MONITORS AND CLINICAL JUDGMENT

Abstract

M ANY of us have been invoIved in discussions of the curricuIa for premedica1 and medica students. In most of these discussions there is genera1 agreement that “eIectronics” is a critica item in the modern curricuIum. I suspect that some physicians are led to this beIief because they are impressed with the array of electrica gear that surrounds the anesthetist, the cardiac surgeon and other physicians who use such instruments. I suspect aIso that those who look upon bIinking, beeping and clicking machines that spew out reams of paper with hieroglyphic tracings or make unintelligibte Iines on an oscilloscope have some idea that these devices are providing answers to cIinica1 probIems that are not possibIe through the exercise of we11 deveIoped cIinica1 judgment. FinaIIy, I suspect that some physicians, incIuding those on the faculties of medica1 schooIs, are interested in incIuding “eIectronics” in medica education because they beIieve that the modern physician needs to be a super electrician. This concept has about reached the stage at which lay people and attorneys (encouraged by the events of this eIectronic era) are incIined to beheve that faiIure to empIoy machinery in the practice of medicine constitutes malpractice. I am incIined to beIieve that modern medicine is overwheImed by gadgetry to the extent that physicians are permitting instruments to usurp cIinica1 judgment. I do not mean to decry the use of instruments in the practice of medicine. The study of “eIectronics” may provide the modern physician with knowIedge that wiI1 be usefu1 in the better understanding of transmission of nerve impuIses, the changes in potential accompanying muscle action, the eIectrophysica1 factors associated with synaptic transmission, and the like. Certainly, there are many usefu1 and dependabIe gadgets that provide reIiabIe information about the patient. It is important, however, for the physician empIoying machines, either directIy or indirectIy, to be aware of their limitations. I propose to cite a few exampIes of standard instruments which are capabIe of adding to the tota information about a patient but which are not capable, even in this age of cybernetics, of doing anything more than providing data which stiI1 have to be interpreted by the physician. I have been invoIved in discussions with the medica staffs of hospitaIs in which a serious effort was being made to require routine monitoring, during anesthesia and operation, with an eIectrocardiograph. Such discussions were often prompted by the naive belief that such monitoring wouId at Ieast diminish, if not entireIy eIiminate, cardiac arrests. It wouId be foohsh indeed to debate the usefuIness of an electrocardiogram. However, it would be foohsh also to assume that such monitoring can compensate for the indoIent, inattentive or inept anesthetist. It is obvious to a11 familiar with eIectrocardiography that this instrument reports only the eIectrica1 events taking place in the heart and it cannot represent functiona competence of the heart. Changes in the eIectrocardiogram may presage deterioration of function, and to this extent the instrument may be useful as a monitor. There have been many documented instances in which essentiaIIy norma compIexes appeared on the tracing in the presence of a compIeteIy nonfunctioning heart. As I wiI1 state severa times during this discussion, the instrument reflects only one aspect of cardiac activity and the physician must be aware of this limitation and not assign to the instrument any occuIt powers. The eIectrocardiograph is usefu1 in those patients in whom there is need to define more specificaIIy changes that may be precipitated or augmented