January 9, 2012
How many of you have visited a physician and got sent straight to the laboratory for an investigation or have been prescribed medicine or a CT scan without the doctor laying a finger on you? If your answer is yes, dear reader, be assured that you are not alone. It was a thought provoking video that arrived in my mail a while ago which inspired me to pen this article. Dr Abraham Varghese, professor for the Theory and Practice of Medicine at Stanford talks about the transformative power of the doctor’s touch, the transcendental power of the human hand, of the ritual of physical examination. He is a firm believer in the old-fashioned physical examination of patients, the bedside chat and the power of informed observation.
Let’s take a look at the scene today. It is not uncommon to see patients being operated upon the wrong limb, having unexpected drug reactions because of wrong prescriptions and suing doctors as a result. In an era where, time is money, patient welfare seems to have conveniently been put on the backburner. A patient is nothing more than a statistic in a drug trial or profit spreadsheets. The higher your insurance coverage, the more expensive are the investigations ordered and the more expensive are the drugs prescribed. Did you know that the average time that elapses when a patient is talking to his doctor before being interrupted by the doctor is 8 seconds?
We have witnessed the gradual corporatization of healthcare in India. Medicine these days is generally not a non-profit venture. Hospitals are watching their profit margins and that means putting pressure on their doctors to see more patients in less time, order more tests, and generally make themselves and their practices financially not just viable, but highly profitable. Technology, data, metrics and the entire gamut of evidence based medicine devices have been touted as being a means to the end of the goal of cure. But in today's era of corporate healthcare do these means justify the end? My answer is no. In fact it is a vicious circle. With information explosion, and doctors who neglect the importance of conversation, patients sue and file litigations and to escape this, doctors have come to excessively rely on laboratory investigations and now practise what is infamously known as defensive medicine. Hiding beneath the cloak of modern laboratory investigations and the plethora of electronic apps available on smart phones and ipads has become quite common for doctors who do not trust their own capabilities or are plain incompetent.
Let’s examine this issue from two perspectives. From the perspective of the patients, they come to the doctor filled with uncertainty and hope and fear; and the clinical response, if determined purely by complex sounding laboratory investigations, however medically accurate, without any physical examination , the visit to the doctor may be emotionally insufficient for the patient. Sometimes, all that the patient wants is for somebody to listen to them, empathize and understand.
From the doctor’s perspective, I'm sure most physicians would love to spend much more time with patients. But there are only so many hours in a day. If we spend twice as long with a patient we will need exactly twice as many doctors. Healthcare is already becoming a huge burden on our economy. The solution for example, perhaps would lie in not running to the cardiologist when you get the flu and instead go to a general practitioner who is equally capable of treating your flu. This would allow a cardiac patient in greater need of the specialist’s time to avail the necessary attention and care.
Cicero once said, “The competent physician, before he attempts to give medicine to the patient, makes himself acquainted not only with the disease, but also with the habits and constitution of the sick man." When I went to medical school, my professors in a bid to drive home the importance of observation always stressed that the diagnosis of an ailment in a patient begins the moment he/she walks in through the door of your clinic. I strongly agree. There is nothing more soothing for a patient than to have a comforting presence, a patient listener who empathizes and puts a warm arm around the shoulder when he/she is confiding their darkest fears and being completely vulnerable.
A thorough physical examination of the patient is a kind of ritual and as such should be cultivated. To be touched from head to toe gently and thoroughly, to look at the patient while he/she is talking about their symptoms or stories , to look for those subtle uncommunicated signs in their body language, to hold their hand and tell them you understand and it will be okay- this is what builds the doctor – patient relationship. The greatest offering our patients give us is their absolute faith and trust. Touch, observation and conversation are 3 vital elements to establishing a successful doctor-patient relationship. Taking the time to spend a few extra minutes taking a thorough history and examining the patient saves time in the long run and offers information unobtainable by the gamut of tests.
Don’t get me wrong. Touch should by no means inherently trump rational analysis or technology. I definitely believe technology has a powerful role to play in the improved diagnosis and treatment of our patients. What I am against however is the obsessive reliance of the healthcare community on powerful diagnostic tools completely neglecting the patient as a whole. The existence of such powerful diagnostics tools does not invalidate the doctor using his senses to get some idea of what to look for in all that data.
Technology should not deny the patient as a human being. No doubt laboratory investigations serve as a valuable tool for diagnosis, yet as physicians we must not forget that unlike the corporate honchos sitting in their plush offices and counting profits, patients are not statistics, they are human beings. Without the ability to unflinchingly gaze at your patient when they are most vulnerable, touch, show compassion and empathize, we are doing our patients a great disservice.
The clarion call of the hour is to return to our roots, to revive the dying art of history taking and the ritual of physical examination, to amalgamate the best of both worlds- a humane approach and technology for the betterment of our patients. Without this humane approach, we physicians would cease to be "healers" in the true essence of the word. Let’s use our humanity or what’s the point of having it?
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