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Is it the End of Road for Clinical Medicine?BACK

There was a time when we as youngsters (till about the end of last century) were taken to the doctor who would examine us and prescribe or dispense medicines. These medicines would have their effect and soon we would be alright. The doctor would barely order investigations.

Times have changed. Now, we find that most of the prescriptions contain a list of investigations and patients mention that the doctor hardly examined them. Doctors find it easier to order investigations before examining a patient. As a doctor with more than three decades of experience Ifind this trend very disturbing. Pondering over the reasons for this I was wondering whether this was due to the demand of the patient or other reasons best known to the treating doctor.

I am reminded of the day when my elder son once told (in the beginning of this century) that in the surgical outpatient department most of the patients would come with an ultrasound report demanding surgery for their gall bladder. Yes, the convenience of better investigations has certainly facilitated diagnosis but investigations should follow (rather than precede) a clinical evaluation of the patient.

I am reminded of an article which I read in the newspapers in the 90s which, though a fiction, was so true. It was something like this:

A middle aged lady developed an uneasiness in the chest and was wheeled into an ICU where machines were plugged to her to monitor her. After two or three days the doctor sat on the console of the machines to analyse the reports but could not come to a conclusion. Monitoring continued and after another day

the console prompted to the doctor:

"Do you want to continue with the patient?"

The doctor punched "Y" for yes and another couple of days passed. The console flashed the bill that had accumulated and again prompted the doctor: "Do you want to still continue with the patient?"

The doctor again punched "Y" for yes but this time the console flashed: "Have you gone and visited the patient?"

The doctor naturally punched "N" for no when he was prompted "Go and visit the patient."

The doctor dutifully visited the patient and took the history and realised that the patient felt an uneasiness in the chest as her bra had given way. She had to undergo admission and investigations which were unnecessary had the doctor taken a detailed clinical history and examination.

Till CT (computerized tomography) became very common, anatomy books mentioned detailed dissection finding for teaching anatomy. However, with the advent of CT the illustrations have been replaced by CT diagrams. Is this one of the reason why investigations are preferred?

As a clinical paediatrician, my experience is that a detailed clinical history (which is certainly time-consuming) brings me closer to the diagnosis even before the clinical examination in majority of cases. This guides me to the appropriate line of investigations rather than ordering a whole battery of investigations which are both time consuming and needless.

Another reason why doctors may be ordering investigations is to save themselves from legal issues which may arise if things go wrong. "Ambulance Chaser" lawyers which started in the United States is fast catching up in other countries too.

I would like to end by stating: Investigations should follow a provisional clinical diagnosis rather than groping in the dark by ordering investigations. They should either confirm or exclude a diagnosis rather than become the basis for diagnosis, though some conditions can only be revealed after due investigations.

Dr Rajiv K Khandelwal Consultant Paediatrician



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