DOCTORS’ DAY ORATION : JULY 1st, 2012
CUTTING-EDGE TOOL IN MEDICINE:
THE CLINICIAN’S HAND
PHILIP JOHN, M. D.
PEEJAYS CHILD GUIDANCE CLINIC
COCHIN, INDIA
www.peejays.in
DOCTORS’ DAY ORATION : JULY 1st, 2012
HOMAGE
Bidhan Chandra Roy, (1 July 1882 – 1 July 1962)
A highly respected Physician, C.M of W. Bengal for 14 years.
Alumnus of the Medical College, Calcutta.
Completed both F.R.C.S. and M.R.C.P. simultaneously in two years
National Doctors’ Day is celebrated on July 1 date of his birth, death.
TRIBUTE
Dr. Abraham Vargheses
THE CLINICIAN’S HAND
NEW SCIENCE OF MIND
Mind is generated by the Brain.
Psychiatry is the Application of
Basic Neurosciences to man’s
day-to-day problems.
Psychiatry is a Branch of Medicine.
Psychiatric Disorders are Physical Disorders.
Psychiatrists are primarily Physicians.
THE CLINICIAN’S HAND
CUTTING - EDGE TOOL IN MEDICINE:
THE CLINICIAN’S HAND
"Fetal Hand Grasp"
Hand of Hope
“Reassuring Hand Grasp”
Gift of Life
Surgeon Joseph Bruner
Any Physician like us
THE CLINICIAN’S HAND
The clinician’s cutting-edge tool :
THE HUMAN HAND
• Quarter of motor cortex in human Brain devoted to Hand.
• Homunculus: hand in the brain.
Hand is a Cognitive Organ, working in coherence
with the brain’s Frontal Lobe.
THE CLINICIAN’S HAND
The clinician’s cutting-edge tool :
THE HUMAN HAND
• Cutting edge tool : rough tasks like pelting to delicate
micro-precision, like a surgeon’s. And Language…
• Thus, hands useless without the Mind in the Brain.
• Hand, a perfect functional Tool, when applying the Mind.
• A functional Hand can accomplish tasks impossible
even for advanced robots.
• And for more – Hands to Touch, thereby, to Talk.
THE CLINICIAN’S HAND
The clinician’s cutting-edge tool :
THE HUMAN HAND
Hand and Mind together : Touch
• Touch to Connect
• Touch to Comprehend
• Touch to Diagnose
• Touch to Reassure and
• Touch to Heal…
THE CLINICIAN’S HAND
MIRACLE OF THE HUMAN HAND
• The only Diagnostic technology till recently was this
Human Hand !
• Even today, the most powerful comprehensive tool in
the Doctors’ arsenal.
• Hands need the Head to Diagnose.
• And the Hands and Mind to Heal – ‘the Miracle’.
• Hands, therefore, must become the Culture of Medicine.
THE CLINICIAN’S HAND
MIRACLE OF THE HUMAN HAND
TOUCH : TO DIAGNOSE, COMFORT AND TO HEAL
THE CLINICIAN’S HAND
HANDS AND
THE MIRACLE TOUCH
• Determine quality of Doctor-Patient interaction.
• The Clinical Touch that examines, undergoes
‘Parivarthan’ – to progress to a Reassuring Touch.
• If thus optimal Rapport builds up, it results in
Interpersonal Trust .
• Trust enough that helps the patient to instantly
confide his secrets and even to disrobe himself !
• Each of us Clinicians is keenly aware of this
‘Healing Energy’.
• This is the Healing Hand, the Healing Touch.
THE CLINICIAN’S HAND
Hands : The Heart of ‘Doctor-Patient’ Relationship
• Bygone Clinical Era - spontaneously connected these two.
• Presently, Physical Examination and Clinical Diagnosis is
“Dying Art”. Scoffed at.
• Old-generation Physicians shudder if examination-skills
atrophy and die.
• And the younger ones these days look at P/E as an
archaic curiosity !
• In this process of decay, the Doctor-Patient Relationship
has been the casualty.
• In a true Doctor-Patient relationship, Physical Examination
must not be compromised.
•
It is a powerful tool not for Diagnosis, but also for Relationship
THE CLINICIAN’S HAND
MEDICINE & TECHNOLOGY
‘Victory of Technology upon Wisdom’
• Medicine as Science – exponential growth.
• Information (overload) and Knowledge.
• Knowledge may not have ‘Wisdom’ ( eg: internet ).
• ‘Scientific Paradox’ : reductionism ( eg: chest pain:
“thonnal”)
‘Victory of Technology upon Wisdom’.
• Medical gizmos and gadgetry have sunk the
‘Art of Medicine’ and the ‘Trust of Patient’.
• Current trends : Practice of Medicine has lost the
‘Human Face’.
• Patient ‘care’ often without ‘caring’ (Prof. Gilvaz).
Without the old bonding.
THE CLINICIAN’S HAND
MEDICINE : ART OR SCIENCE ?
• Fulfillment in Clinical Medicine used to be proving
your intelligent guess ‘right’ - by the outcome.
• Medicine always was known as the tricky
‘Art of Conclusions on Insufficient Evidence’.
• Therefore, William Osler wisely named Medicine
“the Science of Uncertainty, and Art of Probability”.
• The balance between the Art of the Right Brain and the
Science of the Left Brain.
• A good Clinician is this balanced combination,
and the Clinician’s Hand, the successful delivery tool
– to Diagnose and to Heal. (cabg)
THE CLINICIAN’S HAND
DEMISE OF CLINICAL DIAGNOSIS
• The restoration of that most powerful and cuttingedge technology of the ‘Human Hand connected to
its Brain’ can resurrect the balance between Art and
Science.
• Technology in Diagnosis and Intervention may
have permitted a perfect ‘Diagnosis from a Distance’,
bereft of Empathy from the Doctor,
and of Trust from the Patient.
• Lack of Clinical Diagnosis can also precipitate the
overlooking of simple diagnoses, and send the patient
on investigation trips.
• Harrison’s TBM : “no examination of the chest is
complete for chest pain……”
THE CLINICIAN’S HAND
DEMISE OF CLINICAL DIAGNOSIS
i) Patient from USA: Diagnosed with CA Prostate.
On Tesla 3 MR Spectroscopy,
high choline and low citrate levels
suggesting CA.
Diagnosis from a Distance, and the resultant angst !
Simple PR exam by Urologist here unremarkable;
and biopsy normal.
ii) Mr. V, 74 yrs. Father of a Physician.
Investigated extensively with imaging, for Depression.
Referred for opinion. Glabelllar tap +.
Thumb fingers bradykinesia. Clearcut Parky..
THE CLINICIAN’S HAND
DEMISE OF CLINICAL DIAGNOSIS
• Compelling need to restore Clinical Diagnoses.
• An MRI or CT cannot detect Cerebral Palsy.
And computer-generated Questionnaires cannot
diagnose Autism!
• Technology cannot replace Physical Examination
and a resultant Doctor-Patient relationship.
• ‘Get up from the chair’ - to touch the patient for
Physical Examination and Therapeutic Relationship.
THE CLINICIAN’S HAND
RETURN TO THE PHYSICAL EXAMINATION
• The writings of Dr Abraham Varghese, Professor at
Stanford, and Dr. Sandeep Jauher in NEJM.
• Dr. AV developed the
‘Stanford 25 Initiative’ to showcase
and teach 25 fundamental P/E skills
for Diagnostic & Therapeutic benefits.
• Evidence, that Physicians lack P/E- skills (Jauhar, 2006).
• P/E maneuvers have as much Sensitivity and
Specificity as investigations in the final diagnostic round.
• P/E enhance skills and opportunities to strengthen
Clinical Outcome in practice (Janicik).
• Most importantly, learning Humanism and sanctified
Professionalism at the bedside.
THE CLINICIAN’S HAND
PHYSICAL EXAMINATION: A RITUAL
• Dr. AV (Stanford) jokes that the current breed of
Physicians need a scan to locate a limb missing,
because they shortchange the physical examination!
• For my generation, P/E has been a RITUAL.
• Inspection yields awesome information which NO
investigation can replace.
• Palpation and Percussion in bedside medicine
generate Relationship too.
• The Stethoscope still best symbolises my
practice of medicine.
• The passion for my Profession is when I find the
thrill in the ‘Investigation-results agreeing with
my P/E diagnosis’ !
THE CLINICIAN’S HAND
PHYSICAL EXAMINATION: THE RITUAL
• History-taking and P/E establish Therapeutic
Relationship; thus the Physician earning many
rights with the patient.
Something sanctified occurs in this exchange.
• That is the RITUAL, like a Prayer. THE CONNECT.
That instantly enables the patient to confide, to
disrobe, to swallow your chemicals, to allow
anesthesia. It is incredible!
• P/E and the relationship kindle the patient’s Hope and Faith.
• Even when your ‘Science’ fails, the ‘Art’ of Medicine makes
the caring Physician walk with the patient till the end.
Kindling his Faith: “I will always be there with you; I will never
abandon you. I will be with you through the end.”
THE CLINICIAN’S HAND
NOW, OUR SIDE : DOCTORS AS TARGETS
ALL ABOUT RIGHTS. NO RESPONSIBILITIES!
• The NGOism sweeping from the West has become
a fad for the media and some policy-makers.
• For them, it is all about ‘Rights’.
Many of these ‘Rights’ are one-sided.
The soft-target Physician, of course,
has “no rights”, only responsibilities.
So, he can even be attacked !
• Patients are not usually the litigants. We know the
instigators.. Local vested interests, certain
one-sided journalists, aggrandising relatives..
All of which make us do ‘Defensive Practice’.
• Nevertheless, ‘Trust’ may withhold even ‘litigants’.
THE CLINICIAN’S HAND
DOCTORS AS TARGETS
• NGOism has thus now led to this emphasis on
“Patient-Doctor Interface” ! Not P/E..
(Educating, and talking to the Patient and the Family !)
• NGOs advise - “get your doctor to spend time with
you – ie. talking !”
• Therefore, there is compulsion for us to short-cut P/E
and ‘blindly investigate’, in order to ‘bluntly talk’ to
them about our confident findings!
THE CLINICIAN’S HAND
DOCTORS AS TARGETS
• ‘Evidence based Medicine’ is another fad…
‘Research’ studies that are either not
understood, or manipulated to ‘score’ above your
experience.
• So, litigants may not spare you now, even if you
used your ‘experience and good faith’.
• And,society and the media seem to find the worst
in us to make all of us appear as cut throats.
Even the “reality-shows” would concentrate only
on that other side…
THE CLINICIAN’S HAND
PHYSICIANS
AS TARGETS OF PHYSICIANS
• Listen to our own colleagues : “How could he have
missed this..”, “this should never have been done”,
“if only you had come early…” etc.
• We know, we all have to together curb these
tendencies of one-upmanship.
• Specialists function as ‘water-tight-compartments’,
and do not communicate with each other,
but mis-communicate to the patient and his relative.
• Lack of inter - specialty communication gets both
Physicians and Modern Medicine into trouble.
THE CLINICIAN’S HAND
“NOBLE” PROFESSION
• If it comes to the ‘rights’ of the poor Physician,
or to his ‘reward’, suddenly everyone goes ....
“the noble” profession should not do this!
• Other than teachers, Medicine is the only
profession which Society need not have
gratitude for, and need not remunerate. “Noble ..
• The Society needs to start looking at this differentlyour media to judges to political leaders.
• Governments, politicians allow Crores to pass hands
for a medical seat - consciously.
But the Doctors who pass paying those crores
are expected to do Social Service !
THE CLINICIAN’S HAND
CURRENT SAD STATE
Entrances, Admissions, even Examinations have
become playing grounds of disproportionate money.
To pay back loans and keep up a decent life-style,
what is the Physician expected to do ?
• Why are our younger doctors training to become
procedure-oriented Specialists, and not GPs or
Physicians?
• The Society does not reward us Physicians for their
Listening to, or Examining the patients.
There is no reward for a smart Diagnosis or a
Medical-treatment or a healthy Outcome……
•
THE CLINICIAN’S HAND
CURRENT STATE
• On the other hand, income can be indiscriminately
generated by a procedure, or through blind,
investigation-based medicine.
• This social system too needs change where “Clinical
Diagnosis, Physical Examination and a Medical
Outcome are equally rewarded” professionally.
• This will also reduce Health costs for everyone, and
Physicians who do not investigate disproportionately
too will earn a decent income.
• And the cutting edge tool - the ‘Clinicians Hand’ - may
recoup a decent place in our Profession.
THE CLINICIAN’S HAND
THEREFORE, ON THIS DOCTORS DAY…
As Trousseau, the French Physician implored –
“ For mercy’s sake gentlemen,
let us have a little less SCIENCE
and a little more ART.”
- using the cutting-edge tool in medicine
that we now deliberated on.
Thank you