I have a new textbook.
Technically two new textbooks. It seems medicine has expanded so much that the “Harrison’s Principles of Internal Medicine, Twentieth Edition” is now two volumes.
The textbook used in my residency was a manageable tome that could be carried and referenced. Not anymore.
These two beasts have smaller print, more contributors, more data and research than truly is comprehensible to one person.
A profession that barely had any textbooks with science, anatomy, or researched medical treatments 120 years ago now can barely squeeze it all in 3,500 pages of small print two column formatted text.
Why a new textbook when all the data I could ever want is available on digital format and readily referenced from my phone? Because there is a value in being able to see and hold a referenced set of information in one physical volume.
There is a comfort as a human being in seeing something as a whole and being able to scan, cover, assimilate and organize data, information, and structure in one unit that remains, well, one unit.
I will never learn it all. I will never understand it all. But I can surround it, understand its scope, and dive in for an attack at a point where needed. Already have.
It is the difference between seeing the national park in person from Newfound Gap versus seeing a digital picture. Same scene. One is real. It gives a profound impression of the vastness that can be explored — all while providing a sense of location in the realm of infinity.
Page one of the less than humble primer begins with a very clear imperative — the remaining 3,499 pages are useless and of utter irrelevance if an appropriate history and exam is not learned by the physician (medical professional).
It was an emphasis of the first year of medical school. How to learn what the patient is saying, not saying, and needs to say. What is relevant from the past few days and past decade? Has this occurred before? What worked? What did not work?
What other symptoms are occurring that might be important? What is going on in life in general that may be contributing?
Weddings, funerals, divorces, moving and work stress contribute more to our physical health — or lack thereof — than is measurable. It is important to at least attempt to inquire.
Smoking. Alcohol. Family dynamics. Medicines. Supplements. Past surgeries, tests and diagnosis.
Then exam. The exam part has truly taken a backseat to modern medicine and testing. There are entire thick textbooks published prior to my years in medical school on how to exam the heart.
Right. We just order an echocardiogram now. No physician wants to face a lawyer explaining the difference in what they heard between the first and second heartbeat, whether it was crescendo or decrescendo, when an echocardiogram will provide the written observed report.
It is reality. I’ve even had patients wonder why I am ordering an EKG in the office when their smartphone told them they had atrial fibrillation during the night. There is a reason. Twelve leads are better than one. Maybe, just maybe, there is something more ominous.
This retrospective perspective of paper, textbook and technique comes a week before I am to travel back to my alma mater, Tennessee Technological University (just down the street from Ralph’s Doughnuts — get the Buttertwist) and speak to the Pre-Med Club.
I go once a year. I truly enjoy it. I get to speak and interact with college students who are pondering a journey into medicine. Potential physicians, nurses, dentists, veterinarians, pharmacists, physical therapists and occupational therapists to name a few.
“Are you going to tell them to get out while they can?” A friend recently asked.
No. But I am not sugar coating it, either.
I want them to know what they are heading into, at least as best I possibly can express it.
Medicine and the delivery of medical care has been irrevocably changed in the past two years.
The confluence of a global pandemic, digital communication, political tsunamis, infinite information at fingertips and ability to order practically anything to the doorstep in two days has created a recipe for society and medical revolution.
The potential for good — better and more efficient medical care — is enormous.
The potential for bad — the collection, control and distribution of medical information and care — is also enormous.
How this unfolds will depend upon leadership — good and bad, political and medical — and personal decisions made by individuals.
Nevertheless, the connection between the person and the professional begins with communication and assimilation on a direct level.
It is a process of learning. I am far from perfect at it. But it is the beginning of everything in medical care.
That is my message to the students.
And to myself. The distractions in the current world of medicine are extreme — from insurance and medicare requirements, coding and computer charting, internal and external communications, phones and digital devices chirping and chiming during patient interactions — all of it can be enormously distracting and frustrating.
The process of focusing and listening remains the most massive challenge of every day. I know I fail. I know I will strive to improve.
I know that is what I will tell them.
Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and family physician in Sevierville.