Privileged information

In 1910, taking a person's blood pressure was considered revolutionary, a high-tech practice that was of uncertain benefit.

Dr. Harvey Cushing of Johns Hopkins Hospital in Baltimore had observed a blood pressure device while traveling in Europe, developed by Dr. Sciopione Riva-Rocci. Cushing brought this new technology back with him to the U.S. and promptly promoted its use, convinced that this insight into gauging the forcefulness of blood pressure would yield useful clinical insights.

But, in 1910, practicing physicians rejected this new technology, preferring to use their well-established and widely practiced technique of pulse palpation (feeling the pulse), skeptical that the new tool added value. Medical practice of the day was rich with descriptions of the strength and character of the pulse: pulsus parvus et tardus (the slow rising pulse of aortic valve stenosis), the dicrotic notch of aortic valve closure transmitted to the pulse, the "water-hammer" pulse of aortic valve insufficiency.

Over the next 20 years, however, the medical community finally gave way to the new technique, although only physicians were allowed to use blood pressure devices, as nurses were regarded as incapable of mastering the skills required to perform the procedure properly.

Stethoscopes were also gaining in popularity in the early 20th century, but were also the exclusive province of physicians trained in their use. Nurses were not allowed to use stethoscopes until the 1960s. Even then, nurses were not allowed to call them "stethoscopes," but "nurse-o-scopes" or "assistoscopes," and the nurses' version of the device was manufactured to look different to avoid confusion with the "real" doctor's tool.

And just half a century ago, if you wanted to look at a medical textbook, you would have to go to the library and ask for special permission. The librarian would lower her glasses and look you up and down to determine whether or not you were some kind of pervert. Only then might you be granted permission to peer into the pictures of organs and naked bodies.

Such has been the spirit of medicine for centuries: Medicine and its practices are meant to be secret, the insider knowledge of a privileged few.

Fast forward to 2008: The Information Age has overturned the rules of privileged information. Now you have access to the same information as I do, the same information available to practicing physicians. The playing field has been levelled.

Curiously, while information access has advanced at an instantaneous digital pace, attitudes in medicine continue to evolve at the traditional analog crawl. Many of my colleagues continue to be dismayed at the new public access to health information, belittle patients for excessive curiosity about their health, lament the erosion of their healthcare-directing authority. And while new concepts race ahead as we race towards a wiki-like collective growth in healthcare knowledge, physicians are still mired by their reluctance to abdicate their once-lofty positions as chief holders of secrets.

I believe that this is part of the reason why family doctors and cardiologists have been slow to adopt technologies like heart scans and self-empowering programs like Track Your Plaque: processes that take heart disease prevention away from the hands of physicians and place more control into the hands of the people.

Imagine the horror felt by physicians in 1935 of a young upstart nurse boldly trying to use a stethoscope to take a patient's blood pressure. You can imagine the internal horror now being felt as you and I dare to take control over heart disease and deny them the chance to put in four stents, three bypass grafts, then direct our future health habits.

But technology has a way of marching on. It will encounter resistance, bumps, and blind-alleys, but it will go on.

Comments (9) -

  • Barry in Indy

    7/12/2008 1:18:00 AM |

    Power to the people!
    Thanks for leading the way.

  • Zute

    7/12/2008 2:35:00 AM |

    Wow!  That sure is interesting.  I've run into so many lay people that know more than their specialists do about cutting edge treatments and preventions.  It *is* threatening to doctors and they lash out at us all the time.  

    Well, I'll be happy when this crop of fuddy duddies retires and some newer, hopefully better educated about how to utilize wonderful resources their patients are using, takes their place.

  • Anonymous

    7/12/2008 3:35:00 AM |

    It's the 'doctor as god' syndrome.

  • Jenny

    7/12/2008 12:58:00 PM |

    Even more important it that ordinary folks have instant access to the medical journals. In the 1980s, to read journal articles and follow the citations I used to have to drive to a medical school, go into the basement stacks, and hunt up each journal individually. To see the online indexes I would have to wait patiently until all the medical students were done with the 4 terminals and one was free.

    It would take a whole day to follow one series of citations.

    Now I can do the same operation in minutes, at home.

    What I find sad though, is that of all people I know, physicians are the least likely to read the actual research articles involving new drugs and treatments, or even, at times, to have heard about their findings beyond the soundbyte level that shows they read about it in a summary newsletter.

    Doctors are often annoyed when patients have done research they haven't bothered to do, but sadly, this does not seem to motivate them to dig in.  

    This is one reason why doctors are often years behind the patient community in learning about the dangerous and even fatal side effects of the drugs they prescribe.

    I had posted about the heart-related dangers of Avandia, for example several years before they were "discovered" by doctors. The research data was there by then. And even now most doctors are not aware that both Avandia and Actos cause dangerous levels of osteoporosis with long term use. That information has been around for more than two years.

  • Anne

    7/12/2008 2:10:00 PM |

    I took an article that I printed from the internet to my doctor . He told me that he never reads anything patients bring him from the internet. When I said it was from a peer reviewed journal, he told me that did not matter as it came from the internet - huh?

    Patients also need to take responsibility. They need to understand how activity, diet and lifestyle impact health. They need to question their doctors and get copies of all tests. On this forum, and ones similar to it, we meet people who are well informed on health issues. I know too many people who tell me "If my doctor thought that (insert vitamin D, blood glucose, heart scan, etc) needed to be checked, he would have done it".  I can't believe all the people who accept "normal" as the answer to test results. I had a doctor tell me "normal" once and then I found out the wrong test had been done!!

    Kudos to the docs who are willing to listen to their patients and make them partners in health care. Kudos to the patients who learn about their health issues make changes in their lifestyle to optimize their health.

    I love the leveled playing field - it saved my life.

  • Anonymous

    7/12/2008 3:50:00 PM |

    Oh Dr. Davis, you make me think!

    Perhaps the beautiful text of the _Gray's Anatomy_ we had around the house (the real one, my father had been a chiropractic student post WWII) may have sowed the seeds of dissent with many aspects of common "modern" medical practice?  An inquiring mind and a little common sense is a... dangerous thing?  Hardly!

    Knowledge is powerful... so what if it makes some cold, rigid and paternalistic doc uncomfortable?  It's MY health and MY life at stake, not his or hers.

    If history is a guide, I think it's fair to say that what is common practice today, will be outmoded and archaic in a few years.  Hopefully in it's place will be a true HEALTH care system, not the current pharma and equipment-driven SICKNESS care system.

    Thanks for the great blogs, so thought provoking AND informative.



  • Jenny

    7/12/2008 4:01:00 PM |

    The problem is exponentially compounded by the intrusion into the physician/patient relationship of the insurance companies, and by the fear of litigation if "standards of care" which are imposed by professional associations are violated.  As regards standards, they are desirable and necessary, but how are they derived?  In many cases, guidelines such as those put forth by the American Diabetes Association, which blatantly advocates a carb-rich diet which is harming, even killing, people  daily, must owe their existence at least in part to influence by drug companies.  In the light of the latest fiasco about obesity in children and the advocated use of statins for them, unless a miracle occurs, we will see  pediatricians forced to adopt a standard of care which will inevitably lead to great harm.  When will the litigation be brought to bear on the real culprits?  There is not enough money in the world to compensate.  I don't mean to imply that these are the only factors in the "I know better than you and your health is more my concern than yours" attitude, but they complicate and compound it greatly.  Even genuinely caring and open-minded health professionals, and I'm sure there are many, are caught in this corporate/state web.  Power to the people, and to the free market, indeed-- and it may come about through forums like this one if we are determined and lucky.

  • JPB

    7/12/2008 11:19:00 PM |

    There was a blog entry in "Kevin.MD" last year that said it all - "Do you know more than your doctor?"  Of course, this piece totally put down anything that the patient/client might bring to the mix.  When will doctors realize that their clients have brains?

  • davek_

    7/17/2008 4:57:00 AM |

    This thread could go in many directions, but having worked in a hospital during college (as a computer engineering student) - what amazed me is the requirements for pledging the medical fraturnity.  Multiple days without ever leaving the hospital.... Then my cousin's daughter finishes Stanford Med School and almost dies in a car accident falling asleep after two days without leaving the hospital.

    How do we expect doctors to read new materials when they have been programmed to work more than any union would allow, or any person should.  Can you image Pilots being allowed to work a 24 hour shift?

    Doctors are over committed and they shouldn't be - they should have time to "give care".  Not sure if this is greed, the need to pay litigation insurance or what.. but it seems the root cause of much of what is discussed here.

    Drugs are easy solutions to a lack of time to learn about alternatives.