Eclipse of clinical medicine

Doctors ought to rely as far as possible on their clinical diagnostic skills. Today, what we have is the patient being treated as a collection of organs handled by specialists and their machines, says DR. B.C. RAO.

OF the many concerns in the national health scenario, what worries me most is the gradual decline of clinical medicine. Though this word is used liberally, and often out of context, clinical medicine means carefully listening to the patient and arriving at a diagnosis after a detailed physical examination. Adequate treatment follows next.

Till recently, this was the mainstay of managing most illnesses. Lately, however, this is giving place to the patient being treated as a collection of organs (which indeed he is) and each organ handled by specialists and their machines. Often this organ-oriented practice leads to wrong and missed diagnosis that can end in disaster. It is rare for, let us say, an orthopaedist or a plastic surgeon to routinely check the blood pressure of a patient who comes to him because he feels it is not relevant to the problem he is handling.

The World Health Organisation recommends that all patients who come to see a doctor have their blood pressure recorded because early detection and treatment of high blood pressure is the most important factor in the prevention of cardiovascular, renal and cerebral morbidity and mortality. It also makes great economic sense to prevent a potentially serious and expensive disease. Reliance on machines at the expense of clinical medicine leads to missed diagnosis.

One doctor spotted a cancerous growth in the patient's abdomen even though the patient came to him expressing weakness and breathlessness. This patient had gone to a centre specialising in cardiac complaints and was investigated. He was found normal and discharged with a clean chit. Another patient who underwent coronary artery bypass graft (CABG) returned home with severe diabetes that was later brought under control with difficulty. At the time of discharge she was told not to worry too much about the meticulous diet she was following prior to surgery. The resulting stress and poor diet control made her diabetes go haywire and her physician had a difficult time managing her postoperative rehabilitation and diabetes.

Another young woman started experiencing pain in her chest, later in the pit of her stomach and still later on the right lower abdomen. Her whole story lasted six months during which she saw a physician, a cardiologist, a general surgeon, a gyneacologist, a psychiatrist and a general practitioner. The GP diagnosed a tubercular cold abscess that had travelled down from her upper chest along the spine to the abdomen causing pressure effects. The abscess could be seen as a bulge next to the wing bone.

How did so many miss such a simple diagnosis?

None of the others thought it fit to conduct a detailed examination and instead concentrated on different parts of the patient's anatomy.

There is another aspect to clinical medicine, which in some ways appears contrary to what I have written. Should doctors be spending valuable time in the history and examination of patients?

Years ago I was sitting with a busy GP in his clinic. He had an interesting method of solving this problem. As soon as he came in to the clinic he would announce to his patients: "Those of you who have fever, headache, body aches and nothing else get up." Some 15 odd patients would stand. They would then be asked to go to collect their dose of aspirin and diaphoretic mixture and go home without the doctor even touching them. Next he would ask the same question to persons with simple diarrhoea and another batch of patients would be summarily dismissed. After this mass disposal, the remaining 10 patients would meet him. He would closely examine them. Needless to say some of these included those whose fevers and diarrhoeas did not go with the initial ministrations. This was an example of clinical medicine at its best.

The advent of technology is both a boon and a curse. A boon because it has made diagnosis and treatment easy. A curse because it has also made treatment expensive. Investment in expensive, investigative and treatment technology is breeding high-pressure salesmanship in its wake. Diagnostic centres adopt questionable methods to entice doctors to send patients for investigations. There is often a large grey area in medical practice where one can justify sending the patient for a particular investigation. For example, a person who has a headache can afford some tests. Careful history taking makes the doctor believe that it is most likely to be a type of migraine. Of course he cannot be sure - and never was in the last 20 years of his practice. He decides to do a CT scan because the diagnostic centre which does this test has given him a business proposition and the logic of the patient unlikely to have brain tumour is offset by the remote possibility of his having one. Logic defeats reason and the patient is sent for a scan. A doctor who falls prey to such questionable methods will, in the course of time, become a poor clinician - if he is not already one - and stops thinking analytically when confronted with a clinical problem.

Most illnesses need only clinical judgment and no investigations at all in community practices. Even in specialty practices, a lot of these tests can be avoided. It does not need a blood test to diagnose anaemia, gastroenteritis, malnutrition, fungal infection and respiratory infections. Others only need minimum cost- effective tests like a chest X-ray, blood sugar and a sputum study. It is thought fashionable these days is to do a lipid profile. By this test one can determine whether the blood has abnormal levels of fat components, a risk factor for heart and blood vessel disease. Let us say you got these done when you are 30 and the results are normal. It is pointless and a waste of money to repeat these each year if one's lifestyle remains the same and the test results are likely to remain the same for the next 10 years. It is more important for your doctor to check your blood pressure every year.

Doctors must make it a point to rely as far as possible on their clinical diagnostic skills. If they do require to investigate, they should do so to the minimum possible extent. Too much reliance on investigation and organ oriented practice leaves a clinician susceptible to committing diagnostic blunders and more importantly lead to a loss of analytical thinking so essential to arrive at a diagnosis and treatment option.

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