The Doctor's Bag for the New Millennium
By ABRAHAM VERGHESEWhen I was a medical student in Madras, India, in the late 1970s, my uncle, a retired physician, still made occasional house calls. In his early years he delivered babies in dimly lighted huts, often resorting to high forceps on the head - something that is rarely done now. His compounder - the man who would compound his prescription of mistura carminativa and dispense it in corked glass bottles - carried my uncle's medical bag. It was almost like a trunk - a mobile office. The compounder became so experienced from watching my uncle that he secretly began a practice of his own, delivering babies and even applying forceps.
My uncle's doctor's bag from his halcyon days was long gone by the time I was a medical student staying in his house; it had been replaced by a newish model, a small tan suitcase with square corners and latches on the top. When it was opened, two shelves magically unfolded. The medicinal odor that emanated was so powerful it could deliver a buzz.
One shelf held the sterilized syringes, needles, cotton swabs and alcohol that were the bread and butter of a doctor's trade in India - every patient wanted an injection, and doctors were destined to disappoint if they didn't oblige. The other shelf held ampules of adrenaline, Coramine, theophylline and other emergency medications as well as rows of bright orange vitamin B12 ampules - a dramatic injectable placebo.
The bottom of the bag was stuffed with bottled medications, a blood pressure cuff and instruments that my uncle rarely used: Foley catheters, hemostats and the like. I had carried that bag for him more than once and been there when he jabbed adrenaline into a desperately wheezing patient and produced immense relief.
A few years later, when I was an intern in Tennessee, my attending physician and mentor, Steven Berk, carried a leather doctor's bag, one he had toted around since his medical school days. His bag, unlike my uncle's, was small - the size of a loaf of bread, or perhaps a bit bigger - just enough to carry his ophthalmoscope, blood pressure cuff, reflex hammer and a few other things. It was well worn.
The bag became a fetish for me. It embodied all the qualities I admired about the man: He was a careful listener, and he examined patients thoroughly and well. In the Mountain Home Veterans Hospital in Tennessee, which had a large domiciliary and nursing home population, he made original observations about pneumonia in the elderly and became a pioneer in the field.
When I became Dr. Berk's chief resident, three years later, I bought a similar bag even though it was prohibitively expensive on a resident's salary. Mine was stiff, and despite lots of rubbing with neatsfoot oil it remained hard and unyielding.
A year later, in 1983, I was a fellow in infectious diseases at Dr. Berk's alma mater, Boston University and Boston City Hospital. I noticed that in Boston the doctors who carried bags were a shrinking minority - often older, and often the best physicians. Neurologists favored them - more tools to carry, I presumed. Medical students were no longer routinely buying doctor's bags. I stopped carrying mine; my white coat held most of what I needed, and now that ophthalmoscopes came in penlight size, or were mounted on walls, I had eliminated the bulkiest item I needed to carry.
I never got rid of my doctor's bag. Inventorying its contents recently, it was as if I were gazing into a diorama from the early '80s: eye drops to dilate the pupil, prescription pads, a pocket EKG book and EKG calipers, pens, measuring tape, penlights, laminated cards with algorithms on them for various conditions - and everything, of course, with a pharmaceutical company logo on it; no one felt compromised by that sort of stuff.
As the years have passed, I now find myself in a minority of physicians who wear white coats. For those who do, the coat is not a repository of instruments, but a ceremonial robe.
Not so for me; my coat bulges with what I carry: a Queen Square reflex hammer with a bamboo stem (given to me by the widow of my medical school professor who read something I wrote in Granta about her late husband and the way he brandished that hammer; she arranged to meet in a London train station to present it to me), a stethoscope (a bulky, three-headed monster made by Tycos that I love), a tuning fork (frequency of 128 to test vibration), a magnifying glass (to study nail fold capillaries), an Optyse pocket ophthalmoscope, a penlight, a pocket Snellen eye chart, tongue depressors, hand gel, triplicate prescriptions, laminated billing and coding guides, packets of chewing gum....
The coat must weigh at least five pounds. But as a believer, I must walk the talk, carry the tools. I believe that a good bedside examination of a hospitalized patient has a high diagnostic yield: It can reveal the more obvious diagnoses and can guide judicious use of subsequent blood and imaging tests. But the exam also is a ritual, an important one, which when done well validates the patient's complaints and places its locus on the body, and not on a computer screen.
Recently, two of my colleagues at Stanford, John Kugler and Errol Ozdalga, who work with me in what we call the "bedside medicine group," persuaded me to add three tools to my armamentarium.
Dr. Kugler taught me to use a Vscan: a pocket ultrasound machine, which allows a great view of the heart, and adds volumes to what the stethoscope can discern. Dr. Ozdalga taught me to use the PanOptic ophthalmoscope, an instrument that looks a bit like a large revolver; it allows a beautiful view of the retina, and especially its blood vessels, far better than my conventional ophthalmoscope. One look in an eye and I have a sense of the status of the arteries in the kidney, the heart. The PanOptic can also be hooked up to an iPhone to take great pictures.
The third tool I carry around is an iPad: It is a great way to demonstrate anatomy to patients, to take pictures and to pull up videos on a Web site that Dr. Ozdalga has developed, which teaches and reinforces for residents and students specific techniques for examining patients: http://stanfordmedicine25.stanford.edu.
Carrying these three new additions can cramp my fingers, and it is not always easy to find a place to set these down when examining a patient.
Dr. Kugler showed me his modified messenger bag in which he carries his instruments. I've seen similar models made by Chrome, Vega and Eagle Creek - and I've just placed my order. I will soon be able to unburden my coat pockets.
As technology advances and gets more portable, I see us bringing more tools to the bedside, and therefore spending more time with patients, instead of sending them hither and thither to diagnostic suites. The more time with the patient, the better.
This is how you will know us, the doctors of the next millennium: by the things we carry.
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Tuesday, October 9, 2012
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