Don't let 'iPatient' detract from hands-on medicine, Stanford author/educator urges

STANFORD, Calif. - On his first day as attending physician at Stanford, Abraham Verghese, MD, suggested to the ward team that they leave the "bunker" and head out to their patients' bedsides.

"They probably felt that everything I would need to get up to speed on our patients - the necessary images, the laboratory results - was right there in the team room," Verghese wrote in an essay in the Dec. 25 issue of the New England Journal of Medicine. "From my perspective, the most crucial element wasn't."

Verghese makes it quite clear in his journal article: the "chart-as-surrogate-for-the-patient" approach to medical care is no replacement for the skilled, hands-on physical exam. The advent of computerized medical records and easy availability of diagnostic tests has led to physicians getting to meet the "iPatient" - the virtual construct of a patient based on all the lab tests and imaging - even before they meet the real live human version waiting nearby in a hospital bed.

Speaking about this virtual entity, he writes, "The iPatient's blood counts and emanations are tracked and trended like a Dow Jones Index…. The real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer."

Describing his article as a reflective essay and a "manifesto for what we are trying to do here," Verghese writes about the new push at Stanford to emphasize and improve bedside examination skills in students and residents in internal medicine, and calls for a similar national effort at all medical schools.

Long a champion of hands-on medicine, Verghese, a best-selling author, arrived at the Stanford University School of Medicine in December 2007 to serve as professor of medicine and senior associate chair for a new program in the theory and practice of medicine. Board-certified in three specialties - internal medicine, pulmonary diseases and infectious diseases - he is widely published in scientific literature and is also a bestselling author. His next book, the novel Cutting for Stone, is due out this month.

In his article, Verghese describes a dialectic tension between the two approaches to patient care. In the first, the traditional or old-school method, the patient's body tells the story. The doctor works as "bedside-sleuth" using inspection and palpitation along with the help of technology to determine a treatment course. Well-trained in the use of tuning forks, stethoscopes and knee hammers, he or she can detect disease in the appearance, in the gait, in a pulse, well before the relevant test might even be ordered.

"I truly believe that good bedside skills make residents more efficient," Verghese wrote. Doctors who rely on hands-on skills tend to order tests more judiciously, reducing the number of unnecessary and expensive trips to the radiology department, he said.

"In a health care system in which our menu has no prices, we can order filet mignon at every meal," Verghese warned.

The hands-on approach also inspires patient confidence in physicians - a difficult-to-measure commodity that many health-care advocates warn has long been in decline. "There's a reason people seek out alternative medicine in droves," Verghese said in an interview. "Those people put hands on a patient."

The growing trend toward the second method - one that focuses on the "iPatient" - parallels the recent explosion in medical technology, Verghese wrote. While not formally taught, "residents seem to have learned it no matter where in the United States they trained."

It's a simple case of putting the cart before the horse.

Today's doctors spend an "astonishing among of time in front of the monitor" charting in the electronic medical record, moving patients through the system, examining tests results. And medical students learn through example. "In short, bedside skills have plummeted in inverse proportion to the available technology," he wrote.

But Verghese doesn't blame technology for this trend. Instead, he turns his attention toward medical education and educators like himself. "How did we reach this state of affairs?" he wrote. "The fault is ours as teachers of medicine."

Today's routine graduation of medical students without serious testing of physical exam skills is akin to licensing pilots without "ever having been in the air with a seasoned examiner," he wrote. "The public would be scandalized."

Verghese suggested U.S. medical schools "might take a lesson from Canada," where physicians are required to pass bedside examination skills tests. And he emphasized the importance of role-modeling by teachers.

At Stanford, the internal medicine department has instituted regular bedside rounds and faculty-development sessions showcasing good bedside technique as a step in that direction, he wrote.

"What is tragic about tending to the iPatient," Verghese wrote, "is that it can't begin to compare with the joy, excitement, intellectual pleasure, pride, disappointment, and lessons in humility that trainees might experience by learning from the real patient's body examined at the bedside."



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