Wednesday, March 30, 2011

EPTAS after ch. 3 and 4

Prepare for an in-class discussion of these questions on Friday, when we will look at the results from the survey I sent out:
  • What do you think about the mandate that limits residence to an 80 hour work week?
  • Do you agree or disagree with Dr. Sander's take on it? 
  • What benefits and costs do you see from this mandate? 
  • What do you think could or should be done to address the costs? 
  • Do you think that technology will help or hinder these problems/issues?

Please post your response to the following questions by Friday evening:
  1. Dr. Sanders mentions several "unintended consequences of good medicine." Please pick one and elaborate/explain.
  2. Dr. Sanders mentions the power of touch. What does she say about touch, and do your own experiences resonate with what she says? This article from 2006 explores a different aspect of touch,  medicine and the immune system. Taking both of these perspectives into account, if you were designing a training program for doctors, what might you have them do to prepare them for touching their patients?
  3. The final statement in chapter 4 is very charged. Please address and assess Dr. Sander's assertion.


  1. Dr. Sanders states mid-chapter that “It’s just that now there are a lot fewer patients to learn the symptoms from—an unintended consequence of good medicine.” Dr. Sanders is referencing the fact that less residents/interns have the opportunity to learn the methodology of the “physical exam” through experience, instead neglecting the knowledge altogether. Dr. Sanders states again and again that modern medicine lacks the strong roots of tried-and-true methods of diagnosis. Namely, that modern medicine focuses entirely on expensive tests rather than inexpensively performing a standard physical. The anecdote that moved me the most was the one involving Gayle Delacroix. Dr. Sanders dramatically shows the progression of Delacroix’s disease (West Nile Virus) while constantly referencing the lack of attention every doctor pays to her physical state. Her first ER doctor acted like a fool who neither knew what was wrong with Delacroix nor did he seem to care. Her second doctor, Zawahir, while ordering a ridiculous amount of tests to try to confirm a multitude of possible conditions, at least understood that she needed a more experienced doctor to assist her with her diagnosis. This practice, of ordering a multitude of tests, trying to zero in on one particular condition by trying to eliminate all of them, is a waste of time and money. Dr. Sanders does an excellent job of showing how the Iranian doctor was able to deduce Delacroix condition by performing a simple physical while neglecting to order tons of tests. Sadigh (the Iranian) acts the hero by using his extensive medical knowledge and logic to figure out what’s wrong. I found this anecdote the most illuminating of every story presented. To sum up Dr. Sanders’ belief quite well: we have become dependent on medical tests while neglecting their origin, the patient.
    The power of touch. It is presented as one of the most effective and efficient methods of diagnosis in these chapters, such as when Dr. McGee was able to identify an aortic aneurysm in an instant. We told since we are children that it is inappropriate to touch or otherwise violate another’s personal space. I think doctors need to understand that their job is above this social constraint. Patients need to be diagnosed, and in order to do that, doctors must be willing to touch their patients. This level of awkwardness is ridiculous. Doctors should understand that the health of their patient is at stake and that touching a breast or two is the least of their problems. In addition, the attached article gives many examples of how touch can increase the moral or “sooth” a patient’s mindset. We learned in class that the immune system could be affected by a person’s mood, or outlook. The power of touch, I believe is an indispensible tool that should be utilized by every doctor. If I were to design a program to integrate “the power of touch” into, I would start with desensitization. The most effective method of teaching how to remove awkwardness of touching a patient is to become desensitized to it. I would have doctors touching patients many, many times throughout medical school and during their residency. Honestly, if you remove all sexual and social conventions, it’s just a sick human body. That may sound insensitive, but doctors need to view it that way to make an objective decision.

  2. Continuation...

    Dr. Sanders gives the powerful quote, “If not, and the physical exam is lost, we will end p with a health care system that is slower, less effective, and more expensive—a high-tech, low-touch system that fails patients along with the doctors who care for them.” I entirely agree with this statement. Doctors call for tons and tons of tests, and usually, only one or two are relevant to a condition. If doctors were more knowledgeable about the physical, then perhaps patients would be diagnosed even faster. Dr. Sanders shows how patients can be diagnosed in seconds with a simple touch while also showing how patients can nearly die because they were neglected a physical. While these are nice examples aiding her argument, there is some truth to them.

    The testing is what “kills” a patient. It’s the tests, not the treatment. Treatment in this day and age is usually easy, especially if it’s caught early. Patients do tons of tests, blood tests, “echos,” MRIs, CAT scans, lumbar punctures, ultrasounds, etc. These tests have supported what Dr. Sanders says. We have replaced the practice of medicine, the contact with patients and the sharing of their person stories, with mindless testing. It’s mechanical. We test and test and test, to find a diagnosis. There’s no analysis in that…

  3. One of the "unintended consequences of good medicine" Dr. Sanders discusses is that certain diseases that used to be common have faded, as treatments have been discovered-- but as they become rarer, they become less taught and thus more difficult for doctors to recognize. This was the case with rheumatic heart disease. Through the 1940s it was very common: 15,000 people died from it in 1950. This disease is characterized by a strep infection of the throat or skin that progresses such that the heart is attacked by the body's own immune system, leading to the destruction of the heart valves. Now that antibiotics are prescribed whenever a patient has a fever and sore throat, the strep infection cannot develop into rheumatic heart disease. In 2004 only 3,200 people died from it. But the disease was not eradicated completely, only made more rare. Doctors still must be able to recognize the disease, but now have fewer cases of it with which to learn. Thus it is important that doctors not become simply dispensers of antibiotics or other medications, and retain their ability to practice good medicine.

    Dr. Sanders says that the power of touch is huge. She argues that the doctor-patient relationship is complicated by touch, because for the majority of people, touch correlates with love or friendship. As the article states, our brain chemicals are literally changed and calmed when we are touched by someone we feel affection for. Yet we must allow doctors to touch our bodies without the emotional component of touch. It is a reciprocal relationship: we allow that touch so that the doctor can have a better understanding of our health and inform us accordingly. I agree with her that it is a relationship that calls for a lot of mutual trust. If I were designing a program for doctors, I would have them practice simulated physical examination, like Dr. Sanders did with her teacher in the book. I would also ensure that they understand the actual power they wield with touch, to reassure or to alienate their patients.

    Chapter 4 ends with Dr. Sanders' assertion that perhaps the wisest decision the medical community can make in regards to the physical exam is to reevaluate the exam itself, eliminate the aspects that are not helpful in diagnosing patients, and reestablish what remains of the exam as an integral part of patient care. I agree with this moderate stance. To eliminate the exam entirely would be foolish, in my opinion, because not every patient can/needs to be diagnosed by expensive high-tech tests. And the physical exam is a reminder to doctors that they are not technicians but caregivers. But it is also clear that in many cases, technology is the key to diagnosis, and the exam should not be kept around solely for nostalgia. So as Dr. Sanders says, perhaps the best path is indeed to first perform a thorough but strategic physical exam on a patient, and only after that is done, to order high-tech tests necessary to achieve a diagnosis.

  4. The advancement of medicine has made it so that a fair number of diseases that once ran rampant are now rare; this has the benefit that illnesses that were once responsible for countless deaths are now close to obsolete, yet it poses a serious problem for their diagnosis. Dr. Sanders discusses how the advancement of medicine can carry this double-edged sword—while many diseases are becoming obsolete, their diagnoses are becoming archaic knowledge. Doctors learn a considerable part of their diagnostic knowledge from hands on experiences, but the decreased frequency of many of these diseases are making it so that the diagnostic knowledge isn't being passed on to the new generation of doctors. This is what Dr. Sanders refers to as one of the “unintended consequences of good medicine;” although medical advances are saving thousands of lives, the decreased number of cases of certain diseases (as well as an overall decrease in the average length of a hospital stay) are causing the irreplaceable knowledge that comes along with seeing certain diseases first hand to be lost, if not obsolete.
    Dr. Sanders also emphasizes how essential the act of physically examining a patient through touch can be, as it can serve as an integral part of the diagnostic process. She discusses the hesitation that is present in many doctors' minds, because of the social convention typically associated with touching another person, and how what doctors are expected to do in terms of touching a patient are more than social convention typically conveys. Although I do agree that in everyday situations, there is a very strong understood level of physical contact that is accepted, doctors should not be hindered by this. Patients and doctors enter a pact, where the patient lets down any guard against being touched by the doctor, in return for an accurate diagnosis. The doctor should prioritize diagnosing the patient over being at ease themselves. In order to overcome this, doctors have to realize that it is part of their role to touch their patients—when someone walks into a doctor's office, they have come to expect a certain level of physical contact. The only barrier that remains is the doctor's own hesitations, not necessarily the patient's discomfort. For that reason, doctors should be trained to detach themselves from the physical connotations that come from touching another person, and see it simply as an act of medicine and diagnostics.
    She closes the fourth chapter with the assertion that the physical exam itself should be reevaluated, in order to see what parts are legitimate diagnostic tools, and what parts are archaic vestiges that could be better done with technology. I find this statement to be completely reasonable, because it provides a half-way between completely eliminating the physical exam and relying solely on the physical exam. She goes on to say that the consequences of ignoring the physical exam could turn out to be disastrous and could result in a far less efficient health care system. I agree completely, because the physical exam relies on something that machines cannot reproduce—human intuition and the power of touch. The physical exam could be modernized in the sense that unnecessary parts should and could be removed, yet it should never be completely done away with.

  5. 1. On page 45, Dr. Sanders says “it’s just that now there are a lot fewer patients to learn the symptoms from – an unintended consequence of good medicine.” Sanders is referring to one of the problems that modern medicine poses. As medicine and medical knowledge becomes more advanced, the number of cases of certain diseases, such as Rheumatic fever, greatly diminishes. Although this is considered a medical success, and is definitely a good thing, it can also have negative effects, or “unintended consequences.” Interns, residents, and medical students are all becoming doctors in an era where learning the physical symptoms of these increasingly rare diseases is becoming more and more of an unnecessary skill. Many diseases are being treated early on, with newly developed medication at home or with a quick high-tech test. This “loss in skills” of the doctors due to “good medicine” has unintentionally caused the demise of the physical exam - an integral element of medical practice, according to Sanders. Along with (or perhaps because of) the downfall of the physical exam, doctors are having a harder time recognizing these now more rare diseases.

    2. Dr. Sanders states that touch, and the physical exam, is an essential and powerful tool available to doctors. Yet, touch is also viewed as an intimate experience. This can make it uncomfortable for the doctors, and might be a factor in the reason for the demise of the physical exam. Why give an awkward, invasive exam when you could simply order a few high-tech tests? While medical technology is hugely important, the physical exam is also essential. It provides a cheap (in fact, free) and intimate way to make a preliminary assessment of a patient and can provide important clues, if not lead right away to the diagnosis. Plus, as the article states, the act of touching someone is indeed powerful: being touched by another human being can actually change someone’s wellbeing. Touch, especially by a loved one, can have significantly effects, and can make someone calmer, less stressed, and in less pain. I think it is important for medical students to have practice and experience in physical exams. I found it shocking that, according to researcher Salvatore Magnione’s survey, only one in four medical training programs offered structured teaching of basic physical examination skills. If I was designing a training program for doctors, I would be sure to include detailed lessons, instruction, and practice for physical exams. It is important for doctors to know not only the practicality of the physical exam, but also to understand the emotion and effects of touching a patient.

    3. At the end of chapter 4, Dr. Sanders says “If not, and the physical exam is lost, we will end up with a health care system that is slower, less effective, and more expensive—a high-tech, low-touch system that fails patients along with the doctors who care for them.” I agree with this statement: a medical institution and system based solely on modern technology would be much more expensive and time-consuming. Some patients can be diagnosed using only a physical exam, not wasting time, energy, and money on high-tech tests. However, parts of the physical examination that are not useful or effective should be, if possible, disposed of. Medical institutions should strive to find the perfect balance between an involved, physical assessment and additional beneficial high-tech testing. Both aspects are important to finding a diagnosis as quickly and efficiently as possible.

  6. Dr. Sanders states that, while modern medicine is, on the whole, successful in treating diseases that would have been deadly in past era's, modern medicines very success produces unintended consequences. she insists that although modern medicine has been greatly successful in reducing the overall rate of disease, this means that many diseases, such as Rheumatic fever, appear so infrequently that doctors have difficulty diagnosing them. this loss of experience among doctos has lead o the decline of the physical exam, which studies show is a very effective method of diagnosing a patient.
    Dr. Sanders further argues that the physical exam, and the touch of doctors in general, are extraordinarily effective at diagnosing disease and providing the patient with comfort. As both the article and Dr. Sanders argue, this is very important because touch and the physical exam provide a cheap, easy alternative to more expensive and time consuming medical tests. if i were designing a medical school program to educate students on the physical exam, i would try to get the students comfortable with the physical exam before they became residents or fully qualified doctors, so they could overcome their discomfort in a safe environment, when a life isn't on the line.
    At the end of the section, Dr. Sanders states that the decline of the physical exam will result in an expensive, inefficient medical system that is less effective than our current one. i agree with this statement. i think doctors need to adopt the mot effective methods for treatment, not what makes them feel most comfortable.

  7. Sanders’ description of the decline of rheumatic heart disease and the rising inability to identify it that followed well illustrates the concepts of an unintended consequence of good medicine. This portion of the chapter, to me, was reminiscent of our class discussion about the use and overuse of antibacterial hand soaps and how stronger mutations of bacteria breed as a result. Both examples emphasize the idea that by killing the majority of a threat of some sort, we enable the surviving component of the threat to grow stronger and more effective against us. In the case of rheumatic heart disease, the problem is by treating patients for strep throat, rheumatic heart disease is wiped out and so the number of cases has dropped dramatically. And because so few patients have it, it’s becoming more difficult for doctors to study and be able to recognize it, so the few people who do have rheumatic heart disease may be in serious trouble when they go in for a diagnosis.

    I found the article about “the power of touch” very interesting. To me, it seemed to almost contradict some aspects of Sanders’ discussion of the social stigma and general awkwardness surrounding touch. The situations weren’t exactly comparable, though. Sanders focused on the discomfort allied with touching a person in places usually left alone, whereas the article dealt with the companionable touches of loved ones. Personally, I can probably recall being both comforted and discomfited by some form of touch, so I agree with both points of view on the matter. Given the facts presented from both texts – that touch is subject to cultural scrutiny and therefore a sensitive art, and that it can be used as a fundamental tool to de-stress and relax a person - I think it becomes critical for a doctor to be trained in interpersonal relations and their ability to truly keep a patient at a good comfort level and make be able to establish firm boundaries between what would be a socially unacceptable touch and a necessary, practical touch. So if I were training doctors to touch patients, I would try to emphasize the fact that they are not in fact touching someone inappropriately but merely doing their best to help a patient – that the best way to get a diagnosis and full understanding of how to best treat the patient is through this process. I’d also encourage empathizing with the patient and helping them to get over the process, which is equally awkward on both ends.

    Dr. Sanders basically says that if doctors lean too heavily on technology as a crutch, and rely more and more on research and data and stats and not what is in front of their eyes, they will be failing in their fundamental task of caring for patients. Honestly, I think this claim has some truth to it but I would like to believe that it will never come to fruition. I would like to believe that the medical world will not become so impersonal as to cease even examining patients. The way Sanders talks about the issue makes it sound to me as though she thinks doctors nowadays are underqualified and almost, unfit to care for people, and I think the statistics about doctors never improving their exam skills after graduating from medical school support this opinion well. I think it basically comes back to their reasons for entering the field at all. If the reason is money, then the issue of becoming too high-tech and impersonal may actually become a real problem because they won’t have that passion for helping and healing people as their driving motive, and thus won’t be as willing to perform the physical exam.

  8. Posted by Dan Cohen period 4

    1) One unintended consequence of good medicine is the so called death of the physical exam. This is a by product of doctors thinking that a physical exam is now redundant with all of the new high tech tests and diagnoses and the death has also produced a mindset in medical schools that the doctor only needs useful tests. After all, what can a doctor's hands do that a lets say, MRI cannot do? The death of the physical exam is also caused by the patients' shortened stay in the hospital. This is a by product of good medicine because residents and fellows are not allowed as much time to inspect and visit patients at the bedside.

    2) For doctors, touching a patient is an intrusion of their personal space. Dr. Sanders says that patients give doctors permission to enter their private space or areas and in return the doctors would provide care and information that the patient would not know by his/herself. My own experiences with doctors is limited. I tolerate a physical exam partly because I know it is necessary to making sure something is not wrong with my body but also I let doctors into my personal area (now that I have an interest in medicine) to see what they will do or examine. Ever since being part of CHORI this past summer and seeing doctors and nurses at work for weeks I am very curious to see small close up glimpses of what the physician will do in a physical. If I was designing a training program for new physicians I would have a required seminar or course on the basics of giving a good physical exam and what to generally look for. After all, if a doctor needs to determine fast what is going wrong with a patient and cannot rely on just the patient data, they should know the subtle physical signs of what is going wrong with their body.

    3) The final statement in chapter four states that the loss of the physical exam combined with the slow progress of medical practices and techniques are causing medicine to turn into a field where doctors are failing to get the correct diagnosis simply because they refuse to touch the patient and instead rely on technologically advanced tests. I think that this assessment may be accurate but I also believe that Dr. Sanders downplays the role and usefulness of some of the powerful tests that we have today. After all, some of these tests can do things, like examine brain activity, that a simple physical exam cannot do. However, I do agree with her statement. The physical exam should be the first, not the last way to make a diagnosis both because it is quicker but requires doctors to have a more in depth understanding of their patient.

  9. Sorry, this is going to be a short blog post. I wrote a lot for the first question and some for the second and then clicked on the link and it deleted my writing so, ya

    One of the things that is disappearing it the physical exam. It is the consequence of having good technology in medicine because more doctors rely on just what technology can offer as opposed to what they can tell from a physical exam. one example of this is on patient who had heart surgery because of a heart attack, after his surgery, all his monitors said that his body was working fine. unfortunately, he started to feel pain, when a doctor came in to examine him, the doctor quickly recognized it as a critical condition that was common to have after this heart procedure. The patient died on the operating table. This all could have been stopped if a doctor had taken the time to do a physical exam.
    Sanders says that the time spent between a patient and a doctor is decreasing and therefor, the physical exam is being lost. Not only is the physical exam being lost, but so is touch in between a patient and a doctor. this is because, according to sanders, that feel awkward about touching their patients, even though it is very traditional. The article makes an interesting point about touch being able to lower blood pressure and calm a patient down. In some of the studies, the tests are run against spouses and strangers. the results were that spouses had almost twice the effect, however the article also brought up that this could be an inherent flaw with the test, because spouses are much more comfortable touching each other than strangers are, therefor, the strangers will always portray a more stressful emotion.
    Sander's quote in the end of chapter four has both truth and exaggeration. The truth is that without a physical exam, doctoring will never be able to reach its full potential. Her exaggeration is that the medical system will fail or fail those within it. even though the medical system can't reach its full potential without the physical exam, medicine is still extremely successful without it.

  10. According to Dr Sander, good medicine has unintended consequences. One such sample is rheumatic heart disease. In this disease, a strep infection of the throat causes the immune system to attack and destroy the heart valves. Damaged heart valves will create an abnormal heart sound called the murmur. A heart murmur will not be heard unless the valve is severely damaged. In earlier times when antibiotics were yet available, heart murmurs were easily heard because most patients presented very late in the illness. Nowadays in the US, when medical care is more accessible and when antibiotics are easily prescribed (sometimes even before confirmation of strep infection), patients are being treated very early and abnormal physical findings may be difficult to find. The advances in medical treatment indirectly deprives the new generation of doctors an opportunity to learn diagnostic skill.
    Dr Sanders also mentions the power of touch. A good and thorough physical examination helps to uncover clues in making the right diagnosis. With the advances in medical technologies, the physical examination becomes obsolete. The physical examination could also be uncomfortable to both the doctors and the patients. During my last checkup, I was initially embarrassed when my doctor began to examine me. My discomfort quickly vanished when my doctor performed the examination in a professional but caring manner, explaining all the steps in the examination. Besides being a good diagnostic tool, as pointed out in the 2006 article, the human touch helps to speed up healing and recovery. Most of the medical school curriculum nowadays spends little time in teaching physical examination. More often than not, the doctors are placed in the real world only after a few weeks of training. If I have to design a program to train doctors, I would place a great emphasis on teaching physical examination emphasizing good skills and good bedside manner. A physical examination done in a professional and caring manner will ease the anxiety in both the doctors and patients.
    Dr Sander makes the assertion that a high-tech, low touch system will fail both the doctors and the patients, an assertion that I totally agree. Advances in technology fascinate both the doctors and patients. Using technologies without consideration are both expensive and dangerous since imaging studies and blood tests are not 100% accurate. Even if modern technologies are as good as the physical examination, they cannot replace the human touch which brings a doctor closer to his patients and which reassures the patients that they are in good hands.

  11. She explains that some new technological advances in medicine, like the invention of the CT scan, x-rays, MRIs, etc etc, inhibits new medical students and doctors to learn about "old-school" ways of diagnosing patients. This is due to the fact that arising medical students rely less on their own skills, which might or might not be awkward to the patient, and rely more on the "sure", less-awkward diagnoses provided by computers and standard tests.

    Her basis for the power of touch resides mostly in her anecdotes about patients being diagnosed by a simple physical exam. This is a valid point because symptoms like a swollen, inflamed stomach or an irregular heartbeat can be found immediately when a doctor simply touches the patient. However, there are definitely psychological effects to touch that doctors can make use of. As the article says, those women were soothed by the simple act of holding their husband's hands. Touching has probably been the most basic mode of communication between humans and animals, even before language and other modes of communication have been invented. So it seems inappropriate to remove touch from the arsenal of doctors. If I were to teach doctors, I would probably introduce some kind of psychology class of some sort that helps doctors understand and empathize with their patients, making the medical community more humane and less "paper-oriented".

    I do believe that the physical can be modified to provide better diagnoses. I don't know what that is, but the removal of the stethoscope, which she mentions doesnt actually help the doctor determine if patient has lung issues, is a valid point. But then again, keeping these general tests might help the patient feel better, like a little moral boost that says, "hey, my lungs are good! im pretty healthy!"

  12. An unintended consequence of good medicine that Sanders described was that since improved treatments like antibiotics have greatly reduced the incidence of diseases like rheumatic heart disease, it is more difficult for doctors to learn to diagnose these rarer diseases because they encounter fewer patients who have them. This caused Sanders to miss a diagnosis of rheumatic heart disease in one of her patients simply because the disease was rare enough that it did not occur to her to ask the right questions. It’s hard to think of anything that doctors could do about this, except to be more familiar with diseases that were once common but are now rare. This might also be another problem that taking a careful history could help with if doctors asked somewhat broader questions about the patient’s medical history.

    Dr. Sanders discusses the power of touch as part of the physical exam, describing cases in which simply touching the patient to look for abnormalities brought about the correct diagnosis. I definitely think it is a good idea for doctors to use touch as part of their examination, given that it can be so helpful in finding the correct diagnosis. The correlation that the article found between relaxing touch and health amazed me. However, I also thought it was very significant that only certain kinds of touch could help the patients, while uncomfortable touching could actually hinder recovery. Because of the double-edged nature of touch as related to medicine, I think training for doctors in this area is important. Practicing touching patients in ways that are medically effective and do not make them uncomfortable seems like a good idea. I also think it would be useful for doctors to experience what it feels like to be touched well (and badly) as a patient, in order to make them more alert to their effect on patients. Finally, while touch is a vital part of the physical exam, I think it is important for doctors to pay attention to their own comfort level about touching and realize it when they need more practice to become comfortable with this part of medicine, because awkward, inexpert touch as part of the physical exam could make patients very uncomfortable.

    I’d have to agree with Dr. Sanders’s assertion at the end of Chapter 4. With health care costs constantly increasing, it is vital not to do away with simpler, less costly methods of diagnosis like the physical exam. I also agreed with her assertion that a health care system without physical exams would be less effective and efficient. Excessive reliance on high-tech testing seems to decrease the knowledge and skills expected of doctors, and makes them more likely to wait for test results rather than go through the difficult analytical process of diagnosis based on the evidence they already have. While high-tech tests can be lifesaving tools, their overuse leads to inefficiency, higher costs, and sometimes just lazy thinking on the part of doctors. One analogue for this would be the change that search engines have caused in the way that people solve problems and figure things out. Without a search engine, people would be more likely to spend time puzzling how things work, but when it is so easy to just type a question into google and get a ready answer, taking time to figure things out for yourself is less appealing. Of course, like search engines, medical tests have many very valuable uses, but it is important to recognize that there are situations in which they may do more harm than good.

  13. The unintended consequences of good medicine which Dr. Sanders discusses is the fact that many new students not only lose the ability to diagnose some diseases that are less common in the modern world, but they also lose the ability to make many diagnoses without the aid of tests and technology. While I agree with both points, the latter does bother me slightly. While I do think that it is important for doctors to be able to diagnose without needing technology, I also think that it's important to use technology as back up reassurance. Preferably, doctors should listen to their initial hunches and then back them up with solid test results. I think the problem truly is that the current system is out of balance. The exam certainly has its place, but so does modern technology.

    As for the power of touch, I have long believed it to be important. And it goes past just a physical exam. For example, if you're telling a patient that he or she has cancer, a consoling touch or embrace can make a huge difference. Without this, the whole experience can seem very impersonal. Granted it is also important that we allow the doctor to touch us during the physical, in order to greater understand overall health.

    At the end of the chapter, Dr. Sanders explains that more and more in modern times we are making incorrect diagnoses because doctors are less willing to touch the patient and talk to them. Again, it goes back to the point of how, without touch and emotion, the whole experience may be impersonal. As we discussed in class today, much of our communication comes from body language and expression. Machines and technology can't accurately convey this, which is why it's important to place greater emphasis on old-school physical exams that don't rely entirely on machines and technology.

  14. Good medicine has resulted in the ability to treat disease early in the game. While the prior generations of doctors were routinely exposed to diseases that were unable to be caught so early. This meant that the doctors would have to have in-depth knowledge on the progression of certain disease and the odd symptoms that might manifest. One example is rheumatic heart disease. Rheumatic heart disease used to be “commonplace”. The patient would get a strep throat or skin infection and the immune system would soon attack the heart and destroy the valves. However, now that we have been able to develop antibiotics to fight the illness and infection they are able to prevent the development of the disease. It has now become common measure to check patients for strep and subsequently diagnosis antibiotics if needed. Rheumatic heart disease is no longer a commonly/widely lethal disease. This results in a problem for the education of medical students. Disease are now routinely treated early, so as medicine progresses we learn less and less about the developing symptoms and disease and more and more about how to catch the illness early in the game, treat it, and move on to the next patient.

    I think that touch in the rehabilitation; evaluation and diagnostic process of a patient is absolutely imperative. I think that dr. sander experience in the hands on demonstration of a breast exam was a good approach to accustoming the students to the intimacy of the physical exam. I think that these types of demonstrations should be performed and exercised for every aspect of the physical exam. It will accustom the students to the personal aspect of the physical exam and help draw medicine back towards its hands on origins.

    Dr. sandlers addresses the “demise of the physical exam” and claims that if the medical field does not tailor the exam to make it the most efficient and effective it can be, it will become totally extinct. When touch and examination plays such a crucial role in diagnosing and rehabilitation of a patient it is absolutely imperative (to doctors and patients) that the medical field finds a way to construct a physical exam that will withstand the pressing undemanding nature of pills and tests as a way to cure and rehabilitate.

  15. As medicinal knowledge expanded, lots of diseases that once were very prominent became more rare. So, the specific knowledge about these diseases become more and more obscure – unneeded information. So, the downfall of medicine’s progress, or, as Dr. Sanders says, “the unintended consequences of good medicine”, is that the diseases that are made rarer due to better medicine – but aren’t completely exterminated – can be overlooked because the knowledge of these rarer diseases becomes more overlooked and archaic.

    Dr. Sanders stresses that it is necessary for a doctor to examine through touch – to establish a relationship with the patient that agrees that the doctor shouldn’t be hindered by restrictions such as these, and that in turn, the doctor will be able to give a better diagnosis. Even if this makes the doctor uneasy, the doctor has to realize that this physicality is for the greater cause of medicine and diagnostics, for better data; it will be better for the patient in general– it’s a fundamental part of a healthy and effective doctor/patient relationship.

    In the fourth chapter, Dr. Sanders offers an assertion that the physical exam, as it exists today, should be reevaluated. Its important to update the physical exam and make sure all of its components are necessary and which are archaic and outdated – those that could bettered with modern technology, etc. This seems like a very practical idea, because it is of the utmost importance for the physical exam to remain as efficient and effective as possible, which means that any and all new and improved technologies should be implemented in order to keep the process as good as it can be. The process can’t be completely overturned, but some modernization, some evolution, is always for the better.

  16. 1. Sanders mentions the advancement of medicine's capabilities as one of the unintended consequences. As more and more cures and treatments have been created, certain diseases have become incredibly uncommon. Though it is a great thing to almost eliminate certain harmful diseases, it also makes diagnosing the few cases that remain of that disease very difficult. Medicine's ultimate goal is to not only learn and discover about the human body, but also to find ways to use that information to help keep us all healthy. The closer we can get to that state the better and hopefully now and in the future, changes can be made (such as improving and increasing the use of physical exams before any major tests) that will even further attempt to eliminate the cases that remain of these select diseases.

    2/3. The power of touch cannot be denied, whether it is a friend comfortingly patting your shoulder or a doctor carefully examining you, it is important. If doctors are wary to touch their patients (and do so thoroughly enough for it to be effective) then sometimes quick diagnoses can be easily overlooked. The cost of the health care system in the US is obviously a big issue that people have a lot of very strong opinions about, perhaps if doctors were trained to be comfortable doing physical exams for often and more thoroughly, many of the number of extraneous tests that patients do could be limited and costs be minimized greatly. If doctors become to reliant on machines and tests to diagnose their patients, the system will eventually begin to fail. Some tests are very necessary and certain diagnoses would not be reached without them, but if the number could only be minimized even slightly, it would help.

  17. The unintended consequences of good medicine, according to Dr. Sanders, are that with the rapidly expanding medical knowledge and equipment that doctors have access to today, patients can be cured of illnesses before most of the symptoms have time to present themselves. While this is a great thing because people are cured faster, less and less doctors are being able to identify those later-on symptoms because they are less likely to be exposed to them. She used the specific example of Rheumatic Fever, an illness that once was a leading cause of death in the U.S. and other places, but that now is easily cured. As a result, present day doctors and medical students are not taught to identify the symptoms of Rheumatic Fever, almost setting them back in progress. Though many illnesses have cures, if doctors can't identify the illness, the situation could potentially be just as bad as if there were no cure at all.

    I found it very interesting that one of the most difficult things that Dr. Sanders faced in becoming a doctor was being able to touch her patients. She talked about how it is difficult to touch her patients in a professional manner without feeling as if she has crossed some boundary. She said that as a doctor that is one thing she has never truly gotten over, which is part of the reason why she decided to go into a different line of work. After reading the article that talked about the importance and effects that touching and contact have on people, it seemed like being able to make contact with patients is incredibly important as it can lower stress levels, high heart rates, and fear in patients. One potential way for medical students to become more comfortable with touching their patients would be for them to take classes where they had to perform practice physicals and routine check-ups on people that they did not know. This way, it is the true feeling that the student would experience as a doctor, and is better than if they were to perform a check-up on colleagues whom they know better.

    At the end of chapter 4, Dr. Sanders shares her opinion that the physical exam should be trimmed down to include only the most essential and useful aspects. I think that this statement sort of goes against the points that she has made in the rest of the book because she emphasizes over and over again the importance of not rushing through processes in order to not miss any of the details that could lead to a patients diagnosis. I feel that the physical exam should remain how it is, but that doctors should be better trained to execute this task without feeling uncomfortable.

  18. Dr. Sanders believes that the extensiveness of our knowledge in some diseases is decreasing as a result of good medicine – an unintended consequence. In other words, as advancements are made in the field of medicine, certain diseases become less and less prevalent until they’re not as acknowledged or studied. Physicians must direct their attention towards the most common and relevant diseases that afflict individuals. A seldom occurring disease is less likely to be recognized by a doctor than a more common one. Sanders recounts how she did not have to be aware of the wide variety of heart sounds that earlier doctors had to be exposed to during their training; this is perhaps due to the fact that the illnesses associated with those heart sounds and murmurs no longer occur in the human population as frequently as they once did. In the 1950s, many doctors were familiar with rheumatic fever as it had annually claimed the lives of 15,000. Over 50 years later, the death toll has decreased tremendously as a result of good medicine. Consequently, doctors nowadays are not as acquainted with this disease.

    Sanders describes the power of touch, and how a traditional physical examination of a patient can, in some cases, be more useful than any test, no matter how sophisticated it may be. Sanders emphasizes the importance of doctor-patient interaction in not only comforting the patient, but also reaching a diagnosis. It is argued that the advent of new and improved medical technology has rendered the physical examination obsolete. However, several cases have been solved simply by the doctor’s face-to-face examination of the patient. For example, a battery of tests could not reveal that Charlie Jackson’s urethra was blocked by his prostate gland. Rather, all it took was a quick physical examination to deduce that Charlie’s bladder was unusually large. In his article, Dobson mentions how touch may work to both reduce stress and impede the progress of several diseases. So why don’t more doctors value physical examination? To prepare doctors for touching their patients, programs should train doctors to reach and maintain an appropriate distance from and level of comfort with the patient. Many doctors omit the physical examination to avoid awkward and uncomfortable situations. This feeling of apprehension is inherent and inevitable, but can be overcome with the appropriate training.

    Sanders believes that many doctors do not utilize the physical examination because they find many aspects of it to be largely unhelpful. By weeding out its unnecessary components, the physical exam can prove to be much more productive and efficient. However, finding out which parts of the exam are unnecessary or necessary is particularly challenging, and incorrectly modifying the test can have drastic ramifications. If anything is to be learned from these two chapters, it is to be as comprehensive as possible when diagnosing a patient. Whether it be physically examining a patient, listening to a patient story, or running a battery of tests, all fronts should be considered and reviewed. The solutions to many of the cases Sanders described were small, simple details that the physician had overlooked or not been careful enough to notice. It’s immensely difficult to determine the useful from the useless. For this reason, I believe that making alterations to the physical exam is taking too great a gamble.

  19. Dr. Sander’s states “It’s just that now there are a lot fewer patients to learn the symptoms from – an unintended consequence of good medicine”. This quote illustrates an issue of modern medicine by referencing a negative element that can come with the positive aspect of the medical advancement. She discusses how diseases that were fairly common in the past have become rare as physicians have developed more advanced treatment. The drawback to this medical success is the lack of experience future doctors face. The diseases have become rarer resulting in doctors having greater difficulty diagnosing them as they are less knowledgeable. Sanders gives an example of this occurring by discussing the Rheumatic fever. It was very common throughout the 1940s but the numbers significantly decreased by 2004. Although this method of treating patients early has been successful it also has resulted in doctors losing the “critical necessary skills for a thorough physical exam”, doctors are losing the experience of using physical exams to make diagnostics.

    Sanders explains the complicated concept of touch and emphasizes its significance and role in doctor patient relationships. She discusses the differences between the emotional love filled touch between loved ones and families and contrasts it with the potentially awkward in intellectually constituted touch between doctors and patients. Personally, I’ve always felt very comfortable with doctors because I looked to them to make me feel better and thought of them as professionals, not regular strangers touching me for no reason. Sanders references this subject when she describes how the touching relationship between a doctor and patient is a two way relationship that helps the doctor diagnoses the patient and the patient to get better faster. The article heavily emphasizes the power of touch and makes it to be an important factor in helping a patient get better faster. If I were designing a training program for doctors, I would put in many practicums in which the interns could practice touching their patients.
    Dr. Sanders ends chapter four with the statement “if not, and the physical exam is lost, we will end up with a health care system that is slower, less effective, and more expensive-a high tech, low-touch system that fails patients along with the doctors who care for them”. Through this quote she makes the assertion that the discarding of the physical examination to be replaced solely with a technological means of diagnosing patients would lead to our health care system to be expensive and unsuccessful. I agree with her assertion and believe that doctors should incorporate the physical examination into their diagnosing process in addition to ordering technological tests if necessary.