It’s a very important ritual. If you look at rituals, in general, they are all about crossing a threshold. We marry, we have baptisms, we have funerals—all with ceremony to indicate the crossing of a threshold. If we step back and look at the physical exam, it has all the trappings of ritual.Verghese, A. (2019). Eric Topol and Abraham Verghese on What AI Means for the Physical Exam. Medicine and the Machine podcast.
A few thoughts after listening to an episode of the Medicine and the Machine podcast.
Almost immediately we get to the notion that there’s very little value in terms of data collection that happens during the physical exam. It’s clear that the validity and reliability of a lot of what we do during the “laying on of hands” is questionable. So far so good. But then the hosts start talking about the value of physical touch as part of a ritual that includes some kind of threshold crossing for the clinician and patient. This is where it starts getting a bit weird.
On the one hand, I agree that there’s a lot of ritual that frames the patient-clinician interaction and that this may even be something that patients look for. On the other hand I don’t think that this is something to be celebrated and which I believe will fall away as AI becomes more tightly integrated into healthcare. You don’t need to conduct a physical exam to signal to the patient that you’re paying attention; you can just pay attention.
I’m also uncomfortable with some of the language used in the episode that’s reminiscent of priests, ceremony, and the mystical, and I don’t know why but it makes me think of a profession that’s in decline. There’s a parallel here if you think of religion that’s under pressure worldwide as the spaces in which God has room to move gets smaller and smaller. Not that medicine is going to go away entirely but the parts of it that try and hold onto the remnants of a past that are no longer relevant are going to become increasingly disconnected to 21st century clinical practice.
If you think that the value of the human being in the patient-clinician encounter is that we need people to enact a ritual, then surely you’ve lost the plot. There are many reasons for why this perspective is problematic but two big ones come to mind:
- Rituals are used to create a sense of mystery as part of a ceremony related to threshold crossing. While I think that this has value in some parts of society (e.g. becoming an adult, getting married, etc.) I don’t think it has a place in scientific endeavour.
- You don’t need to spend 7 years studying medicine, and then another 5 years specialising, in order to simulate some kind of threshold crossing with a patient.
Having said all that, I think the episode is still worth listening to, even if only to listen Topol and Verghese come up with dubious arguments for why it’s so important for the doctor to remain central to the clinical encounter.