Thursday, April 12, 2012

HAS CLINICAL MEDICINE BEEN TAKEN OVER BY HIGH TECHNOLGY INVESTIGATIVE MEDICINE?



Yes and I state that high tech. investigative medicine has in many cases taken over clinical medicine and in some cases caused irreversible damage to both the medical practitioner and the patient.
The topic of this debate is actually most appropriate and relevant to my present status as a teacher in a new budding post graduate training institute. All these years I have worked in mgm hospital. Working in this hospital is like working with one hand and foot tied. We have been told to deliver 21st century patient care using vintage equipment and facilities. Despite that most of us have made a success of our work thanks to our clinical skills. What we lacked in equipment we made up by keen observation, thorough examination, compassion and care for patient and experience. Our work in MGM has enabled many of us to become better physicians in outside hospitals where we work.

With the advent of medical students since last year, I along with my senior colleagues have become painfully aware of the deficiencies in the trained doctors who have joined as residents. This trend is a worldwide trend has lead to an editorial in the Texas Heart Institute Journal by Herbert L. Fred who has defined such specimens as Hyposkilliacs.  I quote "I call this malady hyposkillia—deficiency of clinical skills. By definition, those afflicted are ill-equipped to render good patient care. Yet, residency training programs across the country are graduating a growing number of these “hyposkilliacs”—physicians who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess the information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly. Moreover, they rarely spend enough time to know their patients “through and through.” And because they are quick to treat everybody, they learn nothing about the natural history of disease." These sound harsh words indeed but if we reflect on them they are indeed true. Before the seniors start gloating, I must quickly add that we too should share the blame. In a book by Groopman titled How Doctors think? the author while observing clinical rounds was shocked by both the lack of depth of his students questions and equally by the fact that rarely did attending physicians explain the mental steps that lead them to decisions.

However, some may say that this situation is there not because of the high tech modern medical facilities but has come about because of the particular individual, who has reacted to the system. I beg to differ because it is human to take the easy way out and in this materialistic acquisitive world, where time is money both students and teachers are becoming increasingly mentally lazy. Hyposkilliacs become proficient in ordering tests, interpreting numbers, analyzing images and calculating drug doses. The barrage of information is so huge and the analysis so complex that in fitting the whole jigsaw puzzle the patient is forgotten. How many times residents refer to patients by the result of tests or cot no or subject, the term made famous by Bollywood's Munnabhai MBBS. He held a mirror for our profession when he protested his seniors calling the patient a subject. Rounds are taken by no touch techniques and even the simplest of ailments which may be cured by simple remedies are treated after a barrage of tests. While this is not the subject of the debate today, I can state with authority that a large number of these tests are unnecessary, of dubious use and their results lead to faulty treatment which often harms the patient rather than does him good. Besides they have the not so insignificant side effects  of burning a huge hole in the pockets of patients and bloating the profits of the modern medical high tech. industry.

Let no one conclude that this old man wants to live in the past and does not recognize the value of modern high technology medical facilities. I believe that in a country whose media created  image is of a super power but which is at the bottom of the Human Development Indices, it our responsibility to utilize scarce resources responsibly. We owe it to ourselves and our patients to train ourselves and use what I would like to call critical thinking. Medical treatment and bedside medicine has traditionally been based on systematic steps, beginning with patient listening to "His story" or history taking, which serves the purpose of creating a bond of caring between doctor and patient and helps development the important component of critical thinking. The next step is a thorough examination and recording of findings. Our seniors always said "what the mind does not think the eyes can never see" and their experienced eyes noticed things we never saw. All this leads to a working diagnosis and an plan of treatment. Pertinent investigations which enables one to diagnose and plan the treatment must be ordered. Communication with the patient and with our juniors explaining the rationale of our thinking and the methods by which we arrive at our conclusions are of critical importance. And if we want to restore modern medical care from a mere science to an art form which it was then we need to construct every storey of the building from its foundation upwards and any step missed along the way will lead to disastrous consequences and an assembly line of hyposkilliacs. Critical thinking is the seed from which innovations and discoveries sprout. Today, I wish to pay homage to one such thinker Dr. BB Joshi who was a giant nurtured in the soil of this institute. A kind word, smile, compassionate touch and genuine concern for the patient and reassurance of proper care cost nothing but are far more critical to a patients well being than all the tests and gadgetry and the attendant anxiety created by their use in patient care.

In conclusion, I wish to thank and pay homage to all my teachers and gurus, from whom I have learnt and who have instilled in me the values of ethical compassionate medical practices, good bedside manners and judicious use of modern high technology medicine harnessed to the service of the IP who is really the VIP of modern medicine. I also wish to apologize to my fellow colleagues and students for harsh words. However, a teacher of mine said the words NEENDAKANCHE GHAR SHEJAR ASAVE. Our critics must be our neighbors and it is in this spirit that I request to take these words.

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