Basis of Good Medical Practice in era of Specialties
Dr M K Bhatnagar
MD, FICP, MNAMS
Ex-Director Professor (Medicine), Lady Hardinge Medical College, New Delhi
Ex-Commonwealth Medical Fellowship, Guys’ Hospital, London
Ex-CEO and Medical Director, Indra Gandhi Medical Hospital, Republic of Maldives
https://meditropics.com/2022-2-editorial/
Internal Medicine is core of medical education, and its expertise is called for in all fields of medical science. Off late, specialty practice is in vogue, and so-called super specialty hospitals are coming up rapidly. In last five decades we see, hear, and feel the presence of so-called super specialists in all the fields. Key decision making is based on latest technology in investigation, diagnosis, guiding treatment and prevention with the introduction of auto-analyzers, genome mapping, immunology, imaging, and other non-invasive techniques.
Many new age physicians get battery of investigations done before interacting with the patient. This fact should not deter the physician from performing a thorough physical examination, since important clinical findings may have escaped detection by diagnostic tests.
Advances in oncology are spectacular. The older treatment of malignancy was surgery, but there is now increasing range of non-surgical treatment, encompassing both radiotherapy and drug treatment. Computer systems have been developed to aid clinical decision making and quantification of medical care.
In 1950, peptic ulcer disease was thought to be caused by stress. Now causes of peptic ulcer disease are identified. Nearly every tumour that was not resected resulted in death. Rheumatic heart disease was widely prevalent. Hepatitis B, and HIV infection were unknown. Now advances in diagnosis and treatment has made it possible to cure 60-70% of cancers, and rheumatic heart disease has virtually disappeared. Atherosclerotic coronary artery disease had become a major health problem, but by management of modifiable risk factors it has started waning off. Hepatitis B and its consequences, cirrhosis of liver and hepatocellular carcinoma became preventable by vaccine. HIV, which was viewed as a fatal disease has now become a treatable chronic disease.
Clinical methods are integral part of medical education. The foundation of a specialist is based on bed side learning of clinical medicine learned during under graduation and post-graduation. There is an increasing need of learning bedside medicine, history taking, and approach to a patient-doctor relationship.
The principles of medicine are difficult to define. They represent the interaction of clinical experience with knowledge acquired by study and is revealed gradually during a clinician’s lifetime and everyday offers an opportunity to learn something new. The wise doctor should always strive to understand human problems, to help the patient and the family to manage problem caused by the disease and offer treatment, cure, or prevention.
Many experienced doctors prefer to obtain details of patients’ occupational past medical history and family history before discussing the presenting complaint, since it provides a context within which the presenting illness can be viewed. The experienced doctor begins the consultation from the moment the patient walks into the room and observes the general appearance, dress, attitude, gait, vocabulary, and personality throughout the consultation. Common courtesy goes a long way in establishing good communication. Identify if they appear at ease, anxious, dishonest, or embarrassed? More than 50% examination of a patient can be complete during a relevant history. This however, requires a keen observation and an open mind.
It is critically important to remember two things: First, ultimate goal of medicine is to prevent disease and treat patients, and second, to build a relationship between physician and patient.
Whenever a patient poses a challenging problem, a good physician must be able to identify the crucial elements in history and physical examination, order the appropriate laboratory, imaging and diagnostic tests and extract key results to determine whether to treat or to just watch.
The combination of medical knowledge, intuition, experience, and judgment defines the art of medicine.
The physical examination should be methodical and thorough, with consideration given to the patients, comfort, and modesty. Due attention should be given by the history of the diseased organ or part of the body. The examination of a new patient must extend from head to toe in objective search for abnormalities.
Now days, physicians rely increasingly on a wide array of laboratory tests to solve clinical problems. However, accumulated laboratory data do not relieve the physician from the responsibility of carefully observing, examining, and studying the patient. It is also essential to appreciate the limitations of diagnostic tests as well as artificial intelligence (AI). Physicians should also weigh the expense involved in laboratory procedures against the value of the information. Physicians must never forget that the patients are individuals as well as human beings. They are not “cases”, “admissions” or “diseases”.
Physicians should instill confidence and offer reassurance but must never come across as arrogant or patronising. A professional attitude coupled with the warmth and openness can do much to alleviate anxiety and to encourage patients to share all aspects of their medical history.
These facts are best described below for a good physician:
“No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering the physician needs technical skill, scientific knowledge, and human understanding… Tact, sympathy and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. The patient is human, fearful, and hopeful, seeking relief, help and reassurance.”
- Harrison’s Principles of Internal Medicine, 1950
Advances in medical knowledge should not undermine the importance of bedside approach to the patient. Judicious use of clinical data obtained by extensive interaction with patient, and relevant investigations is key to the success of a good physician.