I am no Luddite. Like most of the younger physicians today, I grew up with computers. My father had one of those suitcase-nuke Osbornes and I am old enough to remember how cool we thought the Commodore 64 was, what with its sweet cassette tape drive and way cool BASIC instruction set that let you GOTO all kinds of programming bliss. In the now-distant 1980s I was a Computer Science major and did pretty well in those classes even if I failed everything else and ended up being kicked out of the University of Vermont for bad grades. I have written a FORTRAN 77 program on punch cards and even wrote an assembler (a program that converts assembly language into the CPU’s binary instruction set) for the ancient PDP-11. I remember well the DEC VAX, the first version of windows (I preferred DOS until Windows 3.1 which finally closed the gap with Apple for a graphical user interface), and my first real computer was an IBM PS-2 with a giant 5 MB hard drive. I’ve used all the major software; WORD, Excel, and Powerpoint as well as sophisticated structural analysis programs like RISA and STRUDL, not to mention at one time being something of an expert at AutoCAD. My medical school was completely wired and all of the lectures and notes were on line. In fact, mine was the first class were the administration realized that there was no need to have a “This is a Computer, This is an Icon” orientation as everybody in the class had also been raised with computers. On top of that, we use tablets with the T-system at one of our hospitals and I have adjusted to it effortlessly as have most of my colleagues.
I therefore take umbrage to the conventional wisdom that doctors are not technologically adept. I was thinking about this the other day as I manipulated the ultrasound probe to get a better look at my patient’s aorta. It’s not that we’re not adept, it’s that we like to see a return for investment and are well beyond the reflexive, “Golly Gee Whiz” reaction when confronted with something new. We just want the motherfucker to work and by work we mean to simplify our day, not make it more complex. Take for example the typical hospital computer system which is usually an ancient relic from the 1970s, still running on some baroque IBM mainframe and to which has been grafted a modern-looking “front end” to give the illusion that we are, in fact, cooking with future gas. It can’t communicate with any other system, it’s slow, and it can only retrieve a limited amount of information, usually lab values and some dictated notes. Forgive our lack of enthusiasm but there is nothing to get excited about here.
In other words, we are in the doctor business, not the computer business. I don’t really want to learn anything about the equipment except how to get what I need out of it. I don’t trouble-shoot faulty hardware or kludgey software. If the problem can’t be solved by re-booting then I’m done. It’s time to call technical support and let them handle it as that is their business.
Or consider writing notes. Leaving aside issues of legibility and access to your notes by some nebulous doctor in the unforeseeable future, until very recently it was just much easier to open the paper chart and write a note or dictate than it was to find a computer, log in, locate the patient, check this box, click that one, and type the same note, especially on the hospital’s chimera of a system. This is all changing, of course. Windows-based and internet accessible Electronic Medical Records are much easier to use now and very fast but, as the requirement to document for billing and not for medical decision making is driving the EMR business, most of the notes you produce are automatic boilerplate and, except that we must kill what we eat, if it wasn’t for the billing requirement it would still be easier to hand write a quick note on most patients, the important information about which can usually fit on one side of an index card.
I use email and I of course have a blog. I am accessible but for the record I do not routinely carry my cell phone (I have it perpetually charging in my car for the once or twice a week when I use it) and have only a vague idea what a “ringtone” is and if it’s what I think it is, cannot believe that anybody pays money for them. I do not “text message” either and I will ignore anything on my phone written in “Cutesy.” I have a pager and believe me, that’s enough. More than enough. If someone needs to get a hold of me they can and other than that, I guess I just don’t have a lot to say.
On the other hand in our new twenty-acre Emergency Department they have us carry “in house” cell phones and I love these…but only because I can page an admitting physician, for example, and pick up the call anywhere. See? Technology making our job easier and more efficient. (Now that the charts are on the tablets I can also talk intelligently about any patient on the phone from anywhere in the department.)
My point? Nothing, really, except that I am Best Buy’s worst nightmare. I don’t own much in the way of personal electronics, I don’t really listen to that much music, and despite my cell phone having hundreds of features, all I really need is to dial a number every now and then and do not need to be in constant communication with everyone I know all the time. I know how to use all the stuff, I just don’t want to.
Except…I just bought my wife an MP3 player, thirty bucks, one GB of memory, and I’m hooked. I remember when the Sony Walkman first came out and while I eventually bought one, this thing is nothing like that. Keep in mind that most popular music is crap. Utter crap. Filler, compost really, for the one or two good songs on an album (do you kids still call them albums?). Even with the Walkman which I assure you was revolutionary for its time, you still had to buy tapes that were mostly crap to get to the one or two songs that were worth listening to. Come on now. Admit it. Very few artists and bands are consistently good. Maybe the Rolling Stones and the Talking Heads but U2? Madonna? Get real.
Now, on an intellectual level I have known for a long time that you can pick whatever tracks you want to download onto your MP3 player. I just didn’t realize the power of this until I started downloading the songs my wife wanted. She’s into the Latin sound, J-Lo, Enrique Inglesias, Santana’s “Smooth” and the like. I was skipping around her playlist, just sort of checking to make sure everything was there and I realized that every single song, while maybe not exactly my thing, is good. A winner. Worth listening to. (Say what you like about Ricky Martin, that vato can jam.)
Finally, we have been liberated from crap.
Complementary and Alternative Medicine
Maybe I haven’t been clear about the subject of Complementary and Alternative Medicine. Or maybe my articles, as has been suggested by some of my critics, are too long and the reader’s lips and brains are tired by the time they get done with them. Let me summarize:
1. CAM is mostly an expensive, carefully constructed placebo. The major academic centers that sell it to the gullible admit as much but flog it anyways using “well-being” and other nebulous concepts as an alibi (do you really think anybody at the Duke Center for Integrative Medicine with a medical degree, for example, really believes that some yahoo can shoot spiritual fire out of his appendages?). While I rise in support of having a good attitude and a positive outlook, the real medical effects of placebos are terrifically over-rated. You can feel as good as you want about your pancreatic cancer, for example, but it’s going to kill you or not pretty much on its own schedule. The microscopic advantage you may glean by believing that spiritual fire is flowing into your body is nice to have, certainly harmless if not your sole treatment, but not worth the ridiculous expense of having a shaman on the payroll.
2. In other words, even in the real world of medicine, a lot of our therapies and interventions are marginally effective at best and there has to be some consideration of cost versus effect. The effect of most CAM is not even close to being worth the cost as it is mostly entertainment and not medicine. Just because the patients want it doesn’t mean we have to give it them, except of course as part of a customer-satisfaction driven business model which is great…but not on my dime.
3. The CAM that is not pure bunk, some aspects of naturopathy, for example, that use medicinal properties of botanicals and other substances as therapies are unnecessarily complicated, unsafe, and based on a shoddy philosophical basis that makes no sense. “The Healing Power of Nature” is an insipid marketing phrase. “The Vicious Automatic Killing Default Position of Nature” is more apropos as it realistically describes what anybody who has ever watched even a few minutes of the Discovery Channel could tell you. Naturopathy and many of the other bambicentric CAM modalities are political statements, not medicine, and while they may accurately reflect the world-view of their purveyors, are less than optimal therapies in a world that is indifferent to your nature fantasies.
4. In other words, there is no “Mother Nature” or “Planet Earth” who cares about the difference between a quality-controlled dose of digoxin produced by an evil pharmaceutical company or a cup of oleander tea steeped in the hand-made clay urn of a nature-loving hippy. Now, in our Godless and tradition-rejecting society, I can understand the panic that many feel when they look into the void and see nothing. But if you’re going to reject religion, then reject it and grow some gonads. It makes no sense to eschew the irrelevant religious beliefs of your parents but then, without a pause, to eagerly latch on to some hodge-podge of Earth Worship and Eastern Mysticism except that these things don’t require the self-discipline of traditional religions and therefore give you a purpose for life on the cheap.
5. Which is to say that except as it can inform moral decisions, religion has no place in medicine. My priest offers the last rites to our parishioners but he wouldn’t think of recommending ventilator settings. It’s not his job and I wouldn’t dream of asking him. Complementary and Alternative Medicine is a shoddy, cut-rate religion preoccupied with individual ego and, as it doesn’t even offer any moral guidance (except the commandment to recycle) it has even less of a place in medicine than traditional religion. A priest from my old parish often joked that his vestments make him look like Mandrake the Magician. If Reiki healers, homeopaths, acupuncturists, and the like just dressed the part and billed themselves as chaplains I’d be a lot more accepting. I respect everyone’s right to worship or not worship how they please.
6. While it’s true that “Science Doesn’t Know Everything” and even that many things that were once considered preposterous are now generally accepted as true, if you bothered to notice the movement in science is away from mysticism. Science is moving away, not towards, the grand unifying theory that will prove acupuncture, homeopathy, and any other CAM modality devised at a time when science was in its infancy. For most of human history there really was no science as we know it today but only the venerated received wisdom of the ancients, itself based on a faulty view of the natural world. A lot of what was believed to be preposterous was only considered to be because it flew in the face of this received wisdom.
7. A person who believes in homeopathy, Reiki, and the like…I mean really believes and not just keeps his mouth shut because he’s too afraid that his ignorant peers will accuse him of being close-minded….really has no business in the medical profession and should voluntarily surrender their license. Obviously all that medical school was a waste and didn’t really take.
8. On that note, it is possible to be so open-minded that you enter a sort of Twilight Zone, a strange place where the ordinary laws of physics and reason don’t apply and you must contort your mind into impossible positions to accept many strange and often contradictory beliefs. Being open-minded to that extent is no virtue but merely a glorification of chicken-hearted indecisiveness.