What should a doctor do? Should he rely on his clinical judgment [Art] or give preference to investigation [Technology]. This is a question that every doctor with access to technology is faced with. I am from the old school and strongly believe Art or Clinical Judgment should be foremost. Investigation or technology should be used to support the Art, not as a replacement to the Art – which is a combination of knowledge and experience. We hear of Google giving diagnosis and Robots treating. I feel it is a dangerous precedence.
My college, the Armed Forces Medical College in Pune-India, was and is one of the best equipped medical colleges in the country. But our teachers always told us, clinical diagnosis is the first step in the management of a patient, for which history taking and clinical findings are the foremost tools. With experience your clinical acumen and judgment gets fine tuned and you can give the best to your patients. I find the above factual and true.
Unfortunately modern health care management is becoming more and more technology oriented. Many a time, we doctors are faced with a situation not knowing when / where to draw the line. Inclusion of the medical services under the jurisdiction of the consumer court has changed the way doctors’ practice. They have started believing in the practice of defensive medicine, where documentation and investigation get precedence over diagnosis and treatment. The above has resulted in patients not getting the best and treatment becoming costly.
A few years back, I was sitting at the Casualty of hospital ‘X’ in Kochi. A patient with chest pain was brought to the casualty. The duty medical officer started a life line and immediately shifted the patient to the cardiac ICU. I was taken aback with this response. I knew the casualty medical officer was a smart intelligent patient centric doctor. So I asked him as to why he did not spent time to conduct even the basic clinical check up before shifting the patient to the Cardiac ICU. His answer was “Sir if I start doing that, our casualty would have been ransacked by bystanders, they desire immediate action. Secondly my clinical judgment is non-tangible and if anything goes wrong I will not be able to support my action in the eyes of the law”. Once in the Cardiac ICU all are happy.
I started pondering on this case. If the casualty doctor would have taken a proper history, Pulse, BP and clinical examination, this case might have turned out to be a simple case of chest muscle pain or Dyspepsia – Which could have been managed as an Out Patient. Now, once the patient is in cardiac ICU, they have to do the minimum cardiac drills – ECG, Streptokinase, CCICU monitor and in some cases angiography. Three days later, the patient is labeled as a simple case of Muscle pain and discharged. Extra costs apart, the patient and his relatives were put through unnecessary stress. In many a case, the patient gets psychologically handicapped thus labeling themselves as a cardiac patient for life.
For varied reasons the political masters, the executives and the public, all have their axe to grind. I do not desire to go into the merits and demerits of actions taken by the above. With modern internet information, many a times patient feels they are better armed than the doctor. They suggest / demand investigations. Pressure is mounted on the helpless doctor. A consciences doctor is at a dilemma on what is right. Many a time, the doctor is even compelled to conduct the investigation. Very few understand the difficulty the doctor is going through in these life and death situation of his patient.
I would like to use a short story to elaborate on the difference between art and science [Technology]. An individual visited a clock shop to buy a clock. Unfortunately there are only 2 clocks available in the shop. One does not work. The other works, but is slow. He has to buy one. He ponders and decides to buy the slow clock, as he felt he could use it to read time by adjusting to the slowness. Suddenly he remembered that he could use his computer to help him take a better decision. Clear and fast comes’ the reply – “Buy the static clock”. The individual is surprised and asks the computer for the reason to choose the static clock. This time too, the reply was very clear, “Twice a day the static clock shows the correct time, but the slow clock never shows the correct time”.
This simple story aptly illustrates the difference between art and technology. Many a time patients and their relatives believe that technology is superior to art and demand investigations. This belief is misplaced. Always remember “What the mind does not know the eyes do not see”. So technology without a doctor’s art is futile. The public needs to be sensitized on this. They should have faith in the doctor and allow him to use his art.
Way back in 1972, during my second year in medicine, I happened to justify to my medical professor – “Sir I could not hear the heart murmur because I have an Indian stethoscope compared to my friends American Littman’s”. His response is still fresh in my mind. “Son it is what is in between the ear piece of the stethoscope which is important, not the quality of the stethoscope”.
Thus, re-assuring my belief in the Art of Medical Science. I use the art to treat my patients and technology as support to minimize the risk. Not as a replacement to art.
To my doctor friends – let us be judicious in our effort to develop our art and use it to the maximum. It will help us bring down the cost of treatment to our patients and decrease the worry and concern of their relatives too. Does not use technology just because it is available; let us use available technology to support the art only when it’s needed? Our foremost responsibility is to look after the welfare of our patients.
To all patients – have faith in your doctor. His primary focus is your welfare. In India you have the liberty to choose your doctor. Choose someone you have faith in. Once chosen, kindly do not doubt their integrity. Let us make the doctor patient relationship a pleasant one. This will be beneficial to all.