A Few Thoughts by Stephen Vaughn MD, PhD
One of the greatest dangers of the trend towards mechanical medicine is the crippling of the human mind and the way that we all think. Computers are very capable of following a series of well-defined, discrete and inarguable facts through to absolute results. 2+2 = 4 in all huuman languages; (+ 2 2) returns 4 in every version of LISP the argument is offered.
Linear analysis of fact is only one of the several ways that humans think. We have accepted the proposition that ALL human thought – not just algorithmic thought – can be modeled by artificial intelligence machines. That proposition is absurd. We think linearly, of course, but also in shapes and metaphors, in one human language or another. Mathematicians can sketch out ideas in the language of mathematics, not requiring that every statement be made in a human language, but one that is universally spoken by all mathematicians.
Doctors who enjoy the linear, analytic side of medicine can derive great satisfaction from some of the branches of the profession; others, who think in the myriad other ways of human thought, may enjoy others more. When I consider the different branches of Medicine, I often contrast Cardiology as a field with a certain affinity for exactitude and reduction, with Rheumatology, a branch that I find more intuitive and holistic.
Cardiologists make tremendous headway in their profession with contemplating blood flow in three vessels. The more exact nature of cardiology does not mean that it is easier, or even more convenient to algorithmic modeling. One just thinks differently about the diseases of this field in contrast to rheumatology, which has been described as “one disease with a thousand manifestations.”
I enjoy Internal Medicine, because it demands skill in all means of human thinking. I have referred a scleroderma patient whose disease turned lupus-like, and was actually mixed connective tissue disease; and patients I suspected of circumflex artery stenosis. The language to each consultant was different, of course. “The angina was undifferentiated and RCA-ish until it turned circumflexy” is a consult that will raise the eyebrows of the cardiologist; “Sharp’s disease, anti-U1-RNP antibody not measured but I estimate it at 1:2500” is quite pretentious and a bit strange.
We have allowed ourselves to pretend that we view human health and disease through a pinhole; and yes, the world viewed through a pinhole is in focus. But we have insisted that everyone go about life peering through their own small pinhole, which allows some things to be seen clearly, but others not at all.
Of all aspects of medicine, I think I am charmed most by the Diagnosis, the hunt. I love referring patients for whom I have been the first one to diagnose a subtle illness and offer them relief. It feels like the first explorer to see down from the top of some great mountain – I am not the first one to see it, but rather to see down from it.
That is a skill that only comes from years of study and care, through school and residency – there is no way to Google it.
The south Pacific was settled by navigators in wooden canoes, seeking a few square miles of land that five hundred miles across the monotonous and unchanging ocean. It took a lifetime of ocean sailing and intuition to do this, with no compass, no astrolabe. We can now read about how it was done, with some understanding of currents and birds, wind and weather, and try it ourselves.
Good luck with that.
Medicine, like open-ocean navigation in wooden canoes, is easy if you do not care about the outcome – which means that someone else will pay pay the penalty, not you. Every generation has its fools – and every generation puts a few in power, to be sincerely regretted by the following generations who pay the price. We are no different. Here comes the deluge – you can now friend it on Facebook, and watch it on YouTube.
Linear analysis of fact is only one of the several ways that humans think. We have accepted the proposition that ALL human thought – not just algorithmic thought – can be modeled by artificial intelligence machines. That proposition is absurd. We think linearly, of course, but also in shapes and metaphors, in one human language or another. Mathematicians can sketch out ideas in the language of mathematics, not requiring that every statement be made in a human language, but one that is universally spoken by all mathematicians.
Doctors who enjoy the linear, analytic side of medicine can derive great satisfaction from some of the branches of the profession; others, who think in the myriad other ways of human thought, may enjoy others more. When I consider the different branches of Medicine, I often contrast Cardiology as a field with a certain affinity for exactitude and reduction, with Rheumatology, a branch that I find more intuitive and holistic.
Cardiologists make tremendous headway in their profession with contemplating blood flow in three vessels. The more exact nature of cardiology does not mean that it is easier, or even more convenient to algorithmic modeling. One just thinks differently about the diseases of this field in contrast to rheumatology, which has been described as “one disease with a thousand manifestations.”
I enjoy Internal Medicine, because it demands skill in all means of human thinking. I have referred a scleroderma patient whose disease turned lupus-like, and was actually mixed connective tissue disease; and patients I suspected of circumflex artery stenosis. The language to each consultant was different, of course. “The angina was undifferentiated and RCA-ish until it turned circumflexy” is a consult that will raise the eyebrows of the cardiologist; “Sharp’s disease, anti-U1-RNP antibody not measured but I estimate it at 1:2500” is quite pretentious and a bit strange.
We have allowed ourselves to pretend that we view human health and disease through a pinhole; and yes, the world viewed through a pinhole is in focus. But we have insisted that everyone go about life peering through their own small pinhole, which allows some things to be seen clearly, but others not at all.
Of all aspects of medicine, I think I am charmed most by the Diagnosis, the hunt. I love referring patients for whom I have been the first one to diagnose a subtle illness and offer them relief. It feels like the first explorer to see down from the top of some great mountain – I am not the first one to see it, but rather to see down from it.
That is a skill that only comes from years of study and care, through school and residency – there is no way to Google it.
The south Pacific was settled by navigators in wooden canoes, seeking a few square miles of land that five hundred miles across the monotonous and unchanging ocean. It took a lifetime of ocean sailing and intuition to do this, with no compass, no astrolabe. We can now read about how it was done, with some understanding of currents and birds, wind and weather, and try it ourselves.
Good luck with that.
Medicine, like open-ocean navigation in wooden canoes, is easy if you do not care about the outcome – which means that someone else will pay pay the penalty, not you. Every generation has its fools – and every generation puts a few in power, to be sincerely regretted by the following generations who pay the price. We are no different. Here comes the deluge – you can now friend it on Facebook, and watch it on YouTube.
Well said. I find our EMR to be a degrading experience as it questions my ability to even decide that something as simple as giving amoxicillin to a patient with pharyngitis ought not be done without putting them through a rapid strep test. Every time I see the Yellow Exclamation sign warning come up, I want to take of my stethoscope and go work at McDonalds.
love the pinhole camera analogy. but i would offer up that while everything through a pinhole may be in focus, it is not sharp and often fuzzy. perhaps an unintended extension of the metaphor….
I for one am eagerly anticipating MORE mechanical medicine. Doctors and researches are often loathe to share information which then results in useless tests and treatments. Egos get in the way.
well said. and also the comment about rheumatology, which can also be said for FP at its best.
rheumatology remains as one of the few fields in medicine that requires a careful history, physical examination, and integration of laboratory parameters to the clinical scenario. not everyone with a + rheumatoid factor has ra, not every rheumatoid patient has a + rf; hyperuricemia does not equal gout, an ana is very non specific. as one of my mentors said years ago-“if after a careful history and physical you don’t know what the diagnosis is, all the tests you can order aren’t going to help you.” thing have changed some since then, with the advent of mri scanning and newer diagnostics-but the challenge remains to synch the clinical with the results.
Inextricably arcane confabulations
Well said and a fine analogy of why medicine will likely always remain an art. I as the most humble of all practioners ( working at the very feet of my patients) have sensed but not been able to articulate your thoughtful analysis.