2014 Issues   /   May 2014

Simplicity is the ultimate sophistication

By US Medicine

“Simplicity is the ultimate sophistication.” ― Leonardo da Vinci (1452-1519)

Editor-In-Chief, Chester "Trip" Buckenmaier III, MD COL, MC, USA

Editor-In-Chief,
Chester “Trip” Buckenmaier III, MD
COL, MC, USA

I do my best to avoid touching on editorial themes I find interesting in subsequent months. Last month, I touched on the incursion of medical technology into our daily practice and my concern that it was driving a gadget laden wedge between providers and patients. I feel compelled to continue this premise due to recent experiences and because it keeps knocking around in my skull.

I wrote this just prior to leaving for a medical mission to Vietnam. Regular readers of this column know I have used these annual medical missions as a background for a number of past editorials. As I endured about 24 hours of flying (and the incredibly shrinking airline seat) to get to the other side of the planet, I continued to muse over the seemingly overwhelming impact of technology on modern American medicine. In fact, it is the prodigious excess of technology at home that compels us to travel such long distances to less technologically intense environments to train anesthesiology residents and fellows.

The battlefield can be one of the most medically austere environments in terms of technology and resources. It is difficult to prepare young physicians for the medical conditions encountered in war when surrounded by the machinery and systems that cocoon our patients.

Vietnam is an emerging economy with a vibrant medical system in development that provides an appropriate amount of system stress to instill in young anesthesiologists that good medicine can be accomplished without all the bells and whistles and despite a limited resource base.

Our Vietnamese colleagues are keen to learn about the latest technologies and techniques that we take for granted in our system. It is hard to avoid the hubris that comes with being an American-trained physician that symbolizes a medical care standard recognized in countless nations around the world. These feelings are quickly tempered and placed into perspective when I observe how much more care is delivered in Vietnam, to so many, with  much fewer resources and equipment than we use in the United States. Truly, they do more with less and, although cultural and medical standards are different, I would demure from making statements concerning the quality of care between the two systems.

Granted, the two systems of medicine are vastly different. The American medical technological edge is undeniable, although this gap has exponentially shrunk over my seven years of visits to Vietnam. The Vietnamese, on the other hand, excel in something I believe we have lost in American medicine — simplicity.

I am certainly not suggesting that the Vietnamese medical system is simple; on the contrary, this system provides integrated quality care for a huge number of patients with a simplicity that belies its sophistication. Certainly modern Western approaches to heathcare are available for trauma and life-threatening ailments, but routine care does not follow the expensive “pill for every ill” approach trumpeted on American television (including the medication’s side-effect provide that often sounds far worse than the condition being treated). I have witnessed hundreds of Vietnamese patients in traditional medicine clinics (what we would call integrative medicine) after being diagnosed by a physician, receiving inexpensive acupuncture, massage, physical therapy, and herbal therapy with few side effects. If the patient’s condition warrants more high-tech approaches to disease management patients are directed by their physicians to those services. There is something for us to rediscover here.

I am not suggesting superiority of the Vietnamese system; like any medical system, it has its own challenges and flaws. Personally, I believe “right” exists somewhere between the two structures, where the most positive elements of each are integrated into a technologically advanced medical organization that understands that less technologically intense care, centered on the whole patient, is not inferior care and still has an important place in modern medicine.

While teaching in Vietnam I came across a young male patient who fractured his femoral neck after a rather rotund friend fell on him while playing an outdoor game called “stones.” We elected to perform a lumbar plexus continuous block for surgery and perioperative pain management, and I was thoroughly engaged in demonstrating ultrasound anatomy and the technical issues associated with this difficult block.

My wife, Pam, who came along as a nurse on the trip, recognized that while we were focused on the details of what we were doing to the patient, nobody was paying any attention to the actual patient. The poor guy was terrified by the foreigner (me) and the press of young Vietnamese doctors clamoring to learn about this procedure, not to mention the rather large needle I was holding. Pam, also a massage therapist, moved to the patient’s head and began a relaxing head massage to treat this patient’s anxiety: simple and effective.

I was somewhat sheepish about my typical intense focus on technique rather than the most important person in the room, the patient. I suggested some medication to further reduce anxiety (midazolam) but this was resisted by our hosts as this patient was uninsured and would likely not be able to afford the medication. (Sound familiar?)

As a newly minted medical acupuncturist, I have been itching to incorporate more acupuncture into my practice and this seemed a perfect opportunity. As the patient was lying on the operating room table being prepared for surgery, I placed a number of acupuncture needles in his exposed ear, knowing that would be helpful for sedation and relaxation. Between the massage and acupuncture he became visibly relaxed and his blood pressure and heart rate normalized.

Am I positive that the massage and/or the acupuncture produced this effect? No. Could it just have been the added personal attention we were paying this frightened human being? Sure. Does it really matter? I would suggest not at all, as we obtained the desired result.

Perhaps most importantly, these techniques were simple and as close to side-effect free as one can get. We also spared him the cost of expensive medication he could not afford. While my Vietnamese colleagues were a bit perplexed by a Western physician wielding acupuncture needles, they were intrigued by the impact Pam and I had on this patient without medications. From my perspective, this was one of the most sophisticated anesthetics that I have provided in a long time.


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