Clinical Medicine is Dead??

This is a question today but with every passing day it seems to be fast transforming into a statement, almost like a self-evident truth. Let me define clinical medicine. It is a scientific method of evaluating a human being based on systematic history taking, followed by a thorough methodical clinical general and local examination to arrive at a diagnosis or a differential diagnosis. Then you start treatment based on your intuition or clinical judgement and order some pertinent investigations to confirm your diagnosis or decide which one of the differential diagnoses is correct. That is how we practiced medicine and even though we could be wrong at times our experience made us wiser and made us make less mistakes than before. Also, we had our seniors teachers and even our juniors and students provide a second opinion. My mind goes to two books Complications and Check List Syndrome both written by the same author Dr. Atul Gawande. The first book makes a plea that medicine is practiced on human beings and is as much a science as an artful skill developed and honed by coaching, peer learning and a lot of common sense. To predict outcomes with respect to the future course of illness was never on predictable lines and all of us have unique stories to tell of surprising failures and successes contrary to conventional wisdom. This was to my mind the result a healthy respectful doctor patient relationship which went beyond curing to caring. Trust and faith often led to far better outcomes in some cases and the lack of the same led to poorer outcomes. The other book Check List Syndrome lamented the number of errors which occur just because the process of using a check list which has been adopted across industries has not been used by surgeons. A Check List designed for use pre-operatively, before beginning surgery and after completion of surgery has been show to significantly reduce errors and save lives.

What has changed is the advent of modern medicine in the form of precise investigations and their easy availability. Along with these the great boom in medical devices which in turn made medicine an expensive affair. The commercialization of modern medicine and the incentives to investigate and become over dependent on the same gradually made the art go our of medicine. The steps of History taking and painstaking recording of the data created doctors who made history taking and clinical examination redundant. The lack of these in turn created a depersonalized form of "no touch" medical practice. The bond built by a conversation and gentle human touch eroded the patient doctor relationship. Is the lament specific to my experience or is this common allover the world.

My research led me to an article published in  the form of 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.

With the advent of recent medical students, 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 t

However, there are many who claim 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 topic  I feel that many of these tests are unnecessary, and their results which may incidentally be deranged lead to faulty treatment which often harms the patient rather than do him good. Besides they have the not so insignificant side effects of increasing the cost treatment which in turn lead to increasing the profits of the modern medical high technology industry.

 Let no one conclude that I want to live in the past and do 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. 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 accept that I  maybe exaggerating the situation. I hope this article makes the medical faculty our young budding doctors and society introspect and find solutions to improve this situation. We need skillfully humane caring doctors to serve society. Hopefully Clinical Medicine is not yet dead and we can salvage it as yet by going back and using the skills we were taught. 

Vispi Jokhi