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Editorial SEPTEMBER
2009
Reflections Versus Reaction
Anita L. Nelson, MD
It has been said that the largest living organism on the face of the earth
is the aspen tree, because each individual tree is linked to its neighbors
through an elaborate root system that literally extends for acres and acres.
But the aspen’s dominance may be superseded by Homo sapiens, if we
allow electronic interconnections to count as uniting individuals. How
many times have you been interrupted in the midst of a patient encounter
by her cell phone ringing? How many people at the last meeting you attended
were actually sending messages to someone who had no connection to the
meeting?
The immediate availability of information has certainly transformed many
aspects of the practice of medicine. Clinicians can rapidly learn about rare
disease states, double-check medication doses, and update themselves on new
developments in specific areas of interest. Patients can also check us out
in greater detail than ever before. They can read up on concerns they have,
tests we may (or may not) have recommended, and therapies they believe would
be beneficial. We have all experienced an unwelcome “second opinion” a
patient has treated herself to at a nonscientific Web site.
There is such an urgency about text messages. Although historically a ringing
telephone demanded an immediate answer much more powerfully than a letter
ever did, text messages are even more irresistible because they are more
private. The average American teenager has 8 electronic devices in her bedroom.
Parents report that their children are sending hundreds and hundreds of messages
each month to maintain their connections to their group. That’s a full-time
job that doesn’t leave much time for more individual activities, such
as old-fashioned homework.
But there are some other very subtle, yet profound, changes
that have occurred as a result of having such a rich smorgasbord of information
at our fingertips, upon which we can feast seemingly without limit. One of
the most
fundamental impacts has been on how we learn. Medical student textbooks are
on the endangered species list. If today’s students buy a text at all,
it is a booklet full of questions and answers to prepare them for exams.
Rarely are journals read cover to cover. Instead, if you have a patient with
a specific problem, you type a query in your search engine and scan for recent
articles, or you open up your favorite electronic experts (eg, UpToDate,
MD Consult, Epocrates) to see what they have to say. If one of the reputable
sites is consulted, the answers provided there are likely to include more
current developments in the field than do textbooks.
So what have we lost when we switched to a new medium? Context. A unifying
hypothesis. A sense of history. A shared paradigm. And, ultimately, humility,
particularly about the limitations of our knowledge. If there is now a new
answer to an old question, how do we judge the new answer? There is a new,
healthy skepticism about abrupt changes in practice protocols, particularly
in the wake of our recent experiences with postmenopausal hormone therapy
(now devilified for use in our recently menopausal women), and extended use
of DMPA (forget about short-term reversible bone loss). But what tools do
we have to cope with the skepticism?
We embrace evidence-based medicine, but the majority of those analyses conclude
that there is insufficient evidence to support a conclusion.
Perhaps a narrow-band approach to medical knowledge is necessary to implement
more uniform medical practice. In a setting in which outside authorities
provide practice guidelines for the clinician to follow, it could be argued
that the clinician does not need to know more than how to apply the guidelines.
It is hoped that this approach will substantially reduce costs. However,
it is inevitable that situations will arise that do not fit neatly into those
guidelines, and we practitioners will be told to use our “clinical
judgment.” Unfortunately, clinical judgment requires an understanding
of the “bigger picture,” which is not being cultivated with the
question/answer approach to the practice of medicine. And, of course, progress
is not made by repeating what we usually do.
In a larger context, we see that with the rapid availability of information,
the hope of a more educated population may be realized, but very clearly
in this new world, information is being fragmented almost along ideological
lines. There is no Life magazine or Reader’s Digest to bring us together
as a people. Instead, we have great fragmentation, even internally. You can
see it in the CNN and Fox News broadcasts. Totally different spins are presented
as news in their 2 different reports. Hardly anyone watches both to get a
balanced view.
Similar trends can be seen
in medical information as we
see a wide range of Web sites dedicated to “natural” therapies
freely making claims without any basis in science. In contrast, official
Web sites such as ACOG’s or AMA’s strain to give “fair
balance,” which is frequently not appreciated or understood by those
who believe the unsupported claims on “natural” Web sites.
This is the price we pay for freedom of speech. My fear is that these changes
in the way we learn and the way we communicate are happening without much
reflection by those of us who use the newer technologies. For just a
minute or 2, we might want to turn off the texting, set down the BlackBerry,
and think quietly about these issues—all by ourselves.
As a postscript, it has now
been confirmed that Homo
sapiens have finally surpassed termites as the species with the greatest
biomass on the planet. Our footprints are potentially earth-shattering.
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Anita L. Nelson, MD, Editorial Board |
