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Leave the well alone!
- BM Hegde (20 April 2007)
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BM Hegde, Retd. Vice Chancellor Mangalore-575004, India
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Dear Editor, I am happy that you have published many papers that glorify the age old wisdom of bedside medicine vis-a-vis technology which is more relevant today than in the distant past. “If you listen to your patient long enough, s/he will tell you what is wrong with her/him,” was the teaching of that great physician, Lord Platt, in 1949. Later his students did a study to see if the old man’s ideas still hold good today in a very well executed prospective, double blind, randomized, hi-tech based (even PET scanner) study of the role of history taking, physical examination, and investigations in medical diagnosis published in the BMJ. The study showed that 80% of the final accurate diagnosis and 100% of the future management strategies could be arrived at at the end of listening to the patient and reading the GP‘s referral letter. This is refined only slightly by examination and investigations! (1) In an editorial “hyposkillia”, the Texas Heart Institute Journal laments the slow death of clinical skills on the other side of the Atlantic to the detriment of patients.(2) One of the recent meetings of the American Heart Association had a key note address by a revered teacher , Proctor Harvey, on “how to auscultate the heart?” Modern medicine, riding piggy back on technology, seems to have lost its heart and has forgotten the wonderful powers of bedside thinking and the art of listening to patients. What with a few minutes given to each patient where do we have the time to listen to patients? It has become easy and profitable to ask for investigations to get a “euboxic” case sheet, which at times might result in “dysboxic" death, though! (3)This is the reason why the medical fraternity has come to be one of the leading causes of death in the US at least. (4) This is not a modern disease. “A multitude of causes unknown to former times are now acting with a combined force to blunt the discriminating powers of the mind, and unfitting it for all voluntary exertion to reduce it to a state of almost savage torpor,” wrote the great English poet, William Wordsworth, who lived between 1770 and 1850. Mankind does not seem to change the habits ingrained. Anything new is accepted without hesitation and old ones are rejected without any thought. Modern medicine has become prohibitively expensive mainly because of this malady of relying only on technology. The latter is useful in a very small percentage of patients. The majority could be helped with good clinical methods. Sir James Spence was of the firm opinion that medicine revolves round medical consultation, where a man who is ill or imagines he is ill comes to seek the advice of another human being in whom he has confidence. All else in medicine should flow from this summit was his firm conviction. I think we should go back to that line of thinking. Having been brought up by great clinicians like Walter Somerville, Malcolm Towers, Richard Emanuel, and Bernard Lown and inspired by Evan Bedford, I had practised clinical cardiology for four decades with pleasure using minimal technology. In this scenario the “well” segment of the population is logically left alone. The bane of modern medicine, which could (did) bring grief to mankind, is our misplaced enthusiasm to get the well segment also into our fold to use technology to discover what I call the “doctor-thinks -you-have-a-disease” syndrome. Linear deterministic predictability does not work in a dynamic non- linear system like the human body which has the power to manage altered internal environment to a great extent. Only when the internal correcting system fails do symptoms develop and then only will our efforts bear fruit to “cure rarely, comfort mostly, but to console always.” Many studies have shown the futility of screening the apparently healthy population to interfere. We could do a lot by being a placebo effect on patients. Mind alone, a reassured mind at that, could correct many deviations in the human physiology as elegantly shown by Roger Laham of Harvard Medical School with reference to the sham revascularization surgery for coronary artery blocks.(5) I make a fervent plea for parsimony in dealing with the healthy population. Today we have become sellers of medical care and the patient a buyer. Time is running out! Patients can survive without doctors but doctors can not survive without patients. Before our patients leave us and go elsewhere let us set our house in order. Let us leave the well alone if we have to get back our place of honour in society. Yours ever, Bmhegde. Bibliography. 1) Tally NJ, O’Conner S. Clinical Examination-a systematic guide to physical diagnosis. Sydney. Churchill Livingstone 2005. 2) Fred HL. Hyposkillia-Deficiency of clinical skills. Tex. Heart Inst J.2005; 32: 622-24. 3) Davidoff .F. Who has seen a blood sugar? Book. 1998. American College of Physicians. 4) Starfield B. Is US medicine the best in the world? JAMA 2000; 284: 483- 485. 5) Laham R et. al. Longevity of the Placebo Effect in the Therapeutic Angiogenesis and Laser Myocardial Revascularization Trials in Patients with Coronary Heart Disease. The American Journal of Cardiology, Volume 95, Issue 12, Pages 1456-1459 Competing interests: None declared |
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