Once upon a time long, long ago there lived a man who could see things that other people simply could not see. He was not born with this skill but cultivated it slowly and continuously with years of focused attention. He worked as a physician in a large hospital and would sometimes have students go with him to see patients. As far as the students were concerned, he could really see the invisible. When he was asked what afflicted a patient, he would share his impressions and then carefully and systematically explicate the chain of observational evidence that lead to his indisputable conclusion. For example, after shaking an elderly man’s hand, he immediately diagnosed chronic kidney disease secondary to diabetes mellitus complicated by anemia, secondary hyperparathyroidism, and a moderate pericardial effusion. Terry’s half-and-half fingernails with beaking (from distal digital reabsorption) implied the renal disease with hyperparathyroidism while excessive atrophy of the interossei and an early Dupuytren’s contracture suggested diabetes mellitus as the cause. His distended neck veins with loss of the “Y” descent reflected impaired right ventricular filling and a large epicardial bulge seen through his tee shirt suggested a pericardial effusion as the culprit. These and other inferences were confirmed in the medical record. “How do you see all these things?” the students would ask. “My intention is not to make an ingenious diagnosis or even an astute observation,” he would respond, “it is simply to appreciate the truth in the light of the moment, the reality behind the appearance. Each distinct observation is a single mosaic, and when taken together they reflect complex patterns of health and illness. Each of us has the capacity to develop the necessary skills but to do so requires focused attention, self-disciple and diligent practice, so that you actually awaken and cultivate your own organs of perception. Many others have done so.” His colleagues were regularly amused with the student reactions, and some felt that in many ways he was an anachronism who liked to romanticize the past, show off with his stethoscope and wow the gullible with outdated and esoteric clinical pearls. “Why do we need to see the invisible?” his critics would ask. “We have powerful technology at our disposal and besides we are remunerated by the volume of people we see and our clinical throughput and not by the depth of our perceptions.” They had become comfortable performing “fiscal” examinations of patients consisting of remarkably superficial inspections documented with cut-and-paste templates crafted expertly for optimal coding and billing. From reading their notes, it was hard to tell if the patient had even been touched. “I am old enough to remember when the medical record was actually a comprehensive document for inter-professional communication,” said the man who could see the invisible. “The patient’s predicament was the focus. Now the chart has morphed into an administrative, legal record used primarily for justifying reimbursement. Each clinical entry resembles an invoice with a billing code.” An equally serious problem was the sheer magnitude of erroneous documentation. “I read the template reports every day when patients are transferred to my care, and the volume of easily verifiable misinformation being archived in the EMR is simply breathtaking,” said the man who could see the invisible. “Willful blindness and knowledge are incompatible.” “You do not need exemplary auscultatory skill to appreciate a grade 3/6 harsh, late-peaking systolic murmur that radiates under the right clavicle (with a laterally displaced apical impulse, absent aortic closure sound and delayed and diminished carotid artery pulse) in an elderly person who presents with syncope. But the EMR for this patient repeatedly documents “no murmurs, gallops or rubs” on encounters by six separate physicians. The echocardiogram included in the same EMR confirmed my impression of critical aortic stenosis.” “This conscientious observational approach to health care is the ‘greenest’ form of medicine,” said the man who could see the invisible. “The method is highly portable, and no additional energy has to be imported into the interaction. It does take a little more time (but not that much), but individual craftsmanship takes longer than mass production. My patients can feel the expertise that informs the examination, and they sincerely appreciate receiving the most precious thing I can give, my full undivided attention.” “The antonym of compassion is indifference. A superficial examination is an insensitive examination. If a physician truly cares for a patient, the physical examination will be a caring exam and the information acquired will be highly valuable. The process of performing the examination has therapeutic value and creates a powerful healing relationship. Over time you will be able to see the invisible and know at that moment what is happening to your patient.” One day a great storm ravaged the land and after several hours of torrential rains and high winds all the electrical power went out over a huge geographic area. The hospital command turned on the backup generators, but they failed because of major flooding. Cell telephone towers and cable networks were inoperative. The catastrophe occurred at the worst possible time, and some conspiracy theorists suggested sabotage or worse. The situation was desperate and deteriorating rapidly. Without continuous electrical power, most physicians were impotent. It had been so long since they had actually examined a sick person that their basic clinical skills had atrophied and without electricity-dependent technology such as x-rays, imaging studies, EKGs, ultrasounds or lab work they were literally powerless. The EMR was also down. Because of the massive level of devastation, it was impossible to know when electrical power would be fully established. Those who can see the invisible can do the impossible. The man who could see the invisible did all that he could. But the outcome of the disaster is just what you would expect it to be. Fortunately for us, a calamity of this magnitude happened long, long ago and has little chance of ever happening again. Source
