The Lost Sheep Of Modern Medicine

  

In the mad rush of today’s outpatient department , even as I noted the duration of his cough and enquired about the tremulousness of his hand, I could , feel the ticking hands of the clock breathing down my neck.

The corridor outside my tiny room was overflowing with the sick and the needy, ebbing with tales of pain and sorrow. They sat there pleading to be heard, hoping to be understood, and above all, praying to be cured. I felt overawed by this sheer deluge that was now at my doorstep, people, families from far and wide were here, having battled long queues and prolonged waiting lists running into months just to obtain this appointment.

Would the next few minutes they spend with me put a name on their suffering, or would they still be wandering in the dark corridors of ambivalence, oscillating between hope and despair.

 The next few minutes, that is all I have to understand this person’s elaborate story spanning a third of his life, a story of his pain in the arm , and how he lost his job, that of how he was previously the sole bread winner in a family of six, and the repercussions this had on his state of mind and how that in turn worsened his pain , and how he had taken up the bottle in a means to end  his sorrows and how all of this had lead him to today where he no longer recognized his wife.

The wife sat beside, holding back tears that were threating to flood my calm clinical mind. I empathized with the family, I put myself in their shoes, the rather uncomfortable, and worn out shoes to the already aching heels.

How could I bring a glimmer of hope over their furrowed brows? I had a dozen more questions in mind, both clinical and humanitarian. The differentials were stacking up in the back of my mind, yet they were vague and fuzzy, I need to pore over some more details, some old reports, talk to the daughter, I needed more time!

 I jolted back to the reality of my crowded OPD. The next patient was already peeping through the flimsy curtain.

I deftly jotted down the history, the details afforded to me by my brief yet thorough physical examination, I noted that there was no acute emergency, at least none from a doctor’s and medical point of view, ( I tried not to think of the fact that for the stricken family, the gravity of this situation of theirs was no less than an absolute emergency ) . I noted the differential diagnoses that I had arrived at and I moved on to the management plan.

What diagnostic clarity I lacked for the want of time to delve deeper into the history, I tried to make up with the help of the wide array of diagnostic tools I had at my fingertips, the laboratory investigations, imaging modalities and molecular level tests. I picked the best ones for my patient and handed it to them along with the usual slip for a review appointment.

The patient’s wife looked at me confused, how could these tests, whose names she could barely pronounce, help cure her ailing man?

I tried to explain to her how this worked, and she seemed reassured, her faith in my white collared coat, in the degree hanging on my wall and above all in the legacy of my profession had helped ease her doubts.

And thus I made it through a long day in the out-patient department.

Yet I couldn’t block out the gnawing thought at the back of my head. Was I doing justice to my patient?

Are we, the modern clinicians doing justice to the legacy of our great forefathers? Are we giving ourselves sufficient time to delve into the history?

In the halls of our great medical schools, it is often said that history reveals 90% of the diagnosis. That is a resounding number, far better than any PET or PCR.

It is not merely the story itself, but how the story is told, what is mentioned and sometimes, more importantly, what is omitted, that leads us to the diagnosis.

An anonymous quote sends out this ominous warning. “A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment!”

Not just the history but a thorough physical examination, will tell us most diagnoses without having to drag our patient through a battery of tests.

To enunciate my point, merely looking at the nails of a patient can help us diagnose Cyanosis (which is indicative of a respiratory compromise), Obstructive Lung Disease, Inflammatory Bowel Disease, Infective Endocarditis, Iron deficiency anemia, Liver cell failure,Psoriasis and Renal failure.

The beauty of the physical examination is that it can be performed anywhere and is the fastest modality in an acute emergency setting. If done right, it can help the doctor literally scan a patient from top to toe in a few minutes, and voila! Here’s the diagnosis!   

But unfortunately these time tested medical practices have fallen by the wayside.

So why then are we denying ourselves these crucial tools? Those that have been honed and handed down to us over the centuries.
Is it the numbers that is pushing us down this road? The need to see more patients, to write out more prescriptions and ultimately to reach an agreeable number on the balance sheet?

Is that what is eating into all our time? The precious minutes we owe to our ailing patients. Each extra minute spent with one patient, is a minute less to see an extra patient. Is this the eternal tug-o-war of quality vs quantity?

It’s often the bond that a doctor establishes with the patient, that’s the most important determinant in how well the patient fares. This rapport that is at the crux of all our treatment strategies takes time to be established. Are we then able to give them this time? Given time, the patient himself will tell you all you need to know about his illness.

It has been observed that most patients feel reassured ones the doctor palpates and examines them. The mere act of looking into the patient’s eye, examining them and offering a word of comfort, has done us good for centuries up until now.  

Moreover bedside discussions have been at the epicenter of medical teaching, and there is no reason to abandon it. Seeing a sign demonstrated on the patient, auscultating a murmur, these are irreplaceable, even in the era of the internet.

To quote William Osler, one of the clinicians par excellence, “He who studies medicines without books sails an uncharted sea, but he who studies medicine without patients, does not go to sea at all.”

Technology and its advances are no doubt very important to the development and progress of medical science. CT, MRI and 3D printers have allowed us to view the human body like never before. Yet they were never meant to, and they cannot supersede the basic history and examination sequence. It’s here that our clinical acumen and the armory of investigations will aid in putting the final puzzle together.

In other words, trying to arrive at a diagnosis without a decent history/clinical examination is like trying to predict what a picture puzzle will look like when a significant number of pieces are missing.

Ours is a profession that deals with life and its myriad complexities. It therefore takes another human being to feel the pain, touch the wound and heal it.

 Plato the renowned Greek philosopher rightly said, “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”

Tests and drugs will most likely cure the patient’s physical ailments, but will we heal the mind?

It’s the daily interaction with the patient, the physical presence of the doctor, the empathy in the physician’s eye that, the primeval bond that forms between two beings when one helps the other, this is what is at the heart of our profession.

 But has this era of corporatization of healthcare, cutting edge investigations and other modalities, meant to aid us, curtailed our inherent instincts of sitting at a patient’s bed side. Floundering in this vast sea, are we treating then the X-ray or the patient?

The ancient Chinese wisdom proclaims, “It’s easy to get a thousand prescriptions but hard to get one single remedy.”

I wonder if in this nearly mechanized world, will the empathy in medicine, the art of eliciting a history and the clinical examination die out altogether.

 Are we, the clinicians of this era the ‘lost sheep of modern medicine’? And is it time for a relook?