I learnt my medicine at the feet of some of the great teachers in India, the UK and USA. Time was when every patient went through a detailed interview to record the history of his/her ailment and then a thorough clinical examination. Tests were done only when indicated to either confirm or refute the bedside diagnosis and it was not all tests for all patients. What I see today baffles me. Doctors rarely examine patients but rely on all tests to base their judgement. The very act of examining a patient could act as placebo therapy.
I get emails daily enclosing all kinds of test reports for advice. I get confused. This trend is bad for patients, even though it is good for business—if medical practice were to be a business. This has to stop and we should get back to clinical medicine. Even senior doctors have got acclimatised to this new environment. A doctor in Chennai came to see me; I wanted him to get on to the examination couch. He was surprised! He told me that all his reports are in his file and why should he be examined. To the surprise of both of us, his diagnosis was totally different at the end of the day. He was elated and went on to tell his students that he is changing his teaching style.
Hippocrates said that if a doctor listens to his/her patients long enough s/he will know what is wrong with her/him. How very true! When the first corporate hospital came up in a metropolis in India, my former teacher, the late professor CRR Pillai, admitted one of his private patients there with clear-cut instructions. To his dismay, the next morning his patient had been put through all the tests the hospital was offering. He got his patient discharged forthwith and never entered that hospital, during his life time again. The hospital has grown from then to becoming one of the biggest corporate monstrosities, making huge profits at patient’s misery!
Re-emergence of clinical medicine is going to make medical-care very inexpensive from the patient’s point of view and will make for better diagnosis and cheaper treatment also. Many times, it might make major risky surgeries unnecessary. Even the NHS (National Health Service) in the UK has come to the conclusion that intervention is not only a bane but is also prohibitively expensive. It has taken a bold decision to cut down on unnecessary and doubtful interventions for NHS patients by tightening the criteria for treatments where the risks outweigh the benefits. The proposals will ensure that procedures, such as those for carpal tunnel, haemorrhoids and varicose veins, will take place only where there is good reason to do so. Alternative treatments, such as injections, changes of diet or physiotherapy, will be effective in the majority of cases, NHS England said.
National medical director, professor Stephen Powis, said: "If we want the very best clinical care for our patients, we need to stop putting them through treatments where risks and harms outweigh the benefits. By reducing unnecessary or risky procedures for some patients, we can get better outcomes while reducing waste and targeting resources to where they are most needed.” Speaking to the media, he added that this would be the first stage in looking at situations where surgery is better avoided. He said: "We shouldn't, at best, inconvenience or disappoint patients by offering treatments that are not effective and, at worst, harming patients.” In consultation with the National Institute for Health and Care Excellence (NICE), four of 17 procedures will be offered only when a patient makes a specific request, with the other 13 being offered only when specific criteria are met.
If this is the state of affairs in the NHS, one could imagine the status in corporate hospitals, especially in India, which are built to amass wealth from human misery. I am sure, readers will be convinced that if we resurrect clinical medicine, as described above, mankind will be happy. One actual case history will reinforce this point.
A middle-aged gentleman had some unusually spicy food one afternoon and had stomach upset with a vomit. His dinner gave him the same feeling. He slept well. The next morning, the stomach-ache returned with one more vomit. A good doctor in Mangalore, an old student of mine who practises good clinical medicine, arrived at the right diagnosis of acute gastritis and prescribed correctly. The patient was a very rich man who was not impressed by this. He went to a corporate hospital where a cardiologist heard two words, vomiting and upper gastro-intestinal pain.
The patient was admitted to the intensive care unit with a provisional diagnosis of acute coronary syndrome. A good history alone would have given away the secret. He had to go through the usual drill and ended up with coronary angiogram. Lo and behold! There was a block which was angio-plastied. Now, this man gets two blood thinners both of which are gastric irritants. The angry stomach reacted violently. The stomach-ache and the vomiting promptly returned with a vengeance. This is today’s corporate medical practice which netted a few lakhs of rupees to the hospital and the doctor. May clinical bedside medicine return for human good!