The practice & teaching medicine must be based on competence

teachersCan we get back to Hippocrates for a change?
The practice of medicine must be based on competence, character and compassion.

Sir William Osler, a legendary medical teacher and physician of yesteryear wrote: “The practice of medicine is an art based on science, working with science, in science and for science.”

Through the last nearly 75 years the medical world has seen significant advances in basic sciences and, therefrom, clinical sciences. Nevertheless, we are only reaching a stage at which we are aware of how little we know. No wonder, many a discerning patient understands the doctor’s dilemma in difficult cases.

George Bernard Shaw, who authored The Doctor’s Dilemma, wrote in style and humour and debunked the pomposity of the medical profession.

Medicine in Hippocrates’ period was an exercise by the doctor using his special senses — ‘smelling’ disease e.g., acetone breath in diabetic coma, sewer breath of lung abscess, ammoniacal smell in uraemia etc., the eyes ‘saw’ oncoming death in the face of the patient — The Hippocratic Facies, hearing ‘the death rattle’ in the chest.

Discoveries in the 18{+t}{+h} and 19{+t}{+h} centuries improved physical examination of sick individuals and teaching of the art and science of medicine was often to small groups of students, often by catechism.

To go back to Hippocrates — ethical issues in practice must be part of medical teaching, he said. “There should be perfect harmony between the appearance and character of a doctor. Character is important. Patients put themselves in the hands of their physician and he constantly meets women, maidens and possessions, very precious indeed and towards all these self-control must be used,” Hippocrates (460-375 BC) said. Is this not relevant today what with ‘sex doctors” and doctors advertising in subtle ways in the press, television, etc?

The evolution of methods of assessment of disease was a remarkable translation of common and day-to-day events to their application in medicine. For example, Leopald Auenbrugger, a continental physician of the 19{+t}{+h} century, used to observe his father, a wine merchant, tap barrels of wine to check how much they contained. Auenbrugger applied this technique to ascertain whether the patient’s chest had collection of fluid (pleural effusion) and thus was born percussion in medical practice.

Likewise, Laennec, a French physician, observed two children at play in a park. One child was scratching the plank at one end and the other put its ear to the plank at the other end. Laennec translated this observation by hearing the heart sounds of a woman patient with a paper rolled as a tube. He could not put his ear directly to the chest of the lady! A stethoscope ultimately evolved.

We have come a very long way since Auenbrugger and Laennec’s days and today there is a bewildering variety of tests — biochemical, in molecular biology, radiological, etc.

As Richard Asher, a critical medical writer, has said: “It is in the ordering of laboratory or radiological investigations that rational thinking is so necessary. It is a salutary exercise in mental discipline to catechise oneself when ordering any medical investigation. Why do I order this investigation? What do I look for in the result? If I find it, will it affect my diagnosis? How will it affect management of the case? Will this ultimately benefit the patient?”

Recently, there has been considerable discussion on reform in medical education. Most of the issues that have been highlighted involve changes that have students as the focus of attention. Far less emphasis is being paid to the changes that need to happen among teachers also.

In this context, the findings of a study that we conducted nearly 30 years ago are revealing. Forty-five students, 22 house staff members and 20 senior professors were asked about medical teaching, its content and also to suggest changes. The senior professors stated that most classes were unwieldy, favoured small groups for discussions, were not averse to symposia and seminars and generally supported internal assessment. The students too agreed that most classes were large, welcomed lectures with audio-visual aids and feared that the likes and dislikes of teachers may impact their performance in internal assessments.

Reform in medical education must improve the skills of the teachers and aim at upgrading their skills through courses that help teachers teach. It is worth reiterating, as Napoleon said, that there are no bad soldiers, only bad captains. Teachers in medicine should be chosen for their aptitude and commitment to teaching since not all doctors are naturally endowed with skills to teach as is currently assumed. Teachers should be evaluated continuously to ensure that the quality of teaching is assured and the evaluation process should include the consumers — the students.

A welcome move by the Medical Council of India is the introduction of medical ethics through formal teaching in the curriculum. However, didactic lectures alone may rob the subject of its interest and, worse still, may encourage students to actively avoid them. On the other hand, bedside discussions may help students grasp the nuances of ethical issues faced by modern day practitioners. The structuring of postgraduate courses needs to be given considerable thought. The recent move to introduce a two-year degree course followed by an additional year that will confer a three-year degree in medicine and allied subjects should be carefully evaluated before implementation.

In conclusion, the practice of medicine must be based on competence, character and compassion on the part of the medical man.

He should try to understand the patient who has the disease and should not concentrate on the disease alone.

He should not consider investigational results the prime factors in decision making, relegating clinical features including history to the background. That would be the wish of Hippocrates, the father of modern medicine.

(K. V. Thiruvengadam is a former Professor of Medicine, Madras Medical College, and V. Kumaraswami is a former Director- in- charge, Tuberculosis Research Centre, National Institute of Epidemiology.)

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