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To the Editor:
Dr. Herb Fred's insightful editorial “The Downside of Medical Progress: The Mourning of a Medical Dinosaur”1 highlights several important dangers of overemphasis on technology and the changed thought patterns of modern physicians in training and in practice. Dr. Fred's observations cannot be reduced to a mere myopic “in the old days we walked through 10 feet of snow to get to school” type of nostalgic sentimentalism. Rather, what is described is modern medicine's paradigm shift in the way it views patients, and its drift away from the human approach to the care of patients. Having finished medical school in 1984, I have seen only part of the change, whereas Dr. Fred has seen it all. Although it is generally true that at no previous time has medicine been more able to effectively treat and cure complex disease, it is also generally true that at no previous point has medicine been less respected by the population it serves. How can this be? I completely agree with Dr. Fred that there is a chasmal disconnection between the barrage of technology with which the “techno-doc” assaults his patients and the genuine hands-on touch and concern that the truly humane doctor has for his patients. This is not to view technology and authentic human concern as mutually exclusive; appropriate concern for our patients often mandates the use of technology. But what must not be forgotten is the obvious—simple kindness, a gentle touch, a caring word—how hard is it, really? Still, these simple attributes seem at times so elusive. The key, of course, is that the physician must be concerned for the patient as a human being.
On more than one occasion, each of us has seen patients who undergo a “million-dollar workup” via sophisticated radiology and other testing, followed by high-tech surgery, yet they have neglected wounds or decubitus ulcers that spiral out of control because of incompetent wound care and lack of concern. The simplest and most basic care would have sufficed to prevent huge problems in these patients, who would have received better care in the streets of Calcutta with the late Mother Teresa. Mother Teresa once described a man who died after she cleaned his wounds: “… There was the man we picked up from the drain, half-eaten by worms, and, after we had brought him to the home, he only said, ‘I have lived like an animal in the street, but I am going to die as an angel, loved and cared for’.”2 Surely, death in the loving arms of someone who really cares is far better than a cold, anonymous death in an ICU. Viewing the human being as a person with an eternal soul, rather than as an object of technology, is what makes the difference.
While the growing influence of ever-more-sophisticated technology makes the human side of medicine seem somewhat more distant, it is by no means unachievable, as long as the focus remains on the patient as a human being—not as an object on whom to try out new technologies in order to impress our colleagues. Far more damaging than technology per se is the corrosive effect on our profession from the general deterioration of social integrity, honesty, and morality over the past 4 decades. Just look at what has happened to the professions of law, politics, and business. Although we in our profession should be immune, we cannot be, completely. When we remain silent and look the other way at legalized atrocities inflicted upon the youngest, oldest, and most helpless of humanity—when we become callous to the inherent dignity of human life from conception until natural death—then we forfeit in some way, little by little, the soul of our profession. In the recesses of our hearts, we know it.
Furthermore, society's obsession with financial excess and getting a free ride—ranging from playing the lottery to filing spectacular lawsuits to entertainment careers for “American Idol” rejects—doesn't positively influence the attitudes of medical trainees and new program graduates. Some trainees maintain a distressing sense of entitlement regarding service, the feeling of being owed an education (and a luxury car) while avoiding hard work. I completely agree with Dr. Fred that the 2003 Accreditation Council for Graduate Medical Education work-hour limitations for residents “encourage laziness … disrupt continuity of patient care,” and “create extra work for an already-overworked teaching faculty who now must do what the ‘off-duty’ house officers should be doing.”1 Indeed, I write this tonight after having just gone back to the hospital to place a hemodialysis catheter in a patient whose potassium level was 6.7 mEq/dL. Line placement, it seems, is beyond the scope of practice and is beneath the dignity of the vascular fellow and the surgical resident. The procedure may have helped to save the patient's life, but it was not high-tech enough to be “educationally worthwhile.” How sad. At some point, doctors need to be just that: real doctors. And it doesn't get any easier after residency and fellowship. As a surgical resident in the 1980s at Harbor–UCLA, I loved to go down to the ER to admit nonsurgical patients who had cellulitis or deep-vein thrombosis and whom Medicine did not want to admit; the so-called “turfing” of patients was repulsive to me and was an anathema to my concept of being a real doctor. In fairness, of course, now as in every era, there are young physicians who attend to patients in exemplary fashion—physicians whom I would choose to treat members of my own family.
Modern medicine surely can treat disease better now than was possible 40 years ago. However, modern medicine must also care for the patient as well as it did 40 years ago. We must never forget that spark of inspiration that made us aspire to become physicians in the first place.