Five Patients

In trying to find out why, precisely, it is a long way off, one gets two kinds of answers. The first is that nobody is really interested in working very hard, at the moment, to duplicate a doctor on magnetic tape. The second answer is that doctors don't know themselves precisely how they operate; until doctors figure it out, no one can program a machine to carry out the same functions. The classic situation is that of the physician who enters the room of a person with normal temperature, heart rate, blood pressure, and electrocardiogram, takes one look at him and says: "He looks sick." How did the physician arrive at that conclusion? If he can't tell you the signals he used, then the programmers can't computerize them.



This situation is often held up as a kind of limit on the application of machines to medicine. How can one imitate the "unconscious" or "instinctive" or "intuitive" or "experiential" functions of a doctor? But, in fact, as Kirkland and others have pointed out, the argument is really more damaging to the reputations of physicians than machines. For, unless the doctor is flatly guessing when he says, "The patient looks sick," he is drawing a conclusion on the basis of some input, presumably visual. One need only identify that input-and then plug it into the computer. But if the input is truly unidentifiable, one must strongly suspect that the doctor is guessing or expressing a prejudice.



In any event, there is considerable interest in knowing how a doctor decides that a patient looks sick, or looks better, for, as Dr. Jerome Grossman says: "Working with computers has made us look closely at how people think."



But at the moment computer-assisted programs are all that are being used. Dwyer's program, which will be in pilot use by the end of 1970, is specifically designed to help in a major management problem-the burned pediatric patient. These young patients require close monitoring and frequent changes in therapy. This in turn produces an enormous amount of paperwork and accumulated data that is hard for a physician to summarize in his own mind simply by reading the chart. Dwyer anticipates that a computer-assisted program would "facilitate the orderly collection and retrieval of information [and] would not only improve patient care... but would also lead to the development of optimal therapeutic models and a better understanding of the disease process."



The first phase of the project will be a simple bookkeeping function: storing information about the patient and his treatment and displaying it on command on a teletype, or a cathode-ray tube (essentially, a TV screen), whenever the physician requests it. A hypothetical example of such a display is shown on the next page.



Here the computer is summarizing intravenous (Ringers) and oral fluid intake, urine output, and weight change over a five-day period. This achievement will not be very exciting to anyone who has  not spent half an hour going through a patient's chart attempting to extract this information- which the computer can provide in milliseconds.



Chapter 9



8/2/68 11 30AM EUTH. JOHN 123-46-67

TUB RIKGERS ORAL OKIHB HT(KG) OTHER IV

TODAY 8/2/68

BAM 800/300 - 100/100 82

MM 250/650 100/100 100/200 82.6

10AM 100/660 200/300 155/326 S3 100B

11AM 200/850 60/360 122/447 82.5



FLUID TOTALS INPUT: 1300 OUTPUT: 447 "T. CHANGE: +.8



YESTEBDAX 8/1/68



BAH 100/100 60/50 76/76 81



Bill 200/300 -/SO 60/126 81



10AM 800/600 100/160 76/200 81.6 800P



11AM 800/900 100/260 100/300 81.7

UFM 200/1100 76/326 100/400 88

UN 150/1250 -/Z26 160/660.

11PM 12AU



6111 100/2600 -/TOO ZOO/1200 7AM 72/2576 60/750 100/1300 FLUID TOTALS INPUT: 3325 OUTPUT: 1300



82 82 BT. CHANGE: +1



1/31/68 300(200)/3200 1/30/68 3000(-I/3000 1/89/68 4200 (100)/4300



1100 1000 900



B,P



But the second stage is rather different. It is called "computer-generated treatment regimen," and what it means is that the computer will itself advise future therapy, which the physician is free to accept or ignore.



Another hypothetical example, for a new patient admitted to the unit:



ADMISSION DATE T



05/08/69 ADMISSION TIMEN^ 11.22AM ADMITTING DOCTOR'S INITIALS... KRD PATIENT'S NAME... SMITH, JOHN BIRTH DATE... it/20/65 UNIT NUMBER... 1234567



THIS UNIT NUMBER IS ALREADY ASSIGNED.



TRY AGAIN OR USE TEMP. UNIT NUMBER... 123456 LOCATION... SBI WEIGHT (LB OR KG?)... 20 KG HT (IN OR CM?)... 110 IN/CM? CM^ BURN DATE T TIME SAM TOTAL PERCENT BURtT... 16



PERCENT 1ST DEGREE... 0



2ND DEGREE... 9^



2ND-3RD DEGREE... 27



BURN SURFACE COMPUTEoTo BE



0.27 SQ METERS TREATED PREVIOUS TO EW



NO



ew therapy



N/S



.0



ye? enter totals (ml) l!c~ringers... 200 plasma...? blood, urine.. 0~ vomitus



SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML RINGERS BEFORE 4.00 PM 05/08/69 RATE: 315 D/M PED (80 AD) 1640 ML RINGERS BEFORE 8.00 AM 05/09/69 RATE: 100 D/M PED



SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML RINGERS BEFORE 4.00 PM AT A RATE OF 310 D/M (PED)



1640 ML RINGERS BEFORE 8.00 AM ON 05/09/69 AT A RATE OF 100 D/M (PED)



Now this is not really so ominous. The suggestions for therapy are actually based on principles that come from John Crawford, chief of pediatrics at the Burns Unit. In essence, they represent (assuming no error in the program, and no variables that he would take into account but the machine does not) his therapeutic program were he personally treating the patient.



Thus the computer is at best as clever as a single clever man, and at worst considerably less astute than that one man.



Once in use, the MGH burns project will be analyzed by doctors, and adjustments made to refine the program. And as the program improves, it may become more and more difficult for a physician to ignore the computer's "advice."



In the future, it may be possible to have a computer monitor the patient and carry out therapy, maintaining the patient within certain limits established by physicians-or even by the computer itself.



The major consequence, indeed the avowed aim, of computer therapy in any form will be to reduce the routine work of patient care done by doctors. Other elements of that care are already disappearing; nurses have taken over several of these, and technicians have taken over others. Thus, during the week, the MGH has routine blood samples drawn by technicians and routine intravenous maintenance-starting IV lines and keeping them running-done by specially trained IV nurses. These programs were quite radical a few years ago, when doctors thought nurses constitutionally incapable of dealing with intravenous lines or drawing blood from a vein. But a startling consequence of this new specialization of nonphysician health personnel has been better care, in certain areas, than the physician himself could deliver. Even if doctors don't believe this, the patients know it well. On weekends, when the IV nurses and the blood technicians are off duty, the patients complain bitterly that the physicians are not as skilled in these tasks.



As for the special skills still reserved to physicians, such as lumbar punctures and thoracic and abdominal taps, it is only a matter of time before someone discovers that these, too, can be effectively delegated to other personnel.



It would thus appear that all the functions of a doctor are being taken over either by other people or by machines. What will be left to the doctor of the future?



Almost certainly he will begin to move in one of two directions. The first is clearly toward full-time research. The last fifteen years have seen a striking increase in the number of hospital-based physicians and the number of doctors conducting research in governmental agencies. This trend will almost surely continue.



A second direction will be away from science toward the "art" of medicine-the complex, very human problems of helping people adjust to disease processes; for there will always be a gap between the illnesses medicine faces and science's limitations in treating them. And there will always be a need for people to bridge that gap.



Physicians moving in either direction will be helped by a new freedom from the details of patient care; and physicians now emotionally attached to those details, such as those doctors who religiously insist on doing their own lab work, are mistaking the nature of their trade. Almost invariably, they would do better spending their time talking with the patient, and letting somebody else look at the blood and urine or count the cells in the spinal fluid-especially if that person (or machine) can work more rapidly and accurately than the physician himself.



One can argue that this presages a split among physicians, between those with a scientific, research orientation, and those with a behavioral, almost psychiatric, orientation. That split has already begun and some bemoan it. But, in reality, art and science have rarely merged well in a single individual. It is said that Einstein would have starved as a cellist, and it is certainly true that the number of doctors in recent years who have been both superb clinicians and excellent laboratory researchers is really quite small. Such men certainly can be found, and they are always impressive-but they are distinctly in the minority. In fact, the modern notion that the average physician is a practitioner of both art and science is at best a charming myth, at worst a serious occupational delusion.



In the final analysis, what does all this mean for the hospital and for the patient in the hospital? One may look at the short-term possibilities, as represented by the burns treatment program.



It will reduce the mundane work of ward personnel, both doctors and nurses, and leave them more time to spend with the patient. For doctors, it should mean more time for research as well. And for the patient, that should ultimately be a good thing.



Furthermore, as an extension of the hospital, a computer program offers quite extraordinary possibilities. Any hospital in the country-or even any doctor's office-could utilize the program, by using existing telephone lines. A community hospital could plug into the MGH program and let the computer monitor the patient and direct therapy. As a way to utilize the innovative capability of the hospital, and its vast resources of complex medical information, this must surely represent a logical step in 2,500 years of evolution. And for the patient, that, too, should ultimately be a good thing.



Chapter 10



Edith Murphy. Patient and Doctor



Six months before she came to the MGH, Mrs. Murphy, a fifty-five-year-old mother of three, began to notice swelling of her legs and ankles. This swelling increased and she became progressively weaker, until finally she had to quit her job as a filing clerk. She consulted her local doctor, who prescribed digitalis and diuretics. This reduced the swelling but did not eliminate it completely. She continued to feel very weak.



Finally she was admitted to a local community hospital where she was found to be severely anemic, to have bleeding in her gastrointestinal tract, to have chemical evidence of liver disease, and X rays suggestive of cancer of the pancreas. At this point, she was transferred to the MGH. She knew nothing of her suspected diagnosis.



On arrival she was seen by Edmund Carey, a medical student, and Dr. A. W. Nienhuis, a house officer. They found that she was slightly jaundiced and that her abdomen was distended with fluid. Her liver could not be felt because of this fluid. Her legs and ankles were still swollen. They confirmed the presence of blood in her stools.



Laboratory studies indicated a hematocrit of 18 per cent, which meant that she had less than half the normal number of red blood cells. Her reticu-locyte count, a measure of new-blood-cell production, was increased. A measurement of iron in her blood showed that she was iron-deficient. The total picture was thus consistent with chronic anemia from blood loss through the gastrointestinal tract, [The technical reader must excuse some simplification in this presentation] but the situation was more complex: A Coombs blood test was positive, suggesting that her body was also destroying red cells by an allergic mechanism.



A chest X ray and electrocardiogram and kidney studies were normal. Barium X-ray studies of the upper GI tract, to check the suggestion of pancreatic cancer, could not be done immediately. A bone-marrow biopsy was done, but it gave no further clue to the nature of the anemia. Her abdomen was tapped and a sample of fluid withdrawn for analysis. There was laboratory evidence to suggest liver disease and perhaps insufficient proteins in her blood, but this could not be immediately confirmed on the night of admission.



Mrs. Murphy thus presented a complex and puzzling problem. The first question was whether a single disease process could explain her three major difficulties, which Dr. Nienhuis summarized as anemia, gastrointestinal disease, and edema. As he noted, they could all be explained, in whole or in part, by cancer or liver disease, by invoking mechanisms that are quite complicated.



Implicit in his thinking was the notion that the body is constantly changing, and that those features of the body which appear static are really the product of a dynamic equilibrium. Thus the red-cell volume of the body, which usually appears fairly constant, is really the product of ceaseless creation and destruction of cells. The average red cell has a life span of 120 days; anemia can result from either inadequate production of cells or excessive destruction of cells. In Mrs. Murphy's case, production seemed actually increased, but she was losing cells through bleeding and allergic destruction.



Similarly, water, which normally accounts for 70 per cent of body weight, is carefully distributed in a healthy person-so much inside cells, so much outside cells. Individual water molecules are constantly shifting around the body, but the balance in each compartment is closely maintained. Edema, the pathological swelling of certain tissues with water, can be caused by a wide range of factors that disrupt the normal distribution of body water. The same effect can be produced by heart disease, liver disease, or kidney disease, each by a different mechanism.



Mrs. Murphy was admitted to the Bulfinch medical wards and passed an uneventful night. In the morning she was seen on work rounds by Carey, Nienhuis, and another resident, Dr. Robert Liss. Practical aspects of her condition were discussed, particularly the question of transfusion. It was decided to postpone transfusion since she appeared comfortable for the moment. Later in the day Mrs. Murphy's problems were discussed with the visiting senior physician on the wards, Dr. John Mills. He felt that "tumor in the abdomen was strongly indicated," but for a variety of reasons felt that lymphoma, a cancer of lymph glands, was more likely than pancreatic cancer.