Just Google it: Wrestling with a new breed of Internet-savvy patients
Just Google it: Wrestling with a new breed of Internet-savvy patients
The Hospital of Silicon Valley. They weren’t kidding. He’s looking down at his notepad and I’m thinking, ‘Holy balls, he has another question.’ We have been through his history of present illness on his laptop, which included serial photos of the rash on his butt and testicles on days one, five, six and 10. This is the 14th nerd I have seen this week and the most inquisitive and compulsive.
I am no longer insulted by inappropriate questions; the more unseemly the inquiry, the more I tend to freestyle the answers.“What kind of surgical instruments are used to remove my gallbladder?” he asked.“Sterile ones. Many. Tens, hundreds. Good ones, too. Strong ones. Oiy,” I said.“What kind of anesthesia do I receive?”“Propofol.”“What is propofol?”“Anesthesia.”“But seriously what other kinds are used?”“The kind that make you sleepy, forgetful. Some make you dopey, high as a kite, fly like a bird, downright dumb. Frog on a stick. You’ll be trippin’, but no reason to be trippin’ about it now.”He writes down all of my answers. I am in a conflicted position — a dilemma of great proportions — because after asking for educated, prompt, adherent patients during residency and fellowship, I now have them. I stand horrified like facing my own portrait in “The Picture of Dorian Gray.” The lowest point being the day that I said medical therapy for his condition had a success rate of 85 percent in most studies and he looked down at his computer screen and said, “That’s correct.” What is this, attending rounds?I have explained ad nauseum the Krebs cycle, penicillin binding proteins, Bayes’ theorem, pre- and post-test probabilities and the 80s TV drama L.A. Law. He has countered with the coefficient of friction, Jack Welch and Sixth Sigma, Toyota’s Lean Product Development and Moore’s Law. We reach a détente and agree to be more transparent in an effort to increase transparency since the public desires more transparency.What I call these patients is “July the firsts.” They are third year medical students and no more. They’ve read a lot of books, passed USMLE part I, maybe done a few perfunctory histories and physicals, but it is July the first of their third year and they’re still clueless. You see, they’ve never taken care of patients, which you cannot learn by reading, by computer, by simulation. Quite frankly, they couldn’t make the JV squad. The most dangerous patient (and the worst outcome) is the one who tries to manage his own care — a third year medical student left alone with a whole service, without a senior resident or attending.You need to witness people get better despite your best efforts, watch them die when you thought you were helping, and walk next to those who teeter somewhere in between for weeks, sometimes months, years. You need to pronounce someone dead, sign your first death certificate and then the 40th. You run so many codes in the middle of the night that you are doing them at the foot of the bed with a cup of coffee in your hand. You need to see so many patients during residency that when you walk into the room at six in the morning, you look at the intern and whisper, “Is this the lady who had the heart transplant and a stroke or the one who had a kidney transplant and an MI?” You need to deliver more than 400 babies your intern year and realize, ‘Wait a minute; all these babies look the same.’`The number of questions seems inversely proportional to the severity and verity of their illness. The ones in intensive care speaking through a non-rebreather ask one question: “Am I going to die?” To which I say, “No.”The healthy ones, the worried well, ask so many questions that I get dyspareunia of the forebrain, vaginismus of the temples. A headache.My new policy regarding questions is that each patient is allowed a generous four. Any questions beyond that and they must wrestle me for it. At weigh-in I am sizing him up. Is he getting on the scale naked or in his jock? Does he look like he stays on his feet or on the mat? Is he combative like Dan Gable or a wily fish? Does he have two state champion older brothers who beat on him regularly for years and now he’s mean as nails?For a female patient, I have to call a female physician.“Do you want the doctor interrupted?” the assistant says.“Do I want her interrupted? What kind of question is that? Yes, I want her interrupted. I need her to wrestle someone,” I say.“To what?”“Interrupt her, please.”I am not alone in my apprehension of knowledge without experience, the evils of computers. In 2008 the Wall Street Journal ran an obituary, written by Stephen Miller, on MIT computer science professor Joseph Weizenbaum. In 1966, Weizenbaum authored a computer program called Eliza that simulated a psychiatrist so well (with open-ended questions) that the test subjects reported the program empathized with their problems. He then became fearful of the computer’s potential dangers after growing up in Nazi Germany, having been expelled from high school for being Jewish. “How long will it be before what counts as fact is determined by the system, before all other knowledge, all memory, is simply declared illegitimate?” he wrote in his 1976 book “Computer Power and Human Reason.”As an MIT faculty member since 1963, he eventually soured on computers and criticized automated decision-making as antihuman, referring to it as “a solution looking for a problem.” Most working clinicians share that sentiment with rolling eyes whenever a journal article includes a diagram of a labyrinthine and useless treatment algorithm.A colleague at the University of Pittsburg, Bruce Buchanan, who debated Weizenbaum in the 1970s on artificial intelligence (a field he eventually abandoned), said, “He was deeply troubled by the fact that it was easy for people to mistake such simple pattern matching for true understanding.”It is this latter statement that nails down how I cringe whenever a patient says, “I looked it up on the Internet.” Alas, my medical degree, internship, residency and fellowship, all earned in one casual evening like Cliffs Notes.And it is the Internet that failed to move Weizenbaum when he told the New York Times in 1999 that, “The Internet is like one of those garbage dumps outside of Bombay. There are people, most unfortunately, crawling all over it, and maybe they find a bit of aluminum, or perhaps something they can sell. But mainly it’s garbage.” In 2009, the Internet has finally reached its full potential as simply a television for video clips and pornography.But my stereotypes die fast. The consultation after this one only takes 40 minutes instead of 80. This software engineer asks me just one question. I crouch ready to wrestle, and he looks down at his watch and says, “If we are done, I need to go. I have things to do. Where is the lab for the blood tests you wanted?”That’s more like it.Dr. Daniel Shin is an infectious diseases specialist. He is a clinical professor of medicine at UC San Francisco and is in private practice in Mountain View.
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