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“Cure rarely, comfort mostly, but console always” was the advice of Hippocrates and still remains valid to this day of hi-tech stuff. To practice each one of them the doctor must be a great communicator
“One kind word can warm three winter months”—a Japanese saying
“Art” wrote, Henry David Thoreau, “is that which makes another man’s day”. One kind word on the bedside can cure many ills. The art of medicine is that which should make the patient’s day. In fact, the summit of all efforts in the field of medical care delivery is the coming together of two human beings—the one who is ill or imagines to be ill and the other in whom the first has confidence. This is called medical consultation. All else in medicine should really flow from this summit. “Know your patient better than his disease” was the opinion of the father of modern medicine, Hippocrates. Having worked under some of the giants of clinical medicine both in India and abroad, I feel sorry for the patient as also for the doctors of today who think that the hi-tech investigations give them the diagnosis and management strategies. “Patient care is caring for the patient!” This is the motto of Massachusetts General Hospital and was coined by Sir Francis Peabody.
Hardly anyone talks with the patients these days. Most of the big bosses make what they call the “chart rounds” in the ward-side rooms where all the details of the patients, including the scanners and X-rays, are kept. Little time is spent on the bed side. The present jargon for good medical practice is “euboxic medicine” where all the right boxes should be ticked in the computerised case sheet. Whether the patient feels better or worse is of no consequence. “Patient doing well; do not interfere” wrote Sir William Osler, a great clinician of the last century. “God give me deliverance from treating suffering human beings as cases, not letting the well alone and making my interventions worse than his disease,” was the daily prayer of Hutchinson. If you talk to a present day sub-specialist, he/she would say that all those ancient timers didn’t have the array of scopes and scanners that we have today!
Recently a triple blind, computerized, prospective study was undertaken in London by some of the great teachers in different medical schools there—John Mitchell, John Hampton, Michel Harrison and Carol Seymour, to name a few of them—to study the role of listening to the patient and reading the referral letter from the family doctor vis-à-vis examining the patient physically and investigating the patient with all the gadgets including the positron emission tomography (PET), in the diagnosis of medical out-patients. These giants were all students of Lord Platt on the University College Hospital London. Platt had written in 1949 that “if one were to listen to the patient long enough, the patient would give away his/her diagnosis.” Platt’s students, who now have access to all hi-tech stuff, wanted to check the veracity of the old man’s statement.
This study was published in the British Medical Journal. The study showed that 80% of the accurate final diagnosis and 100% of the future management strategies could be arrived at, at the end of listening to the patient and reading the referral letter. This could only be refined 4% more by all the physical examinations and only 8% by all the investigations including the PET scanner! A very strong message there from a very robust study, indeed. This will be a boon to all doctors ready to practice—even in a remote village. Unfortunately, all our doctors are trained within the four walls of the five star hospitals where their teachers rely only on the modern gadgets. It is not a surprise that such doctors tomorrow will feel frustrated to practise medicine without those gadgets. The new trend is being propped up by the industry through their indirect advertisements under the guise of scientific data.
Every disease, in a manner of speaking, is “slightly mental”. Diseases start in the human mind and also end there. If one wants to get a grip on the patient’s problems one needs to have an inkling into the patient’s mind—his worries, his anxieties, his fears, his obsessions, his spirituality, his environment, his family ties and his problems—all of which will have a say in the final outcome. These important aspects of disease management could only be gauged by listening to the patient. In his beautiful book Talking with Patients, Prof James Calnan, who was Emeritus professor of plastic surgery at the Hammersmith Hospital, London goes to great lengths to show that “talking with” or listening to patients is an art that should be mastered by every medical student. (Calnan J: Talking with patients - a guide to good practice. William Heinemann Medical Books, London. 1983. 151 pages.)
In our days, we followed the foot steps of our teachers by observing how they talked to and listened to patients in the out patients as also on the bed side. This is absent in today’s atmosphere. That breed of teachers is almost extinct—like the dinosaurs. Even the so called bed-side clinics are now conducted in what they call the ward side teaching rooms where another mini didactic lecture takes place on the patient’s problems! Real beside clinics should happen at the bedside where the patient could be observed carefully even while he is talking. His facial expressions, showing his internal turmoil, could be a pointer sometimes to the final diagnosis. Sir William Osler had a prescription for all doctors to have two great qualities on the bed side—imperturbability and aequanimitas— equanimity and the capacity not be perturbed under any circumstances on the bed side. These two, in their absence, could send wrong signals to an anxious patient.
Some of the important clinical research data in the field of modern medicine have emanated from the bed side. Genuine clinical research is nothing but a question on the bed side and the effort to go as far away from the bed as needed to get an answer! Some of my original works, reported in the prestigious journals abroad, have come from the bed side. Time spent by the students on the bedside will bear fruit in the long run to make them very good humane doctors. Every patient is another human being in distress and needs to be understood with compassion before being treated with drugs or surgery. A good doctor knows how to treat from the books, a better doctor would know when to treat from the books again, but the best doctor knows when not to treat from his bedside experience only. Our present biggest problem is over treatment, resulting in adverse drug reactions and over interventions.
In conclusion, one could easily say that if one trains himself/herself to be a good bedside clinician one would have achieved great success in dealing with patients. One must learn to listen-—a very difficult art, indeed. Medicine is basically an art based on the scientific foundation that seems to be shaky. If doctors have done any good to the suffering humanity, that was mainly because of their bed side skills and not based on the faulty science of reductionism. “Cure rarely, comfort mostly, but console always” was the advice of Hippocrates and still remains valid to this day of hi-tech stuff. To practice each one of them the doctor must be a great communicator. Pain and suffering were the problems for our ancestors in medicine and they are our problems today and will remain the problems for the future generation of doctors as well.
So bed side medicine will remain the sheet anchor of medical management for all times to come. Time was when medicine was purely paternalistic where the doctor was considered God and he/she did what he/she wanted. Today it is gradually becoming more of an equal partnership where the patient takes part in his /her management. It is more important today to know one’s patient than it was in the days gone by—all the more reason why today’s doctors should be better bedside clinicians and communicators. Long live the fine art of doctoring.
“They also serve who stand and wait”— John Milton
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also Editor-in-Chief of the Journal of the Science of Healing Outcomes, Chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former Vice Chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London. Prof Dr Hegde can be contacted at [email protected])