PLANETARY HEALTH WEEKLY

Jay’s BLOG #6

By: Jay D. Kravitz, MD, MPH

Posted on March 11, 2021

The old adage, “the more things change, the more things stay the same,” while worthy verbiage in former times, has lost traction in recent times. The rapidity of modern technological innovation has sped transitions to the point that the scientific and medical fields are changing and accelerating faster than many people can absorb.

Obscured in this swiftly evolving process is the hazard that health care professionals will lose sight of the need to maintain basic, fundamental, clinical and intuitive reasoning skills. Rather, they might choose without rumination to just “push buttons” to gain diagnostic and remedial information. Obviously, technology provides important, highly desired accuracy and more timely diagnoses to guide more effective therapies for many maladies – for which we are grateful and happy to use. But, what happens when technology isn’t available, inaccurate (low sensitivity and/or specificity), intrusive, malfunctions, or is improperly calibrated? Do health professionals then conclude they simply can’t “practice medicine?” What can and should we do?

Once, while conversing with a junior colleague, engaged in the application of sophisticated diagnostic medical imaging and laboratory technologies, I inquired how one would practice medicine if electricity were not available during a complex disaster. Would this person – or you – be able to practice medicine? The response was a blank stare… This potential reality was apparently not on the radar. Yet, loss of these flowing electrons is not a hypothetical possibility.

Honestly, electricity generated from various sources, inferred to be taken for granted by most people, is truly our ultimate technology. The world runs on electricity! Without it we would revert to the 19^th century. Refrigeration, heating, lighting, potable water pumping, sanitation, education as we know it, computing, manufacturing, etc. would be at risk. Yet, in lower resource settings electricity is often unreliable or not available. This reality is problematic for most people who are technologically dependent.

Regions of California, Australia and elsewhere have repeatedly suffered loss of power episodes in the past few years due to large scale wildfires. Storms in SE Asia and North America have also compounded power grid vulnerabilities…and now in Planetary Health. How do – or should – people cope? Power outages with loss of Wi-Fi and the internet are also a too frequent, unwelcome reality during the winter storm season in the rural area where I live in Oregon. L At times it is unclear whether evolving technological dependence is a blessing or at times a curse…Reading by candle light is more romantic than desirable! And when a power outage occurred during a 2008 National Football League televised game, a commentator observed, “When you strip modern technology away, it’s a bit of an adjustment.”

Unless one has a back-up generator or solar power storage system, when the battery on your laptop computer or mobile phone is spent – or you lose internet access – you will have to resort to ancient modes of communication, like voice and penmanship! L Use of electric-dependent medical diagnostics, including newly evolving, hand-held mobile phone ultrasound tools, intended by some to replace the stethoscope, may be delayed or unusable.

That is exactly the issue and the challenge: Teaching and incorporating basic assessment skills is fundamental to the educational process and for practicing professionals. If one takes a detailed, accurate history and completes a thorough physical examination, it is possible that “pushing buttons” may not really be necessary. Incorporating a public health perspective regarding endemic or more likely diagnostic possibilities will also enhance one’s clinical acumen, although one must still remain vigilant for more esoteric possibilities.

Anecdotally, one of my former surgery colleagues related that while serving as an attending faculty in the emergency room at a major teaching hospital, he was asked by the resident doctor-in-training and medical student to assist in the evaluation of a patient with a chief complaint of abdominal pain. My colleague’s first question: “What did you find during the physical examination?” was met with the response: “We haven’t completed the exam yet. Here is the patient’s CT scan.”

Case in point. What has happened to the practice of medicine? How many unnecessary physical and time-related resources might be saved by adhering to a basic standard of assessment principles? Yes, the necessity AND luxury of technology is a very important and crucial part of the modern medical practice landscape. Certainly, if one becomes ill, having technological options is something to be grateful for…when applied appropriately.

The confused evolution of diagnostic methodology sequencing priorities requires serious reflection. Incorporating the epidemiological concept, ‘pre-test probability,’ (the probability of a target ailment, either likely or not, before diagnostic tests are ordered), can provide insight during a sometimes complicated, deliberative process whether further orderly testing would be worthwhile or necessary.

It is imperative that medical education continues to foster the inclusion of basic clinical assessment skills, both diagnostic and therapeutic. That includes one’s hands and a stethoscope, even as we gain benefit from evolving technological mechanisms. The skills learning process cannot be deflected, minimized or forgotten, regardless of reliance on technology as we move into the future. Touching patients cannot and ought not to be replaced by practitioners sitting in front of computer screens or staring at smart phones.

I take issue with a hyperbolic commentary by an East Coast university medical educator, who once wrote, “…As part of my teaching to residents, I tell them that, after 2 weeks of experience in CT scanning, a first-year radiology resident is a better diagnostician than any of the greatest clinicians in the pre-CT era, including Sir William Osler…” This tunnel-vision, egocentric opinion is important to contemplate because imaging actually has little value when pondering the vast number of disease entities that can present clinically through a myriad of physical, psychological and dermatological expressions.

Remember, the body only has a limited means of expressing illness, including pain, respiratory distress, fever, nausea, weight loss, vomiting, change in motor skills, diarrhea, swelling, visual change, sweating (diaphoresis), mental status change, rash or weakness. Assessing a patient’s condition can include technological methodologies, but competent clinical skills are the initial operative imperative.

Complementary to clinical competency is familiarity with locally prevalent diseases. Knowledge of these maladies can help a practitioner anticipate problems, assess the temporal sequence of an illness and help determine how sick a person may be. Cognizance of animal and insect vectors, health literacy, poverty, food insecurity, environmental hazards, behavioral choices (poor diet and smoking), current medications, access to health care and preventive services, general aging issues, social demographics and chronic disease burden can all contribute to an accurate, clinical assessment.

Having worked in complex disaster settings in a number of countries, I faced the reality that electricity was not available; laboratory support and advanced communications minimal or absent. Early on, during those volunteer experiences, I was a student, gaining knowledge from local practitioners, both doctors AND nurses. They were brilliant…The important lesson learned was to be observant and respectful – and absorb information from those who know their environments best.

Even under austere circumstances with fragile, under-resourced health care systems and minimal technology, knowledgeable practitioners who understood the clinical expressions of local endemic disease patterns (malaria, cholera, typhoid fever, and severe malnutrition amongst others), provided medical services with the most basic of supplies. Uncomplicated clinical evaluations and admirably competent care were effective with minimal loss of life, even amongst the seriously ill. Clinical entities for which technology could have served as the basis for diagnosis would have been of limited value.

One must also be aware that in lower and middle income countries professionals experienced with advanced technical options may represent a minority. Location-specific needs, infrastructure and competencies must be carefully considered when technological interventions are introduced if they are to be used effectively and safely.

Coherent strategies for the distribution and reliance on advanced equipment must be developed in tandem with host countries. When health care professionals choose to work abroad, an understanding of local clinical environments, social determinants, cultures and training programs must be incorporated. Governments and both non-governmental global and local organizations play a critical part in streamlining processes to ensure a suitable strategy for innovation, regulation and deployment of knowledge and technology.¹

Yes, we have remarkable, highly valuable and relied upon imaging capabilities that have saved many lives and lessened suffering. Cellular mobile phone technology and tele-medicine have greatly broadened communication and assessment options. Powered by electricity or solar photovoltaics, diagnostics, portable ultrasound, visual, voice and texting consultations are available, even in more remote settings. Needless to say, we are quite fortunate to have these options.

Reliance on mobile phones, however, does have limitations when considered for use as an epidemiological tool. In the case of COVID-19, surveillance data are inconsistent when this technology was used to capture individual-level and population-level movement patterns related to non-pharmaceutical preventive interventions.²

Therefore, I would remind everyone, especially educators, that many skilled practitioners, based on years of experience, rely upon numerous epidemiological and diagnostic physical examination pathognomonic signs and nuanced “tricks of the trade.” Clinical acumen and ingenuity can guide clinical decisions and data collection. This valuable body-of-knowledge and ‘art’ must be passed on and employed!

Clinicians today must also address diagnostic dilemmas framed by the facility of modern day transport. Puzzling maladies may present among returning overseas travelers, military veterans having served abroad, migration patterns, refugee movement and socioeconomic factors. These complex variables can affect disease burden patterns in our communities, posing significant diagnostic challenges. Advanced technologies may or may not provide insight.

In conclusion, the premise of these comments is that “low-tech diagnosis” learning and practice skills are essential. One must encourage and promote the basics of clinical evaluation. Fundamental is the personal interaction between patients and their medical care providers! It isn’t the issue that technology has no place. Most certainly it does. Evolving technologies, providing extraordinary value, have changed the world. However, the aforementioned contemplations must guide whether advanced technologically-oriented testing and interventions are appropriate, required or necessary.

While I anticipate this blog will generate strong feelings on both sides of the aisle, especially when management and budgetary pressures – and medical-legal concerns –lurk in the background, a thoughtful introspective dialogue on this issue is important!

Reference:

1. Shipley R, Brealey D, Haniffa R, Elwell C, Baker T, Lomas D, Singer M. Lessons and risks of medical device deployment in a global pandemic. Lancet Global Health 2021. Published Online: February 3, 2021 https://doi.org/10.1016/

• Badr HS, Gardner LM. Limitations of using mobile phone data to model COVID-19 transmission in the USA. Lancet Infectious Diseases. November 2020; https://doi.org/10.1016/ S1473-3099(20)30861-6/