Michael D. Lockshin, MD

So, two things in The New York Times set me off this week. (Actually three. The third was an article about people who start their sentences with the word “so”, but I don’t want to go there.)

The first thing that set me off was an article about a hospitalist (by Jane Gross, May 26, 2010). A hospitalist is a new breed of doctors who work full time taking care of hospitalized patients, a role we used to assign to interns. Hospitalists are the doctors of record for all in-patients. No longer is the primary or specialist physician who sends the patient for admission in charge. The hospitalist is. The hospitalist idea is not very new. For several decades the patient’s physician has ceded responsibility to the intensivist in the coronary care or intensive care or post operative care units, special circumstances that required a certain technological skill in care. Now this ceding of responsibility has grown; it now covers all hospital care.

There are two reasons for the change: one is to improve hospital efficiency (translation: prevent delays in discharge because tests were not done on time, not for the patient’s convenience but to avoid hospital days for which insurers will not pay); the other is to provide more classroom-type teaching time to interns and residents. This pedagogical goal is ordered by the accrediting commission for training; the apprenticeship model is no longer thought valid; the pedagogical goal has nothing to do with patient care.

The goals of having hospitalists are admirable, the practice less so. What one sees in this transition time, as doctors are adjusting to the new rules, is the insensitivity of some hospitalists to long-term goals for patients with chronic illness, an inpatient’s sense that no one physician, including his or her personal physician, is in control, and—from the patient’s point-of-view—a different set of inefficiencies.

An example: a patient I saw this week, at the end of a three-week hospitalization for a very confusing and severe complication of her chronic illness, still disabled and with visiting nurse service planned, was discharged by the hospitalist with instructions to follow up with…a dermatologist, urologist, gynecologist, hematologist, and rheumatologist. The point is that a single physician, whom she knew before, could handle all the concerns. There was no need to make five follow-up visits when one would do. Efficient, yes—to coordinate multispecialty care in the hospital—but not for the patient’s life outside, when the multiple issues had already been resolved. And, yes, while the rapid and multiple consultation process did save money in the hospital (because of its rapidity, but one can argue that most of the in-hospital consultations were unnecessary), the hospitalist’s discharge plan would waste both money and the patient’s energy if the whole package of outpatient and inpatient care is considered together.

So, on to point number two.

In an article in the May 30, 2010, Business Section, by Milt Freudenheim, a Dr. Oscar W. Boultinghouse, speaking of the marvels of telemedicine, says, “In today’s world, the physical exam plays less and less of a role. We live in the age of imaging.” That comment earns from me a disrespectful, “Hunh?” or an ironic “Right!” Tell the young lady now on our hospital floor, who has lost several fingers to blocked blood vessels, that physical examination plays little role. She had been seen by many physicians, all of whom wildly speculated about possible causes that had not been identified despite several inpatient days of extensive laboratory tests and imaging studies (see point one above). A quick examination by an experienced physician who actually took the time to look at and see the skin of her elbows, knees, and ankles, a physical examination that took less than five minutes, identified the cause.

What is the point? That physical examination (old-fashioned doctoring) still plays an important role. Also, you hospitalist and telemedicine advocates, a physical examination is cheaper and more efficient, too.

So?

According to Sharon Begley and Mary Carmichael in their Newsweek cover story Desperately Seeking Cures, a cornucopia of cures for an infinity of diseases is (or would be) available but for (a) a culture that sets the wrong incentives for academic scientists and (b) a stodgy bureaucracy that does not prioritize urgent needs. 

Well, maybe…but posing the question that way misses important points. The article has a handful of examples, but ignores the fact that literally thousands of such examples exist. Scientists, venture capitalists, government, advocacy groups all have their own priorities, with no rational way but the marketplace to choose among them.

The article focuses on today’s Holy Grail, that a single aberrant molecule—a single target—if corrected or blocked, will reverse the course of an illness. Well, maybe that, too—if, as is unlikely, the illness results from a single gene mutation. But the chronic illnesses that I know, and possibly most cancers as well, have a better analogy: their origins are like the flap of the butterfly’s wings in Brazil that sets off a tornado in Texas. Human biology and human illnesses are so complex that it is unlikely that targeting a single molecule will “cure” any but the most narrowly-defined genetic diseases.

I am not nihilistic: I do believe that “cures” will be found. My argument is that the molecular-target-found: cure-imminent concept lacks humility. The butterfly wing concept is a better model of illness. If our goal were not to find molecular targets but rather to ameliorate those symptoms that we can recognize and measure, then we might take more pride in the progress we have made and we might direct our future research toward more attainable goals.