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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA |
This week has not been a good one for me in terms of technology. I'm working from home today because of car battery issues. And, as I'm sitting here typing in the kitchen on my recently replaced laptop computer (the prior one died along with other technological issues which I lamented in Practice Perfect 360), I have a repairman fixing my microwave. Apparently, the magnetron tube needed to be replaced (for a pleasant $539 – yeah, who needed that money anyway?).
 Yesterday, at the end of my workday, I walked out to the parking lot, opened my car door, sat down, started the car, and…
Nothing.
I tried to start the car again. I heard a click, click, click but no start, start, start.
Dead battery.
AAA came out and gave me a jump, unfortunately not in time to pick up my son from his dance class. My wife had to drive 35 minutes from home to pick him up, since my car was out of commission. Very inconvenient!
This morning I started the car, it turned over, but with a hard start. As it turns out, my battery needed replacing, since it would no longer hold a charge. Luckily, this occurred on a "slow" day at work, and I didn't have surgery until later in the day. So now, here I am at home, typing away, while my microwave is repaired. It's incredible how difficult life becomes without our technology.
We rely so much on our inventions that we become beholden to them. Take me, for example. Because of my car, I am capable of living about 30 miles away from where I work and am capable of traveling almost 100 miles to various hospitals. I live in a typical suburban town, commuting what in the past would have been prohibitively long distances with ease.
Similarly, I can contact almost anyone in the world on a moment's notice with my cell phone, text, video conferencing, or email. Remember when we used to write actual paper letters to each other? I haven't written a paper letter since I was a kid! Like many people, I am becoming an anachronism by reading paper books instead of eBooks. You'll have to peel those paper books from my cold, dead hands!
Similarly, I wonder if I'm becoming an anachronism in podiatric medicine. I find that much of what I do in daily practice is less technologically based. Is this becoming a thing of the past?
Here's an example. Regularly, I or my partners are consulted at any of a number of local hospitals to see patients with supposed infections, either of bone or soft tissue. In most of the cases – yes most – when I arrive to do my consult, I find out an MRI has already been completed and various noninvasive vascular tests have been done. And, as is often the case, these tests were completely unnecessary – if one had simply gathered a history, performed an adequate physical examination, and had an understanding of the disease he or she was treating, these tests would not have been necessary.
I once had a patient with a neuropathic dorsal 2nd digit ulceration with an MRI positive osteomyelitis. At least it was positive until I did the surgery (an arthroplasty and NOT an amputation) and found out a few days later that there was no histologic or microbiologic evidence of osteomyelitis. And, miraculously, the wound healed uneventfully and has remained healed without any recurrence almost three years later.
A couple of years ago, I saw a diabetic man in my clinic with a midfoot Charcot that was as obvious as the nose on my face. Obvious, that is, after two venous duplex Doppler ultrasounds looking for DVT, radiographs, an MRI, and several weeks of parenteral antibiotics for possible osteomyelitis. At no time did he have an ulcer or other skin damage. Unfortunately, this is too common an error as a result of relying on technology without an understanding of the patient's complaint.
 The further along in practice I get, the less need I feel for high technology. Now, don't get me wrong. I like gadgets, new instruments, and new technology as much as everyone else, but there is an appropriate time and place for them. For example, the advent of the surgical screw has revolutionized bone surgery and is a huge improvement over Kirschner wires. On the other hand, indiscriminately using external fixation is not a good idea.
But the place where I find the most frustration with new technology is in the nonsurgical arena. Physicians are becoming less and less adept at obtaining full detailed histories and comprehensive examinations. We're all well aware that physicians rarely allow their patients to relate the full story of their complaint. Increasingly, though, I see this reliance on advanced imaging to diagnose as evidenced in the examples above.
Some situations require more advanced technology. For example, should a patient with chronic pain after ankle sprain that does not respond to standard therapy receive an MRI? It's not to say that a radiograph might demonstrate ankle pathology, but the MRI will tell the physician something she wouldn't otherwise know.
On the other hand, does a patient with heel pain and a history and physical exam consistent with plantar fasciitis/fasciosis always require an immediate radiograph? Probably not. It's when that patient fails to respond to therapy or the examination reveals something atypical that further imaging may be necessary.
Despite the high availability of advanced technology, it would be best if we started asking ourselves:
Is it the right time and place for advanced imaging?
Is that advanced imaging going to tell me something I wouldn't have otherwise known?
Was the history and physical adequate or am I using the technology as a substitute for my own ears, hands, and mind?
Too often, we fail to consider these questions and go right to the advanced technology.
It's interesting how our perspective changes when the power goes out. Think about how you feel during a storm when the electricity fails. All of a sudden, the television, lights, kitchen appliances, and landline phones don't work, and your first thought is, "What do I do now?" All of a sudden, your world looks a little different. Things aren't so easy. Boiling water becomes a major undertaking. Everything is just a little foreign, a little dangerous. This is all because we've become so reliant on our technology. Try this with your medical practice. Turn the power out on your medical care for a bit and see what happens.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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