I may sound like a nostalgic grandparent that simultaneously brags about the “good old days” and complains about “having to hike uphill both ways” in driving snow to get to school.  Technology is a wonderful thing in many aspects of our lives.  We have endless supplies of information at our finger tips, we can talk to speakers and have them order toilet paper for us, we can power our houses with solar shingles, and most importantly we can check the nanny camera to spy on our dog when we are at work.  There are also negatives to technology because humans are inherently lazy due to our evolutionary wiring to save energy and resources.  To our primitive brain “lazy” means nothing more than efficient because calories and seconds saved on a task can keep us from starving to death or help us escape that saber tooth tiger in the primitive world.

Last time you took your modern vehicle in for a repair the mechanic likely opened the hood, plugged in a computer, the computer spit out a code, the mechanic entered a code on the computer, the computer spit out what part is faulty, the mechanic looks up part in computer, the mechanic installs part, happy day.  Let’s step back to the “good old days” when cars had carburetors and didn’t look like a big plastic barrier warning us to not explore the inner workings.  Prior to the magical computer the mechanic would take your car for a drive and you would point out the magic noise, shimmy, shake or wiggle that necessitated their expertise.  The mechanic would need to rely on past experience and critical thinking to formulate a list of possible culprits for the problem.  Then the mechanic would take the list of possible problems and examine those areas to check for signs of wear or damage.  Inspection of those areas may reveal problems near the symptomatic area that may not be producing noticeable changes in the functionality of the vehicle but likely will cause problems in the near future.  After repair the mechanic can go for a post-repair test drive and compare the function of the vehicle to the pre-test drive to conclude that the work is satisfactory and fixed the problem.

Let’s compare the modern mechanic to the modern physician.  Let’s say you go to your doctor with lower back pain with no known trauma it just hurts after you do some yard work or make your occasional trips to the gym.  You also have some knee pain that flares up at the same times as the back.  You sit down in the doctor’s waiting room for your 9am appointment and kill time on your phone until 9:45am when the nurse brings you back and takes your vitals.  You sit in an exam room until 10:10am and your doctor rushes in obviously behind and stressed.  You discuss that your back and knee hurt and the doctor said that they only have time to address one problem today and the other one will wait until you make another appointment.  You decide your back is the most important.  Your doctor asks you some quick questions about how long it has been there and if you can remember any trauma.  You bend down to try to touch your toes and it feels tight.  Your doctor replies that it’s probably just a strain because you’ve gained 20 pounds since last year and that’s probably why your knee hurts too…..fatty.  Just to be safe your doctor orders x-rays and writes a prescription for a muscle relaxer and anti inflammatory and tells you to rest for a few weeks and lay low.  You go and get the x-rays done and 5 days later a nurse calls to tell you that you have arthritis in your back but everything else is normal.   No follow up is scheduled because the arthritis is probably from you just being fat.  Now you have it in your head that you’ll always have arthritis so your back is always going to hurt.  You’re also afraid to move.  If you were told to rest for a few weeks for a strain then for something that won’t go away you should cancel your gym membership because moving it has to be dangerous for the brittle arthritis in your back.  Let’s say you aren’t satisfied and you make a followup a few months later with your doctor.  The doctor consults your chart and reviews the x-rays and wants to order an MRI on your low back because the magic pills and x-ray beams didn’t help resolve it.  You wait for insurance to approve your MRI and when you go in to review your results with your doctor they sit down to tell you that you have 2 herniated discs and that must be why the pain hasn’t gone away.  You leave with a referral to a neurosurgeon because shit is getting real now.  After watching 15 back surgeries on YouTube you get super freaked out and scared and start asking your friends who you know have gotten back surgery if this is the same kind of thing they went through.  Most of them said the kind of pain you were having is nothing like theirs.  Yours didn’t go down the legs at all and felt worse with activity.  Theirs went down the legs and kept them awake all night and wasn’t resolved with heavy duty narcotic medications.

I hope that you can see the parallels between the diagnostic computer used by the mechanic and the MRI and x-ray used by the doctor.  Instead of slowing down and using the diagnostic skills that we were taught we get sloppy and lazy and just default to plugging the computer into the car or ordering an MRI on a patient.  Physicians before they were rushed to the point of having to wear feeding tubes and catheterizing themselves had time to sit across from you and inquire about your family, shoot the bull for a few minutes and get down to taking a history about why you are in for your visit.  With that extra time they were able to do an in depth physical exam to get to the bottom of the problem and determine if any additional testing needed to be done like lab work or imaging (instead of jumping straight for it).  After the exam they would review the findings, render your diagnosis, set up the plan of care and ask if you had any questions.

I’m not saying doctors used to be good people and now they are evil.  Most are victim of a flawed system that obligates them to double book and rush all day limiting the quality and quantity of time they can spend with their patients.  I think the majority of doctors inherently want to do the right thing for their patients and care for their well being.  The system is spilling more patients over into specialists and imaging centers without proper exams to substantiate those referrals.

Like a foreign language if you stop using it you forget it.  If doctors get out of the habit of physically examining their patients and taking a good history their skills get rusty.  These skills are the art of medicine.  These skills are what make us doctors rather than technicians reading test results. Nobody is going to pat you on the back for how many MRI’s you ordered or how many narcotics prescriptions you wrote out.  If a doctor can tell the patient what their problem is with confidence based on his/her history and exam he/she is the damned Wizard of Oz.

Cars technology will continue to improve so the mechanic’s art is probably lost except those that wrench on old motorcycles or rebuild hot rods on weekends.  Doctors can still save the art of medicine because they aren’t working on Teslas, they are working on the same human beings that the older “exam and history” doctors worked with.  Doctors can strategically use this great technology to their advantage in medicine but it shouldn’t be the first recommendation due to lack of time or lack of confidence in diagnostic skills.

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