74 - R2D2
Bedside Rounds
What does it mean when a computer can make better medical decisions than a human? The progress in large language models, and in particular the popularity of ChatGPT, has brought these questions to the forefront in 2023, but we’ve been discussing this for over 50 years. In this episode, Dr. Shani Herzig and I are going all the way back to the early 1970s with the invention of AAPHELP, the first real clinical decision support system, and the first time doctors had to contemplate working with – or competing against – computer systems.
info_outline
73 - Seadragon
Bedside Rounds
What happens when a patient far from surgical care – say, at the bottom of the Pacific ocean on a submarine, or at a research base in Antarctica in the middle of the winter – develops a surgical abdomen? This dilemma was the impetus to build the first truly effective clinical decision support system – and to grapple with what it means when a computer can make better medical decisions than a doctor. In this episode, part one of three, we discuss the dramatic stories of appendectomies at Novolazarevskaya and aboard the submarine Seadragon. Also, there’s a brand new #AdamAnswers about the...
info_outline
72 - Problems
Bedside Rounds
American doctors spend the majority of their time during the day on the computer, either writing or reading notes about their patients; only a small fraction is spent with the human beings in their care. Technology itself – especially the electronic medical record – has often been blamed for this. But in this episode – a recorded grand rounds that I gave at the San Francisco VA in 2022 – I argue that this alienation has its roots in the way we’ve decided to organize clinical data, and the assumptions that we’ve made about the nature of medical care. In particular, I’m going to...
info_outline
71 - A Doctor's Work, part 2
Bedside Rounds
In the past episode, cultural and medical historians Lakshmi Krishnan and Mike Neuss discussed the history of the actual work of the doctor – Holmesian detective, data entry clerk, or something else altogether. In this episode, we conclude our discussion by talking about what type of metaphors are best suited for clinical work. Plus a brand new #AdamAnswers about the reason that American doctors are so obsessed with using, well, the # symbol in our notes.
info_outline
70 - A Doctor's Work
Bedside Rounds
What do doctors actually do? Are they Sherlockian detectives, hunting down obscure clues to solve intractable cases? Are they virtuosic experts, training for half a lifetime to bring the latest science to bear to cure disease? Or are they clerks, whose main job is to collect and enter data into the electronic health record? In this episode, Adam is joined by medical and cultural historians Lakshmi Krishnan and Mike Neuss to discuss the stories we tell about our own work – and how this often conflicts with the realities of clinical practice.
info_outline
69 - The Database
Bedside Rounds
How do doctors actually think? And if we can answer that, can we train a computer to do a better job? In the post-WW2 period, a group of iconoclastic physicians set about to redefine the nature and structure of clinical reasoning and tried to build a diagnostic machine. Though they would ultimately fail, their failure set the stage for the birth of the electronic health records, formalized the review of systems, and set up a metacognitive conflict that remains unresolved to this day. This episode, entitled “The Database,” is the second part of this on the history of diagnosis with Gurpreet...
info_outline
68 - The History
Bedside Rounds
Internal medicine physicians like to pride ourselves on our clinical reasoning – the ability to talk to any patient, pluck out seemingly random bits of information, and make a mystery diagnosis. But how does this actually work? In this episode, called The History, I’ll be joined by Gurpreet Dhaliwal as we explore the beginnings of our understanding on how clinical reasoning works – starting in the middle of the 19th century with polar tensions between two ways of approaching our patients that are still felt today. Along the way, we’ll talk about the American Civil War, Car Talk,...
info_outline
The Facemaker with Dr. Lindsey Fitzharris (#histmedconsultservice)
Bedside Rounds
Modern plastic surgery was born out of the horrors of trench warfare in World War I. In this episode, Adam interviews historian Lindsey Fitzharris about her new book The Facemaker, about the life of surgeon Harold Gillies and his quest to rebuild his patients' faces.
info_outline
67 - Fever on the Frontier
Bedside Rounds
In the early 19th century, a strange new illness, seemingly unknown to medicine, ravaged settler communities in the American Middle West. As fierce debates about this new disease, now called milk sickness, raged – was it from toxic swamp gasses? arsenic in the soil? infectious microorganisms? from the poor constitutions of the settlers – an irregular medicine woman named Dr. Anna and an indigenous Shawnee healer discovered the cause of the disease and successfully prevented it in their community. But their discovery went unheeded for over a half century. This is a live podcast that I gave...
info_outline
66 - Burnout
Bedside Rounds
Burnout seems to stalk healthcare workers; between a third and a half of doctors and nurses had symptoms of burnout BEFORE the COVID-19 pandemic. Major medical associations have recognized burnout as a serious problem and the condition is being added to ICD-11 as an “occupational phenomenon.” How has burnout gotten so bad? In this episode, the first #HistMedConsultService, I’m joined by historians of healthcare and emotions Agnes Arnold-Forster and Sam Schotland to historicize burnout.
info_outlineCan we ever know what causes a chronic disease? In this episode, I’m joined again by Dr. Shoshana Herzig to finish a three-part miniseries on Bradford Hill and Doll’s attempts to prove that smoking caused lung cancer. We’ll talk about the first prospective cohort trial in history, 1960s “Fake News” from tobacco companies, public spats with the most famous statistician of the 20th century, and the development of the Bradford Hill Criteria, a guideline, however imperfect, that gives doctors a blueprint to finally figure out what causes diseases.
Sources:
- Crofton J, The MRC randomized trial of streptomycin and its legacy: a view from the clinical front line. J R Soc Med. 2006 Oct; 99(10): 531–534.
- Daniels M and Bradford Hill A, Chemotherapy of Pulmonary Tuberculosis in Young Adults, Br Med J. 1952 May 31; 1(4769): 1162–1168.
- Dangers of Cigarette-smoking. Brit Med J 1, 1518 (1957).
- Doll, R. & Hill, B. A. Lung Cancer and Other Causes of Death in Relation to Smoking. Brit Med J 2, 1071 (1956).
- Doll, R. & Hill, B. A. Smoking and Carcinoma of the Lung. Brit Med J 2, 739 (1950).
- Hill, A. The Environment and Disease: Association or Causation? J Roy Soc Med 58, 295–300 (1965).
- HOFFMAN, F. L. CANCER AND SMOKING HABITS. Ann Surg 93, 50–67 (1931).
- Keating C, Smoking Kills: The Revolutionary Life of Richard Doll. 2009.
- Morabia, A. Quality, originality, and significance of the 1939 “Tobacco consumption and lung carcinoma” article by Mueller, including translation of a section of the paper. Prev Med 55, 171–177 (2012).
- Ochsner, A. & bakey. Primary pulmonary malignancy: treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. Ochsner J 1, 109–25 (1999).
- Ochsner, A. My first recognition of the relationship of smoking and lung cancer. Prev Med 2, 611–614 (1973).
- Parascandola, M. Two approaches to etiology: the debate over smoking and lung cancer in the 1950s. Endeavour 28, 81–86 (2004).
- Phillips, C. V. & Goodman, K. J. The missed lessons of Sir Austin Bradford Hill. Epidemiologic Perspectives Innovations 1, 1–5 (2004).
- Proctor, R. Angel H Roffo: the forgotten father of experimental tobacco carcinogenesis. B World Health Organ 84, 494–495 (2006).
- Wynder, E. RE: “WHEN GENIUS ERRS: R. A. FISHER AND THE LUNG CANCER CONTROVERSY”. Am J Epidemiol 134, 1467–9 (1991).