Years ago, when I was applying to medical schools, I was frequently asked why I wanted to be a doctor. I regurgitated a series of bland justifications: I wanted to help people, and make a difference in their lives; I was inspired by the challenge of diagnosing and fighting disease; I came from a medical family and had seen firsthand how satisfied my parents were with their careers. At the time, I was convinced that these were not only sincere answers, but ones that served my application well. Upon reflection, a decade and a half later, I chuckle at my responses. Not only did they lack originality, but they left out the seminal inspiration for my medical career: bones. Actually, Bones, as in Dr. Leonard “Bones” McCoy, the chief medical officer of the USS Enterprise.
Dr. McCoy was my favorite character on my favorite childhood television show, Star Trek. Throughout much of grade school, my brother and I settled down daily to watch an hour of exploration of space's final frontier. We didn't care how beautiful a day it was outside or how much homework waited to be done; Star Trek could not be missed. We never went so far as to attend a Star Trek convention, but I do recall owning (and wearing) a blue Starfleet uniform.
There were lots of great characters on Star Trek: the charismatic Captain James Kirk, the intellectual Mr. Spock, and the inflective Montgomery “Scotty” Scott, who happened to be, that's right, Scottish. But Dr. McCoy was the most marvelous of all: passionate, principled, intuitive, and as cantankerous as a cactus. He was also a peerless physician who made the job look exceedingly easy. Walking up to a patient in the sick bay of the Enterprise, Bones need only wave his medical tricorder — a salt shaker with lights and a hum — and he'd have the diagnosis. Then he'd aerate the patient with a puff or two of noninvasive hypospray, and voilà, the ailment was cured. No needles, no blood, no pain, no stink, no discernible liability, absolutely nothing but easily applied medical technology. To boot, Bones could play the “doctor card” to get out of other tasks, punctuating the copout with lines like “Dammit, Jim, I'm a doctor, not an engineer,” or “Dammit, Jim, I'm a doctor, not a bricklayer,” or “Dammit, Jim, I'm a doctor, not a coal miner.”
Who, I wondered, wouldn't want to emulate Dr. McCoy?
Sadly, medical practice in the 21st century is not as easy for me as it was for Dr. McCoy in the fictional 23rd century. A diagnosis isn't always apparent, and most serious complaints require invasive testing. Treatment is rarely as simple as a nasal spray, and everything I do is shrouded by the specter of medical-legal ramifications. Nonetheless, as I reflect on my fictional mentor, it becomes apparent how current medical practice is moving, perhaps inexorably, toward a Dr. McCoy-like future.
More and more, physicians rely on noninvasive testing for important information: X-rays, CT scans, EKGs, MRIs. And treatments have evolved; we now have a nasal flu vaccine, and pain medication can be given via skin patch. Surgeries can be performed by inserting cameras through tiny incisions and in some cases by using pulses of sound waves or lasers. Recently, I read about proton-beam therapy, a developing technology that involves zapping tumors with a beam of high-speed protons that deliver DNA-warping radiation to a malignancy without damaging the surrounding tissues. Someday soon, writes William Hanson, MD, the author of The Edge of Medicine: The Technology That Will Change Our Lives, proton-beam therapy will emerge as a “medical tour de force, in which the patient walks into a room, lies down on a bed, and, for the minutes he's there, all of this magical stuff happens around him and to him, painlessly and silently, perhaps while he listens to his iPod.”
Such technology, while amazing, also highlights a fundamental transformation in the practice of medicine. Nowadays, the doctor-patient relationship is more about interpreting laboratory or radiographic tests, and explaining the risks and benefits of treatment, and much less about hands-on artistry. Test-based medicine is more scientific, and has less variation in quality, but its practice blurs the essence of what being a doctor used to mean.
Dr. McCoy made doctoring look easy, perhaps too easy. Surely, any lowly officer on the Enterprise could have been taught how to use the tricorder and the hypospray? Was there really anything to it? I encounter many patients who have a similar attitude toward modern medicine. I occasionally have patients come into the emergency department, and declare, “I am here for an MRI,” or ask “Doctor, don't you think I need a CT?” Sometimes these statements are justified, but sometimes I feel like boldly beaming these people to the land of reality checks.
Often, I feel like a secretary as well as a physician: ordering tests, filling out forms, reconciling medications, and documenting the hell out of all of it. This physician focus on bookkeeping will likely only increase in the future. And while I'll admit that on the macro level this amounts to “progress,” it does make me reconsider some of those answers I gave to the medical school admissions officers years ago.
Dr. Ballard adapted this article from a piece he wrote for Marin Medicine, the magazine of the Marin Medical Society.
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