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Dr. Alvin Rajkomar is a virtuoso of the computer, using applications to help him practice medicine. The history of medicine has long been defined by advances born of bioscience. But in recent years, it been driven by advances in digital technology.

Jim Wilson, New York Times

Doctoring in a digital world

  • Article by: KATIE HAFNER
  • New York Times
  • October 9, 2012 - 5:01 PM

Dr. Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco Medical Center when he came upon a puzzling case: a frail, elderly patient with a dangerously low sodium level.

As a third-year resident in internal medicine, Rajkomar was the senior member of the team, and the others looked to him. An infusion of saline was the answer, but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain swelling, seizures, even death.

He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his iPhone.

With a tap on an app called MedCalc, he had enough answers within a minute to start the saline at precisely the right rate.

The history of medicine is defined by advances born of bioscience. Never before has it been driven to this degree by digital technology.

The proliferation of gadgets, apps and Web-based information has given clinicians -- especially young ones like Rajkomar, 28 -- new tools to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.

And it has created something of a generational divide. Older doctors admire, even envy, young colleagues' ease with technology. But they worry the human connections at the core of medical practice are at risk of being lost.

"Just adding an app won't necessarily make people better doctors or more caring clinicians," said Dr. Paul C. Tang, chief innovation and technology officer at Palo Alto Medical Foundation in Palo Alto, Calif. "What we need to learn is how to use technology to be better, more humane professionals."

Dr. Paul A. Heineken, 66, a primary care physician, is a revered figure at the San Francisco VA Medical Center. He is part of a generation that shared longstanding assumptions about the way medicine is practiced: Physicians are the unambiguous source of medical knowledge; notes and orders are written in paper records while standing at the nurses' station; and X-rays are film placed on light boxes and viewed over a radiologist's shoulder.

One recent morning, while leading trainees through the hospital's wards, Heineken faced the delicate task of every teacher of medicine -- using the gravely ill to impart knowledge.

The team came to the room of a World War II veteran who was dying -- a ghost of a man, his face etched in pain, veins in his neck protruding from the pressure of a failing heart.

Heineken apologized for the intrusion, and the patient forced a smile. The doctor knelt at the bedside to percuss the heart. "Do it like this," he said, placing his left hand over the man's heart, and tapping its middle finger with the middle finger of his right.

Each trainee took a turn. An X-ray or echocardiogram would do the job more accurately. Heineken wanted students to experience discovering an enlarged heart in a physical exam.

He fills his teaching days with similar lessons, which can mean struggling upstream against a current of technology. He has seen the advent of CT scans, ultrasounds, MRIs and countless new lab tests. He has watched peers turn their backs on patients while struggling with a new computer system, or rush patients through appointments while forgetting the most fundamental tools -- their eyes and ears.

For these reasons, he makes a point of requiring something old-fashioned of his trainees.

"I tell them that their first reflex should be to look at the patient, not the computer," Heineken said. And he tells the team to return to each patient's bedside at day's end. "I say, 'Don't go to a computer; go back to the room, sit down and listen to them. And don't look like you're in a hurry.'" One reason for this, Heineken said, is to adjust treatment recommendations based on the patient's own priorities. "Any difficult clinical decision is made easier after discussing it with the patient," he said.

It is not that he opposes digital technology; Heineken has been using the Department of Veterans Affairs' computerized patient record system since it was introduced 15 years ago.

His first appointment one recent day was with Eric Conrad, a 65-year-old Vietnam veteran with severe emphysema. First came a conversation. Heineken had his patient sit on a chair next to his desk. Despondent, the patient looked down at his battered Reeboks, his breaths shallow and labored.

Heineken has been seeing Conrad since 1993, and since then, he said, "we've been fighting a saw-tooth battle with his weight."

In an instant, the computer generated a chart showing the jagged history of weight successfully gained, then lost. Heineken pivoted the screen so the patient could see a steady gain in recent months. "It's looking a lot better than it has," he said. Conrad's face brightened slightly.

Then Heineken turned his back to the computer and sat so close to the patient that they were knee to knee. It was not until Heineken was ready to listen to Conrad's lungs that he asked him to move to the examining table. "I love him to death," Conrad said. "He's right to the point, good news or bad news."

Thirty-eight years and a technological revolution separate Heineken and Rajkomar.

Among the new crop of device-happy physicians, Rajkomar is an elder statesman.

He stores every clinical nugget on an application called Evernote, an electronic filing cabinet. "I use Evernote as a second brain," he said. "I now have a small textbook of personalized, auto-indexed clinical pearls that I carry with me at all times on my iPhone."

He is aware of the pitfalls of computerized records, particularly the "if the problem is X, then do Y" templates.

Rajkomar's outpatient clinic is at the San Francisco VA, where he works down the hall from Heineken.

Where Heineken is competent with the electronic record system, Rajkomar is a virtuoso.

Yet he knows when the computer needs to be set aside. When a patient confided that his wife was taking his pain medication, Rajkomar excused himself and walked down the hall to consult with a pharmacist.

Rajkomar knows he has a great deal to learn about being a physician, especially patients' social and psychological complexities.

"One patient fired me," he said, smiling. "Dr. Heineken gets those patients."

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