HAS CARDIOLOGY LOST ITS HEART?
Posted by bmhegde on 1
"Of the terrible doubt of appearances,
Of the uncertainty after all-that we may be deluded……"
Walt Witman.
Let us first examine the basic sciences, the foundation of our clinical cardiology. Ever since European Universities accepted physicians as scientists (surgery was still considered barber’s job) in the twelfth century AD, medicine, like other biological sciences, started following linear mathematics of the reductionsit science. The latter does not work well in the dynamic system like the human body. Let us take water as an example. Hydrogen is a very volatile atom while oxygen abets volatility. The two atoms combined together, the resulting molecule, water, is anything but volatile! Moral of the story is that the “whole” need not be the sum total of the “bits” always. Human body is not a machine comprising of parts (organs) that run on its bio-electrochemistry and could be mended like a motor car. Organs work in tandem “mode-locked”, in tune with the environment and dictated by the genes but completely modulated by the human mind. This is the non-linear holistic concept. This is the essence of Indian Vedic non-linear laws of the universe. If one concentrates just on the final outcomes of the present reductionist research we come to realize the futility of this kind of scientific medical research and technology that we depend on fully in place of our time honoured bed side common sense clinical cardiology.
I am sure I have made the reader realize the need for humanism in science, nay in all areas of human activity. Science needs a conscience to see that its activities should be there for the good of humanity at large and not work at cross-purposes. If there is anything that helps man to live happily on earth that should be scientifically examined to see if it is really good. God concept, spirituality and the whole lot of non-science activities should be viewed with this background of science audit. The bottom line should be human welfare, nay welfare of all living things, sarvabhootapreeti. A recent prospective randomized controlled study of patients after myocardial infarction in the CCU of a teaching American hospital showed that intercessory prayer was an excellent adjunct to conventional treatment after a heart attack!(1)
Most of the technology and interventions that we use in cardiology are based on reductionist ideas. Consequently, what we do with them can not be called truly scientific. Many of them are not even audited properly before being used. The example of Swan-Ganz catheter stands out significantly in this back ground. Another area where cardiology has made life miserable for the hapless people is in the area of regular check ups in apparently healthy. Linear laws of future predictions do not work in any dynamic system. Time evolution in a dynamic system, like the human body, can never be predicted with the patchy knowledge of a few phenotypic features as we do now. To predict the future of man we need to know all about man at the initial stage. Man is 40% his consciousness, 30 % phenotype and the rest 30% is his genotype. To know all about man (100%) is impossible with our present knowledge. Cardiologists (doctors) have been, therefore, predicting the unpredictable future of man! (2) Unfortunately screening has become a big business for technology manufacturers. Intervening when one is in trouble is logical and morally correct even if knowledge in that area is not complete, but to intervene in the healthy without one hundred percent certainty is asking for trouble.(3)
Patient’s trust in his/her doctor is the pivot around which revolves medical care delivery. This trust is the one that stimulates the immune system in the patient for speedy recovery. This has been recently shown even by PET scanning of the brain during a consultation. There has lately been an erosion of the holy bond between the patient and his healer for the detriment of both. Doctors today have become the sellers of medical technology and the patients the buyers! This does not bode well for the future. The signs of danger are already seen in the advanced countries like the USA where doctors’ interventions and drugs put together send the maximum number of people to meet their maker in heaven, pushing cancer and heart attacks to the second and third places! (4)
Modern medicine has got itself into a cocoon from where it finds it difficult to get out. The powerful drug and the technology lobbies have taken modern medicine to the market place enabling market forces to act on the medical establishment. The summit of medicine is the coming together of two human beings- medical consultation-where a man/woman who is ill or imagines to be ill, comes to seek the advice of another of the species with full trust and faith in the latter. All else in medicine-the medical school, the laboratory, the hospital, the library and technology flow from this summit. Today that very apex has been threatened. (5)
In advanced countries people practise defensive medicine to save their skin from the ambulance chasing lawyers who are ready to sue the doctors for any small mistake. This forces doctors to practise euboxic medicine where the doctor is keen to fill all the right boxes in the computerized case paper without leaving any blank places. Consequently, every patient gets investigated for everything, at times many times over, using every possible machine available! This has taken medical expenses sky high. More than 80% of the world population today can not access modern medical hi-tech stuff. They however live happily inspite of modern medicine not touching their lives.
The unique feature of patient care is that time evolution in a dynamic human system can never be linear. No doctor, however great he/she is, can ever predict accurately the unpredictable future of the patient. Doctors, like others, are fallible, but to say that a doctor should never make a mistake is like saying that doctors can not treat their patients. If one practises medicine he/she will make mistakes! Unfortunately, in a country like the US where there is a lawyer for every three hundred people what else could you expect other than malpractice suits that keep the lawyers’ till moving?
In the midst of all these the most important part of the doctor-patient relationship-the bedside medicine-takes a back seat. This is a curse. In fact, a recent double-blind prospective study of out-patients in London teaching hospitals showed that eighty per cent of the final accurate diagnosis and one hundred percent of the future management strategies could be arrived at, at the end of listening to the patient and reading the referral letter from the family doctor! This could only be refined 8% more by all the investigations right up to the positron emission tomography. If this were so we have lost the soul of medical practice, thanks to the dogmatic hi-tech medical practice. (6) Simple bed side assessment could give a clue to even complicated diagnoses. (7)
Wise people had warned us about this happening. The first Continental Congress of the United States debated and voted for the freedom of religion and speech bill; it also fiercely debated the freedom of health care. This debate was led by Benjamin Rush, who later became the first Surgeon-General of the United States. He was also a signatory to the Declaration of Independence. Rush passionately argued for the freedom of medical care, in addition to religion. He argued that without such a provision in the Constitution, scientists (medical included) could become the new high priests, dictating a new orthodoxy! (8) How true today even in India? One can not have the freedom to practise any system of his choice even if he/she thinks that there is enough competence. Many States in the US, led by Maryland, have permitted people to practice medical care (if they are confident) after letting the patients know that they are not licensed to do so. If both parties agree one could use acupuncture, Qi gong, homeopathy or, any other system, in addition to his/her own field.
It is a pity that in India the new high priests, referred to earlier, emulate their counter parts in the west in ignoring the patient and concentrating on the charts only. We used to have great bedside clinicians of yore in India but their species is threatening to be extinct soon. That would be a sad day. Recently in the Annual conference of the American College of Cardiology the key note address was delivered by a great teacher of teachers, Proctor Harvey, of Georgetown University in Baltimore, on the topic of How to Auscultate the Heart? This might give the reader an idea of the levels to which modern medicine has degenerated. Two recent editorials in the Texas Heart Institute Journal were on Hyposkillia-cardiologists lack of clinical skills including auscultation of the heart and the other one on the stethoscope song written years ago by Oliver Wendell Holmes Jr. (9, 10)
“Time has come” the Walrus said “to talk of many things”, “cabbages and kings”… and also of bedside clinical cardiology. Unless we take a lead here India would soon be in the same state in which the west now finds itself from where they find it impossible to get out. A well trained bed side clinician is not only a boon to the patient but he/she could save tons of money for the establishment that today goes down the drain needlessly investigating every patient for every possible disease lest the doctor should get caught on the wrong foot. Doctors must learn to enjoy mistakes and learn from their mistakes not to repeat the same mistake twice. That is growing up. To pretend that we do not make mistakes is the most dangerous mistake. If one owns up the mistake and explains the situation honestly to any patient he/she will be forgiven. (11)
Long live good bedside medicine for the good of humanity at large all over the world. Let the medical fraternity get down from its high pedestal to face reality. We must remember that patients could survive without us but, we will find it difficult to survive without patients. The rate at which we are going large chunks of the patient population, even in advanced countries, are leaving modern medicine, opting out to complementary systems.( 12, 13) Let us read the writing on the wall and mend our ways.(14, 15) Common sense is our best asset. But common sense died a natural death in cardiology long ago. Common Sense was preceded in death by his parents, truth and trust; his wife, discretion, his daughter, responsibility, and his son, reason. He is survived by three stepbrothers, I know my rights, someone else is to blame, and I'm a victim.
The Stethoscope Song; a Professional Ballad
Oliver Wendell Holmes Sr. (1848)
There was a young man in Boston town,
He bought a stethoscope nice and new,
All mounted and finished and polished down,
With an ivory cap and a stopper too…………
……………. Now use your ears, all you that can,
But don’t forget to mind your eyes,
Or you may be cheated, like this young man,
By a couple of silly abnormal flies.
Like Austin Flint in the early 1850s who wrote that the cardiac physical examination included “percussion, palpation, auscultation and inspection,” Oliver Wendell Holmes Sr. an author, physician, and a poet taught for sometime at the Harvard Medical School. His satire is also conveying the same message that the user of new technology should keep his ears and eyes open and be aware of the limitations. The subtle message is clear in the above poem. The whole body of the poem is not given here. A couple of flies got into his stethoscope tube and gave him abnormal rales even in young and healthy patients. He declares them to be seriously ill only to be driven away from town by the town’s folk!
Acknowledgement:
I have liberally drawn material for this from my editorial in the Journal of General Medicine. I thank the editors for this.
.References:
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