The Doctor in the Doorway

 

   The lungs sound clear, but the x-ray shows disease; the abdomen feels soft and healthy, yet the hardened cancer lurking deep within is visible only to the probing view of the machine. Modern scientific medicine, with all the bells and whistles of technology, has taught physicians to distrust their personal observations. They quickly learn that their touch, their gaze, the sounds traveling through their stethoscopes can deceive them. Personal observation is frequently held suspect and always in need of verification from without - the laboratory or the CT scan- for only machines can confirm what the senses may lead one to suspect. 

 

   In this world there is a discrete hierarchy of information that is reinforced by the gamesmanship of hospital rounds. Medical residents quickly learn to cite the medical literature and to discount experience not quantified and verified by someone else. Here information has no authority unless it presented in published form. Yet, not all articles are equal: the New England Journal of Medicine trumps JAMA. The larger the study, the more patients enrolled, the more privileged is the information. Thus, the search for knowledge has been removed from the bedside of the individual patient, whose course of disease may be exceptional and, therefore, misleading, to data collected from large groups of patients which is believed to be more representative of the disease process in general. And so physicians are taught to worship at the altar of big data and to consign what goes at any one patient's bedside to the world of anecdotal medicine- a term used pejoratively. The only facts that matter are those verified by someone or something else. It is for this world that the electronic medical record was created. Not for its stated purpose which was to facilitate the transfer of patient information between multiple institutions and providers, which it does poorly; but rather to gather data that can be used to determine the collective disease experience. Because in modern medicine the only experience that matters is aggregate. So although the case presentation still lives on, it has been relegated to the back of the medical journal and the meta-analysis has been given the coveted first position.

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   This devaluation of the importance of personal experience in medicine, of both the patient and the physician, is the product of the rise of a type of scientific medicine that emerged in the second half of the nineteenth century. W.F. Bynum has written that the decades between 1850 and 1900 witnessed the construction of an intellectual framework for western medicine that made physicians men of science more than practitioners of an art, as bench science replaced the bedside as the font of  knowledge of disease.

 

    This culture was removed from the medicine of an earlier age, that was itself a break with the past. In The Birth of the Clinic Michel Foucault argued that in the eighteenth century there emerged a new medical rationality based on the power of perception as medicine moved beyond a centuries old Galenic understanding of disease based on theory. The body, once closed and mysterious, became a text- to be opened up and studied; its secrets revealed on the anatomist's table and under the surgeon's knife. Thus the eye became the source of clarity and experience read at a glance the visible lesions of disease- but only by a privileged few: physicians. This reorganization of medical discourse translated into a practice of medicine in which each diseased body was to be observed as the source of information that was to be discovered and interpreted.  This was a world in which seeing was truly believing, but the knowledge gathered was intensely personal. Each case was its own story, to be read by the one person with specialized knowledge and access to the diseased: the physician. And so began the professionalization of medicine. 

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  The scientific medicine that Bynum writes takes hold in the nineteenth century was also rooted in observation, but of a different kind- this time the gaze was fixed on the test tube, the microscope, the culture plate - and a collection of statistics. Medical knowledge could now come from somewhere other than the bedside and from someone other than the physician. Cellular pathology, bacteriology, epidemiology, and other scientific disciplines permeated the medical conceptual framework and gave authority to information that was quantifiable - and often far removed from doctor at the bedside. And then came the machines- the x-ray, CT scanner and MRI whose findings were given an authority greater than what any one physician saw, felt, or heard.

  

   So now the  doctor just stands in the doorway. There is no reason to come into the room or touch the patient. He asks a few questions, checks his computer for the appropriate algorithm, orders the prescribed test, and moves on to another doorway. His gaze no longer matters- and soon neither will he.

 

 

W.F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge

    University Press, 1994).

Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. Alan Sheridan

    (New York: Vintage Books, 1973).