Social distancing…..you must be kidding me

The unscrupulous assassination of clinical acumen

Vijay Gopichandran, Chennai

Today I saw a young man all of 28 years of age who came with gradual and progressive weakness of his hands and feet over 2 years. It all started 2 years ago when he was hospitalized with a fever in a local hospital and treated with some “injections” for more than 10 days. He became better and went home and started noticing the weakness. After a thorough history and a physical examination, it seemed that he may be suffering from some form of motor neuron disease, which was gradually and progressively impairing his muscle activity and would probably confine him to a wheelchair soon and maybe even cost him his life prematurely. Long after this patient left the clinic to a tertiary care center for further evaluation, I was contemplating on the looming uncertainties in medicine and how not a day of clinical practice passes without having to confront these uncertainties.

As a medical student posted in the outpatient department and the wards of medicine, surgery, obstetrics, gynecology and pediatrics in the second year of medical school, I remember it was all about the excitement of seeing patients with huge swellings and gross abnormalities. Our clinical teachers exposed us to the patients with the most obvious diagnoses. The young lady with bulging eyes and a huge swelling in the neck had Grave’s disease. The middle-aged man with a hugely swollen testicle had hydrocoele. The pregnant women with a hugely distended uterus with multiple fetal parts had a twin pregnancy. The young man with breathlessness had loud abnormal sounds in his heart indicating some obstruction of valves of the heart. These were “classical textbook cases” and we were excited to see them, learn from them and understand how to identify grossly abnormal variants of the human body. During the second clinical posting in the third year of medical school, it was more subtle. We learned to take a history, do a thorough physical examination and arrive at a diagnosis. Our teachers grilled us in the skills of case-presentation. They taught us how to organize the history and physical examination and present it effectively in a gathering of doctors so that everybody could visualize the patient even without seeing them. The presentation was about intricate details of the history, for example, when the pain started, how the pain progressed, where is the pain, what aggravates it, what relieves it and any unique characteristics of the pain.  The details in the physical examination were also extremely important with intricate information about the size of swelling, surface, texture, consistency, movements, the plane of swelling, etc. By this time, the young medical student graduated from the excitement of seeing gross abnormalities and understanding them, to piecing together and synthesizing elements of history and physical examination to understand the disease further.

The final year, when all the medical students appear for the final exams to assess their capability to function as an independent medical practitioner, exposed the students to higher order analytical thinking and reasoning about appropriate tests and investigations and treatment choices. By this time, students understood the nuances and difficulties in choosing the right investigations and the right treatments. The excitement of picking up a diagnosis was still high, but it was complemented by analytical thinking and clinical reasoning on the choice of investigations and treatments.

The internship period was when the revelation of the gross difference in the academic world of medical education and the real world of clinical practice dawned on the medical student. I remember the 70-year-old man who was admitted to my general medicine ward. He was thin built, emaciated and was very uncomfortable and breathless at rest. His notebook of medical records declared him as a patient of chronic obstructive lung disease, with recurrent admissions in the hospital for acute exacerbations of the breathlessness. Every time the treating team in the ward would hook him on to the nebulizer and give him some medications directly to his airways. They would treat him with some intravenous medications, and he would be relieved in a few days. This time it was the same routine. As an intern, after I finished my evening rounds and gave the evening dose of injections to all the patients, I sat down in the nursing station to write the drug indent for the next day. It was at this time that I noticed this old man watching me closely as I sat there writing. I stopped writing and went next to him. We started a casual conversation. He was telling me about his family and asking me about mine. As we were talking, I noticed a small red swelling inside his umbilicus (belly button). I asked him about it. He said it was painless, but it was present there for a long time. Occasionally it would bleed, and he would hold a clean cloth against it, and it would stop. I was not sure what it was. Out of curiosity, I stuck a needle in it and took out some tissue, fixed it in the cytology solution and ran with it to the cytology lab and requested for a fine needle aspiration cytology, which is a test that will show the nature of cells in the swelling. The next day the report came as small cell carcinoma of the lung. This old man had cancer of the lung, which was not diagnosed, but he was repeatedly being treated as an exacerbation of chronic obstructive lung disease. At last, it was picked up by an intern who was curious to know about a strange swelling in a strange place. This is typically what happens during an internship. The intern spends long hours in contact with the patients. This gives them a distinct advantage over the treating physicians in the team – the assistant professor, the associate professor, and the professors. In addition to clinical excitement and analytical skills, that was learned during the medical school, the internship gives the student the experience of doing what they learned. It gives them the chance to ask independent questions, seek answers for these questions and build their subconscious repository of knowledge and experience.

The internship period also teaches the medical student, the importance of accepting and embracing uncertainties in diagnosis, treatment, and outcomes of treatment. A patient was admitted to the critical care unit where I was posted as an intern. She was bitten by a snake and the poison had led to the disorder of blood clotting. It had led to bleeding from her nose and her blood pressure was falling. Immediately under the supervision of my senior colleagues, I started the patient on anti-venom which would break the toxic effect of the snake bite. After a few hours, the patient’s blood pressure stabilized and she regained consciousness. It was all going on well when suddenly she developed a massive ventricular arrhythmia, the abnormal beating of the heart and collapsed suddenly and died. My shift had ended when she had stabilized and I had gone to my room with a satisfied smile on my face having successfully treated my first snake bite victim. But I came back to work the next day to the empty bed to be told by the nurses that the patient had died. It upset me deeply and I felt like I had climbed a big mountain peak and instead of celebration was being pushed into the valley. It was my first brush with uncertainty. Subsequently, when I saw a rich multimillionaire succumb to septicemia in the critical care unit, despite lakhs and lakhs of rupees worth treatment and when I saw a normal pregnant woman in labor deliver a stillborn baby, the idea of uncertainty in medicine was entrenched deeply in my mind. This was an essential part of medical education and training. Embracing uncertainty in medicine was a hard-hitting necessity.

By the time a medical student passes out and become ready to practice as a doctor in the real world the student passes through these four phases – (1) an early phase of discovery and clinical excitement, (2) an active learning curve of clinical analysis and decision making, (3) a phase of excitement of treatment and happiness in seeing its impact and (4) a shocking stage of realizing the uncertainties in the practice of medicine. This is how I remember the process of making a doctor. It was not easy, it was a lot of pain and hard work and it was a unique process for each student. What has medical education become today?

The seamless four-stage process has been slowly taken over and replaced by “medical education technology”. Medical education has become standardized. The dictum is, “What cannot be evaluated, cannot be taught; What is not taught should not be evaluated”. Increasingly medical teaching has moved away from the art of clinical reasoning, from the power of history and physical examination, from the pattern of bedside teaching and learning into a highly standardized and systematic process of instructions with simulated patients, mannequins, technologically simulated orifices through which tubes can be inserted and a completely evaluation driven process of learning. The pride of every medical college today is the strength of its simulation laboratory, the number of mannequins they have and the type of critical care simulations that their simulated model can generate. There are specialists in medical education with doctorates, who specialize in the technology of teaching medicine. The Medical Education technologists argue that medical education cannot be left to the laws of nature. They argue that the system cannot invest in the education of doctors and leave it to the probability that the students learn well. They emphasize the importance of standardization of curriculum so that every student who passes through the system learns the bare minimum. What they do not realize is that the process of medical education is as much affective as it is cognitive and psychomotor. While a standard curriculum with a good simulation lab, a good exposure to standardized patients, etc. may improve the knowledge and skills of a student to practice as a doctor, it can never teach them to empathize; it can never teach them to emote; it can never teach them to embrace uncertainty; and it can never teach them humility in the face of powerful technology. Unless the medical student passes through the four phases of medical education – the early clinical excitement, analytical clinical reasoning, phase of excitement of seeing impact of treatments and the final shocking stage of realizing uncertainty, it is going to be difficult to produce the well-rounded doctor who is not just knowledgeable, but also wise; not just skilful, but also knows when and how to deploy the skills; and not just a good decision maker, but also a sensible one. There has been a systematic attempt at assassination of clinical acumen in order to promote the fast-growing technological applications in medicine and medical education. It is time to halt this blind dash towards an unclear goal. It is important to go back to our clinical roots and pass through medical education side by side with patients, spending time at their bedside, talking, listening, doing and learning.