‘The Doctor’ by Fildes. Part 3: the trouble with telemetry

The ‘doctor-patient relationship’ is a problematic term. What exactly is it? Would Fildes iconic image leave the observer with a different taste if instead it portrayed the parents propping up a smartphone next to their poorly child?


Learning objectives

1. Review how The Doctor has stood the test of time

2. Consider the impact of technology on the doctor-patient relationship

3. Reflect on the authentic human doctor experience


Previously we noted how incredibly low-tech the doctor appears in Fildes’ image even by the standards of the time it was painted. We have to remind ourselves that although the doctor portrayed in the painting it is often used as a paragon, there isn’t even a stethoscope on show. Well, perhaps that’s the point.

Today, GPs usually have an array of gadgets in their doctors bag such as sphygmomanometer (often automatic), digital thermometer, ophthalmoscope, otoscope or even a pulse oximeter. In the clinic setting, many clinicians today sit behind a desk, a computer monitor and utilise the internet to access the latest clinical guidelines or medical calculators. These tools were designed to assist in the diagnostic process.


Questions

Why did Fildes decide to omit commonplace doctors equipment in his painting?


The more such technology is used, the more it is normalised. Even as late as the 1990s, many general practitioners didn’t take the temperature of patients or did so infrequently (less than once a fortnight). Today, measuring patient temperature has become a commonplace part of scoring patients to identify serious illness.


Questions

What will doctors be routinely recording and documenting in 30 years time?


Fear of litigation, increasing documentation and completion of clinical templates are some of the reasons doctors are using more technology when ‘seeing’ patients. The increasing use and sophistication of mobile phones has allowed patients and clinicians a further opportunity to utilise technology in facilitating the medical consultation. A plethora of apps now allow patients to consult a doctor over a video screen.


Questions

What benefits do video consultations offer over audio telephone consultations?

What benefits do audio telephone consultations offer over telegram consultations?

What benefits do telegram consultations offer over postal consultations?


Reduced waiting times and increased accessibility are often cited as some of the major benefits with any type of remote consultation, but we must carefully reflect and ask ourselves accessibility to what exactly? Although such telemedicine can be useful in certain clinical situations, we should accept that a doctor at the end of a phone line is not the same as a doctor at the end of the bed. In removing the physician from the physical examination, we can lose the serendipitous opportunity that physical examination allows clinicians to act upon.

It’s also peculiar to reflect that in the physical face-to-face setting, failing to take a measurement such as the temperature of a patient may now be considered a dereliction of clinical duty. Yet conversely, the increasing use and promotion of telemedicine consultations makes this simple measurement impossible. Well, of course, proponents of telemedicine could argue that many patients can record this measurement themselves and relay the result to the remote doctor.


Questions

What aspects of the clinical examination are you comfortable in allowing a patient to perform independently?

Can you recall an incident when you identified a serious medical issue on examination unrelated to the patients presenting complaint?


It’s interesting to consider how the portrait of the doctor would be different if Fildes was commissioned to paint it today. Would he leave out the paraphernalia of modern medicine or accept that the technology that travels with doctors has become an essential facet of doctor-patient interaction? I suspect Fildes would have rejected the technology of today as he did in his own time. Diagnostic equipment would create not only a physical barrier but obscure the raw human engagement he was attempting to highlight.

Practicing clinicians will all have felt this to some extent. However, the technological barriers we increasingly encounter are impeding the experience. Even in the clinic setting, it is not uncommon for doctors to lament at the amount of time they are looking at a screen instead of the patient. Similarly, from a patient perspective a doctor with little eye contact can seem uninterested or lack even the most basic communication skills of human interaction. Ironically, poor communication is often the major cause of dissatisfaction for patients and the root cause of many complaints against clinicians.

For many doctors it may feel like a ‘no-win’ situation; the monitoring, recording and documentation of even normal findings has become expected medical behaviour. Yet, as doctors we persist with the increasing encroachment of technology into the consultation perhaps with the hope that somehow it will save us from missing a serious diagnosis or avoiding a complaint.

Returning to Fildes’ ideal, imagine a doctor today undertaking a home visit to see a sick child and not bringing any equipment with them. Most patients and doctors today would agree that this would be unacceptable, yet the virtues portrayed in Fildes’ image remain paramount in societal expectations of doctors.


Questions

If possible, would the automated recording and documentation of patient consultations help or hinder the doctor-patient relationship?


In The Doctor, Fildes was drawing the focus of the observer to the elusive nature of the doctor-patient relationship. I call it elusive as it seems incredibly hard to define. Authors have previously described it as fiduciary, special or more broadly as a process. Perhaps because of this difficulty in articulating the relationship using words, images (such as Fildes) have become alluring explanatory devices to healthcare professionals and tutors in relaying the complex nature of the interaction.

Perhaps one of the major difficulties with defining the doctor-patient relationship is that it is protean. Like the doctors and patients involved, the relationship changes with both time and technology. A number of other factors such as culture also have a considerable influence on what we mean when we think about the doctor-patient relationship. If this line of thought is to be followed, then we can see how a using a Victorian era painting to instil the values of a good doctor to medical students today might cause some conflict.


Questions

How would you describe the doctor-patient relationship?


In Victorian times the role of the doctor is said to have evolved from a provider of compassion to a person of science and skill. Scientific understanding has given value to the technological devices we now utilise during consultations but this challenges the traditional understanding of doctor-patient relationship.

Contrary to popular belief, this is not only a contemporary issue; consider a comment about the painting made in the Lancet in 1887:

“The child lies desperately ill while the parents huddle in the background, fearful, helpless and grief-stricken. There is nothing more the physician can do medically to save the child. Why, then, is he still there? He can only keep vigil – watching as the girl’s delicate breath grows ever more shallow. Now picture a different scene – one with the physician’s chair empty, and the two distraught parents clutching a telephone receiver.”

Debate over the use of technology in the medical consultation is a chronic one, albeit one that appears to now be increasingly visible due to the velocity of change. In a world that seems increasingly obsessed over the measurable health outcomes of particular medical interventions, what we often neglect is the debate about the quality of the human experience during the medical consultation. This involves the understanding of human relationships, empathy and compassion, values core to being a doctor and not only a scientist.

Verghese describes the conceit of medicine, that cure is all that matters while forgetting that simply engaging with patients could heal. If this is indeed true, then there is no doubt that telemedicine consultations are inferior to the consultation presented by Fildes. The only circumstances I could conceive they would prove beneficial would be in those rare instances where the doctor and patient were unable to physically meet.


Questions

So why is telemedicine being so heavily promoted?

Who is promoting video consultations and why?


Perhaps it is a response to the issues of supply and demand, time management, cost saving or convenience. These are no trivial matters but to explore the credibility of these claims would require separate posts. Of importance, however, is that doctors and wider society must seriously reflect upon what we really value from the doctor-patient relationship and how together we can enhance and not debase the experience.

There is another theme at play here that requires further consideration. Remote consultations may create further healthcare disparity amongst patients. Fildes’ painting is a fine example of social realism and healthcare. The wealthy doctor undertaking a home visit for an impoverished family is an aspiration that ubiquitous technology may make less achievable. Strange though it may sound now, the ease and cheaper cost of telemedicine may mean that only the wealthy will experience the authentic engagement and healing that a real physical human doctor can offer.

‘You must study mankind as well as medicine, and also bear in mind, when acting upon diseased bodies, that they are possessed with hearts and minds that have strong passions, warm sentiments and vivid imaginations, which sway them powerfully both in health and disease.’

de Styrap, 1890


Summary

With the increasing technology clinicians have at their disposal, the authenticity of real physical human engagement can be lost. Mobile phone video consultations are just one manifestation in a long line of technological innovations that have attempted to physically remove the doctor from the patient. There will be plenty more to come. With these opportunities doctors and wider society must remember that there comes a potential cost: the connection between human beings. The doctor in Fildes’ painting healed, even if the patient died. This was because he was there. This was the enduring memory that Fildes put to canvas when recording the status of the doctor of his time.

studio

Image from http://www.victorianweb.org/painting/fildes/studio.html


Further resources

Empathy in the age of the electronic medical record
https://danielleofri.com/empathy-in-the-age-of-the-emr/

The Cost of Technology
http://artmedinsight.org/wp-content/uploads/2016/06/The-cost-of-technology.pdf

‘Study Mankind as well as Medicine’: Representing the doctor-patient relationship in The Young Practitioner (1890)
https://victorianclinic.wordpress.com/2017/05/15/study-mankind-as-well-as-medicine-representing-the-doctor-patient-relationship-in-the-young-practitioner-1890/#_edn1

The Most Important Part Of A Doctor’s Job Is Not Her Bedside Manner
https://www.wbur.org/cognoscenti/2018/10/04/practicing-modern-medicine-katherine-mckenzie

We’ve killed the way physicians should be
https://www.kevinmd.com/blog/2015/12/weve-killed-way-physicians.html

Dr. Abraham Verghese on how computers steal time with patients
https://www.ama-assn.org/delivering-care/patient-support-advocacy/dr-abraham-verghese-how-computers-steal-time-patients

Being There
https://journalofethics.ama-assn.org/article/being-there/2001-03

Medicine in the digital age
https://inkvessel.com/2019/03/22/medicine-in-the-digital-age/

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