand on a Samsung mini-tablet.
He is aware of the pitfalls of computerized records,particularly the if the problem is X,then do Y templates,which encourage a cut-and-paste approach to daily progress notes. While efficient,they can give rise to robotic bookkeeping without regard to how the patient is faring.
As the conversation with the patient goes,so goes Dr Rajkomars interaction with the computer. Lab results? On the screen in a flash. A list of past and current medications? Voilà!
He knows when the computer needs to be set aside. When a patient confided that his wife was taking his pain medication,Dr Rajkomar excused himself and walked down the hall to consult with the pharmacist about a plan to keep that from happening.
Dr Rajkomar knows he has a great deal to learn about being a physician,especially patients social and psychological complexities.
One patient fired me, he said,smiling as he added,Dr Heineken gets those patients.
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