Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!” Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion. Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.
One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows. In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.
Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds. In this case, the cow is not an animal but a machine. In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base. It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.
As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence. For one thing, people in hallways and patients’ rooms are constantly making way for the COW. As an expensive and essential piece of equipment, it is handled gingerly. Often only the senior member of the medical team or his or her lieutenant touches the COW.
Others know that they have said something important when they see the chief keyboarding the information into the COW. Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. A visitor attending medical or nursing rounds in a large hospital would observe that members of the healthcare team often spend more time looking at the COW than at the patient. After all, the COW is replete with readily accessible information about the patient’s past medical history, current hospitalization, assessment and treatment plan, and notes from all the teams caring for the patient. Much of it is represented in eye-catching graphs and charts. The COW is a wonder of modern medical information technology.
Compared to the COW, patients can seem rather drab and uninformative. Often when you ask patients a question, they misunderstand, or hem and haw, or take a long time to get to the point. In many cases, patients do not understand their medical conditions, tests, or treatments in much depth, and interacting with them beyond asking “How are you doing today?” proves less than edifying. The COW, by contrast, responds immediately and directly. In contrast to the patient’s story, which is largely subjective, the COW offers reams of objective data, the kind of information most healthcare professionals have been trained to think they can take to the bank.
Yet there is something seriously wrong with contemporary medicine’s sacred COW. For one thing, the patient, not the COW, is the one who has fallen ill. It is the patient, not the COW, that calls health professionals to action. And no one ever became a great physician or nurse by serving the COW. To put the matter in philosophical terms, the COW is a mere means, while the patient and the patient’s well-being are medicine’s end, goal, and purpose. We must guard against the tendency to mistake the means for the end, and to think that by doing the cow’s bidding we are somehow practicing good medicine.
It is for the patient, not the COW, that we are called to care. In fact, the most important source of information available to physicians and nurses is not the COW or the vast array of clinical monitors, laboratory devices, and imaging equipment that feed it data.
The most important source of information is the patient. It is often said that listening to the patient and eliciting a good history is sufficient to arrive at the diagnosis in the vast majority of cases. Moreover, the health professional’s mission is not to buff up the electronic medical record, but to help restore the patient’s health, relieve the patient’s suffering, and offer the patient comfort and hope. The COW can serve as a useful tool in this mission, but the mission is never centered on the COW.
Chicago sportswriter Irving Vaughan wrote of the Cubs in 1940, “By the nursing of sacred cows on which there isn’t enough healthy meat to make up a five cent hamburger, the Cubs have deteriorated to such an extent that the National league seems to have gone away and left them.” Something analogous is happening in medicine.
If we focus too much on COWs, we lose sight of what the profession of medicine is really all about – the patient. If this happens, we risk transforming medicine’s warm human touch into something cold and impersonal, grinding up what is truly sacred in medicine – the humanity of our patients – into a mere hamburger of data. To this medicine should say, look not to the COW but the patient!
Richard Gunderman, MD, PhD, is Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy at Indiana University; he was a past president of the faculty at Indiana University School of Medicine and currently serves as Vice Chair of Radiology. Gunderman is also the 2013-2014 Spinoza professor at the University of Amsterdam, the author of over 380 scholarly articles and has published eight books, including Achieving Excellence in Medical Education, We Make a Life by What We Give, Leadership in Healthcare and most recently, X-Ray Vision.