https://meditropics.com/the-fading-art-of-clinical-and-collaborative-medicine/

^*Madhur Yadav

^*Director Professor, Department of Medicine, Lady Hardinge Medical College, New Delhi

Medicine is the shining gem of all branches of Medical Sciences; interesting, challenging and enjoyable at every stage from training to practising. Another joy of practising medicine is collaborating with other practitioners. As a physician in Internal Medicine, I have teamed up with many in the past and continue to do so but do feel the art of professional collaboration is slowly fading away. Not only is the process is of collaboration exciting, it is bound by a common purpose and learning for all. For a patient, to know that their health care team is working together provides confidence and comfort.

World has moved on tremendously in terms of diagnostic work-up and management from the 1919 pandemic of the last century to the COVID-19  of this century. The only guideline which has stood the test of time is a good clinical approach, which is history taking, examination and good communication. Regrettably with the advent of latest diagnostic procedure, and its easy accessibility, clinical medicine as a skill has eroded.

Could any gadget or AI algorithm ever replace the experience of the physician in community or cross-referral and team approach in patient management? The answer is a NO. But gadgets, equipments and facilities have affected each of these very foundational pillars of practising Medicine. Corporate hospital giants have become factories and workshops producing new diagnostic approaches and models, ordering investigations relentlessly and treating values rather than people. The money-making machines claim superiority based on the size of their ward ‘suites’ rather than skills. The pseudo-inflated egos of ‘consultants’ makes them have a condescending attitude towards well-meaning community physicians, misleading patients and families.

A decade ago a patient (43 yrs/ male) presented to the emergency of a government hospital, was diagnosed with acute myocardial infarction, treated conservatively and discharged. Time passed by, patient was serious about his health and was on regular visits till the time he got transferred to another city and where he underwent regular follow-up with a ‘super-specialist’, a cardiologist.  I was kept in loop by the patient regarding his health regularly. A thallium scan was ordered because of patient’s complaint of shortness of breath during walking. The scan was negative for inducible ischemia. When he returned back from the city, he consulted me, and wished to have all his cardiac tests done and reviewed, including coronary angiography (CAG) as he was due to retire soon. I assured him that since everything is within normal limits (symptoms, weight, and blood pressure) the invasive investigations were not required, but he insisted. On the day of CAG his wife made a frantic call to me that the cardiologist had diagnosed triple-vessel disease, and has to be operated as early as possible. The cardiologist had also complained that their primary physician, me, did not understand the gravity of the situation and had ignored this serious disease. Having confidence in my clinical approach, I gently advised the patient for another thallium scan, which again came out to be negative for inducible ischemia. When they confronted the cardiologist with the new report, he unapologetically rebuffed the family saying, ‘these results can be confusing, I may have commented on some other coronary angiography report’. In truth, the patient had only a single-vessel disease. But for the trust in the physician, he would have been operated by the cartel of private hospitals.

In an another incident, a distraught laboratory attendant, regular to our hospital OPD department, came to my colleagues for second opinion for his son diagnosed to have lung malignancy following a battery of investigations including chest computed tomography (CT). Detailed history and physical examination revealed that there was a right-sided pleural effusion and while two fluid taps were done, they were difficult and scant. The fluid analysis revealed exudation, with increased lymphocytic count. He was managed conservatively on anti-tubercular therapy for a period of six months and became well. The family narrated how the specialists of the private hospital were breathlessly running from one nursing home to another, giving prescriptions over phone to floor doctors who may be just alternate medicine degree holders. The doctors did not really sit down and touch the patient. Their work was done after increasing the hospital admission count and the number of CT scans for the day.

I wish to conclude by emphasising that the patient is not just a disease or diagnosis to treat. They are people with emotions, and belong to families who suffer collectively with the label of a disease in a member. We have to be more reassuring in our approach, know our patients ‘by their pulse’, and help them develop trust and confidence in us. It’s a long journey in clinical Medicine. A patient well treated converts into a family that will lean on to us for life. For a physician in community or Government set-ups it may not mean a lot financially, but definitely makes one richer in terms of gratitude and blessings.

Interpersonal relationships on a professional level must also be strengthened over time. Poor communication and misunderstandings between health professionals negatively hamper patient outcomes, at the same time affecting the nobility of our profession. A physician’s learning curve must never end. Each new case makes us wiser and we always remain students of Medicine. Humility and eagerness to learn will help develop understanding with colleagues and a team approach in managing disease goes a long way in improving the health of the patient and society. Only together we shall be able to beat the onslaught of gadgets and AI in our lives, lest we lose our jobs to robotic doctors with no empathy or communication skills.