The Technological Imperative in Medicine: Proceedings of a Totts Gap colloquium held June 15–17, 1980 at Totts Gap Medical Research Laboratories, Bangor, Pennsylvania

153 Pages·1981·7.503 MB·English

by  Stewart Wolf, Beatrice Bishop Berle (auth.), Stewart Wolf, Beatrice Bishop Berle (eds.)

THE TECHNOLOGICAL
IMPERATIVE IN
MEDICINE
THE TECHNOLOGICAL
IMPERATIVE IN
MEDICINE
Edited by
STEWART WOLF
Director, Totts Gap Institute, Bangor, Pennsylvania,
Vice-President, Medical Affairs, St. Luke's Hospital, Bethlehem, Pennsylvania,
Professor of Medicine, Temple University, Philadelphia, Pennsylvania
and
BEATRICE BISHOP BERLE
Former Assistant Clinical Professor of Medicine and Preventive Medicine,
Cornell University Medical College, and
Associate Professor of Clinical Medicine,
New York University School of Medicine, New York, New York
PLENUM PRESS • NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data
Main entry under title:
The Technological imperative in medicine.
"Proceedings of a Totts Gap colloquium held June 15-17, 1980 at Totts Gap
Medical Research Laboratories, Bangor, Pennsylvania" - Verso t.p.
Bibliography: p.
Includes index.
1. Medical innovations-Social aspects-Congresses. 2. Medical innovations-
Economic aspects-Congresses. I. Wolf, Stewart George, 1914- . II. Berle,
Beatrice Bishop, 1902-
RA418.5.M4T396 362.1 '042 81-17751
ISBN-13: 978-1-4684-4120-8 e-ISBN-13: 978-1-4684-4118-5 AACR2
001: 10.1007/978-1-4684-4118-5
Proceedings of a Totts Gap colloquium held June 15-17, 1980 at
Totts Gap Medical Research Laboratories, Bangor, Pennsylvania
© 1981 Plenum Press, New York
Softcover reprint of the hardcover 15t edition 1 981
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
TOTTS GAP MEDICAL RESEARCH LABORATORIES, INC.
OFFICERS, DIRECTORS, AND TRUSTEES
Mark D. Altschule, M.D., President; Visiting Professor, Harvard Medical School; Con
sultant, Francis A. Countway Library of Medicine, Boston, Massachusetts
Beatrice B. Berle, M.D., Vice President; Former Assistant Clinical Professor of Medicine
and Preventive Medicine, Cornell University Medical College, and Associate Professor
of Clinical Medicine, New York University School of Medicine, New York, New York;
Former Research Associate, Albert Einstein College of Medicine, New York
Stewart Wolf, M.D .. Secretary; Vice President for Medical Affairs, St. Luke's Hospital,
Bethlehem, Pennsylvania; Professor of Medicine, Temple University School of Medicine,
Philadelphia, Pennsylvania
Phylls B. Sheridan, Ed.D., Treasurer; Assistant to the Vice President for Medical Affairs,
St. Luke's Hospital, Bethlehem, Pennsylvania; Former Administrator, Bureau of Applied
Social Research, Columbia University, New York
William B. Bean, M.D., Sir William Osler Professor of Medicine, University of Iowa, Iowa
City, Iowa; Former Director, Institute for the Humanities in Medicine, University of
Texas Medical Branch, Galveston, Texas
Andre Cournand, M.D .. Professor Emeritus of Medicine, Special Lecturer, College of
Physicians and Surgeons of Columbia University, New York
George Giaquinto, President, Atlantic Apparel, Wind Gap, Pennsylvania; Former Mayor,
Roseto, Pennsylvania
Miss Helen Goodell, Research Associate Emeritus, Department of Neurology, Research
Consultant Emeritus, Westchester Division, Cornell-New York Hospital Medical
Center, New York and White Plains
Mr. George Plush, Realtor, 8angor, Pennsylvania
Mr. Albert Rosenfeld, Consultant on Future Programs, The National Foundation, New York;
Former Science Editor, Saturday Review
Sol Sherry, M.D., Professor and Chairman, Department of Medicine, Temple University
School of Medicine, Philadelphia, Pennsylvania
Eliot Stellar, Ph.D., Professor of Psychology and former Provost, University of Pennsyl-
vania, Philadelphia, Pennsylvania
Mr. Richard Suck, Former President, St. Luke's Hospital, Bethlehem, Pennsylvania
Mr. Oscar Swarth, President, D'San Corporation, New York
Nicholas T. Werthessen, Bioscientist, Office of Naval Research; Senior Research Asso
ciate, Brown University, Providence, Rhode Island.
Joseph M. White, M.D., Executive Director for Medical Education, St. Paul's Hospital;
Professor of Anesthesiology, University of Texas Southwestern Medical School, Dallas,
Texas
PREFACE
This volume contains the edited proceedings of a Totts
Gap Colloquium held June 15 to 17, 1980 at Totts Gap Medical
Research Laboratories in Bangor, Pennsylvania under the
sponsorship of three neighboring community hospitals in the
Lehigh Valley; St. Luke's Hospital of Bethlehem, Easton
Hospital of Easton and Muhlenberg Medical Center of Bethlehem.
The objective of the meeting was to examine from several
points of view the impact of rapidly proliferating technology
on medical education, practice and research, on hospitals
and on the community at large. The participants were selected
not only for their diversity of experience and point of view,
but also for ability to listen as well as to speak. They
were asked to examine, in an informal analytical dialogue,
the effects on the quality and cost of health care and
health education brought about by increasing reliance on
medical technology. A further aim was to explore various
strategies through which might be devised an affordable
way to benefit fully from technological advances without
compromising human initiative or diminishing emphasis on
clinical judgment and effective communication between doctor
and patient.
The participants included a medical student, seasoned
practitioners and medical educators, young specialists,
researchers, administrators and members of boards of trustees
of community hospitals and laymen as follows:
Dr. Robert Ackerman, Associate Professor of Radiology,
Harvard Medical School and Director of the Carotid Evaluation
and Cerebral Blood Flow Laboratories at Massachusetts General
Hospital.
Dr. Paul B. Beeson, Distinguished Physician, VA Hospital
Seattle, Washington, formerly Nuffie1d Professor of Medicine
Oxford University, England.
vii
viii PREFACE
Dr. Stanley Joel Reiser, Associate Professor of the History
of Medicine, Harvard University.
Dr. Howard Spiro, Professor of Medicine at Yale University
and Director of the Division of Gastroenterology.
Dr. William A. Tisdale, Professor of Community Medicine,
University of Vermont.
Dr. Sankey V. Williams, Assistant Professor of Medicine
and Associate Director, National Health Care Information
Center, University of Pennsylvania.
Other participants, viewing the issues from the
perspective of the community, were:
Dr. Mark D. Altschule Dr. James Regan
Mr. Nicholas Balabkins Dr. William Reppert
Dr. Edward Benz Dr. Charles Saunders
Dr. Beatrice Berle Dr. Lee Serfass
Dr. Andre Cournand Dr. Hilary Siebens
Dr. Stephen Diamond Mr. George St. George
Dr. George Donaghue Mr. Oscar Swarth
Dr. David Feinberg Dr. Nicholas T. Werthessen
Miss Helen Goodell Dr. Kenneth Wildrick
Mr. Albert V. Moggio Dr. Stewart Wolf
Mr. Donald Porter
Background literature made available to the participants
is listed at the end of the book following the bibliographic
citations.
We are grateful to Oscar Swarth who generously took
charge of projection and recording, to Helen Goodell who
assisted mightily in the process of editing and Joy Ann
Lowe who dealt patiently with the manuscript through its
many revisions.
CONTENTS
Chapter 1
LEARNING THE RATIONAL USE OF TECHNOLOGY
IN MEDICINE ••••••..••••••••.•.•..•••••.• 1
Chapter 2
IMPACT OF TECHNOLOGY ON MEDICAL PRACTICE ••••• 35
Chapter 3
IMPACT OF TECHNOLOGY ON MEDICAL EDUCATION ••• , 55
Chapter 4
IMPACT OF TECHNOLOGY ON COMMUNITY HOSPITALS
AND THEIR PATIENTS •••••••••••••.••••••.• 87
Chapter 5
ADAPTATION TO MEDICAL TECHNOLOGY--SHAPING
THE FUTURE •••••••••.••.••••..••.•.••.•.•• 99
Chapter 6
MEETING THE CHALLENGE--SUMMARY & FORMULATION •• 125
REFERENCES •••••••••••••••••••••••••••••••••••••••• 137
BACKGROUND LITERATURE ••••••••••••••.•••••••••••••• 143
INDEX •••••••••.•.•.••••••••••.•..••••.••..•••.•..• 147
ix
CHAPTER 1
LEARNING THE RATIONAL USE OF TECHNOLOGY IN MEDICINE
DR. REISER: An accurate identification of the first
application of technology to the diagnosis of disease would
certainly elude the conscien-
Historical Perspective tious historian. A conven-
ient place to start, would be
with the stethoscope introduced by the 19th century French
physician, Laennec.
Physical diagnosis in Laennec's time consisted mainly
of visual examination of the patient: looking at the color
of the skin, facial expression, posture, anything that the
eye could convey about the problems of illness although
centuries before, Hippocrates had suggested that the
physician place his ear to the chest of the patient to
inquire about the sounds within.
One day in 1876 Laennec was called as consultant in
the case of a young woman with possible heart disease. He
found that the traditional methods of evaluating patients
were inadequate· to the task at hand. Laennec had seen
direct auscultation used occasionally by a couple of his
colleagues, the less intellectual surgeons, but was reluctant
to apply it in this case because the patient was a young
woman. However, in one of those rare insights which
suddenly occur in a flash and result in a great discovery,
he thought of the fact that sounds passing through solid
bodies become augmented. Quickly rolling some sheets of
paper into a tube, he placed his ear to one end and the
other to the chest of the patient.
2 CHAPTER 1
The heart sounds which emerged led him to think that by
pursuing this mode of examination, he might learn new
signs of heart and lung diseases and develop a new set of
diagnostics. In discussing his discovery, like most
innovators, Laennec was perhaps too enthusiastic about its
prospects and too critical of the older evidence of illness.
For the hundred years that preceded Laennec's discovery,
history taking was viewed as the most important, even the
ultimate, diagnostic tool. G.B. Morgagni, in his book,
THE SEATS AND CAUSES OF DISEASES INVESTIGATED BY ANATOMY,
published in 1761, urged the correlation of the patient's
symptoms with the location and nature of lesions found at
autopsy. Knowledge gained at the autopsy table enabled the
physician to visualize the anatomical disorder from a
careful analysis of the patient's symptoms. According to
Laennec verbal testimony gave inferior evidence: the same
symptoms were described by the patients having different
diseases, and different symptoms were expressed by those
wi th th.e same diseases. He argued that the doc tor's senses
were superior to the testimony of the patient, that the
doctor should listen to the patient through his ear but
bypass the patient's mind. This was the fundamental change
in the attitude of doctors toward diagnosis, to ignore
the subjective evidence from the patient in the evaluation
of his illness. This was the heyday of physical diagnosis
and also of individualism in medicine. Doctors were trained
in the use of their own senses, trained to believe that
they could depend only on themselves as diagnosticians.
Just as they had decreased their reliance on the patient,
in many ways they did the same to colleagues. We all know
that the sounds heard through a stethoscope placed on the
same spot may be interpreted differently by different
listeners. Alvan R. Feinstein in his masterly treatise
CLINICAL JUDGMENT (1967) shows how difficult it is to
compare that sort of clinical evidence. (1).
The 20th century has created an entirely new set of
diagnostics, which developed along side those of physical
diagnosis in the 19th century. This is the whole armory of
material which we refer to as laboratory diagnosis. It
encompasses the automated analyzer of the laboratory, the
x-ray, the electrocardiograph and other machines that
essentially produce numerical and graphic data. These forms
of evidence have taken precedence in the 20th century over