FEATURE

Bedside Medicine- A Forgotten Art.

Prof. B. M. Hegde,

hegdebm@gmail.com

Talking with Patients: 

Talking with patients is simply listening to patients while observing the patient’s body language very carefully. The latter might give vital clues for the diagnosis. Listening is an art. “Art” wrote David Edward Thoreau “is that which makes the other person’s day”. The art of listening requires certain prerequisites on the part of the listener, the doctor in this case. Two important facets of that art are imperturbability and equanimity. Any judgmental attitude on the part of the doctor might put off the patient from opening up. 

“If you listen to your patient long enough, he/she will tell you what is wrong with him/her,” wrote Lord Platt, an illustrious teacher working at the University College Hospital, London in 1949. Some of his students, who are now the noted pillars of medical education in the UK, wanted to scientifically verify the correctness of that statement. They conducted a double-blind, computerized, prospective study of one hundred medical outpatients in the London teaching hospitals using even the PET scanner for final diagnosis, reported in the British Medical Journal. The conclusion of the study is very relevant to the subject matter of this chapter. “Eighty per cent of the accurate final diagnosis and one hundred per cent 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 physician. That could only be refined four per cent more by all the bed side clinical examinations and further eight per cent by all the investigations including PET scan, was the conclusion. The remaining diagnoses were possible only on the postmortem table!

Following the above study there were pleas for parsimony in the systems review. Writing in the BMJ Barry Hoffbrand, the then editor of the Postgraduate Medical Journal, made a strong plea for avoiding the subtleties of bed side clinical examinations. Another mile stone study, by three generations of teachers over a period of sixty years in the cardiology department of St. Andrews University in Dundee, Scotland, reported in the British Medical Journal by Finlayson and his colleagues, once again reconfirmed the truth that teaching minor clinical signs on the bed side was counterproductive among the junior students. Ten senior professors of respiratory medicine in London did another blinded study to authenticate multitude of bed side clinical findings in the examination of the respiratory system. There was the shocking revelation that majority of the finer aspects of respiratory signs had very low specificity and sensitivity in the diagnosis except a few unequivocal bedside signs! These facts are borne in mind while writing this book. I would like to reiterate the truth that it is listening to the patient that contributes the maximum to the final diagnosis. This new scientific medicine could be practiced even in the remote village of any country, thanks to the art of listening to the patient and letting him/her give away the diagnosis in the bargain.

That said, I must hasten to add that there are some hypochondriacs among patients that need a clear guidance to take them through the right path. They have a tendency to stray away into uncharted territory that might have no bearing on the problem on hand. Care, however, should be taken to see that patients don’t feel offended by any rude remark by us or show of our disinterest in their story. Experience teaches this special art to all of us if we have to survive and succeed as doctors. One can never learn that art from a book or in a day. It takes time and patience. There are certain risks involved in learning the art of bedside medicine and one has to learn to live with it. Rome was not built in a day. Your great teachers also could be seen without their robe occasionally. This should teach the student the next great art of listening to the patient that is humility, a sign of great learning. While one’s vanity deals with one’s honour, one’s conscience brings one in touch with justice.

The next important part of listening to the patient is to get to know the personality of the patient which will have a great bearing on the final diagnosis. Patient’s worries, anxieties, relationship with his/her surroundings, convictions, phobias, emotional traits, obsessions, family ties, financial stability, belief in supernatural forces, working conditions, colleagues at work, reactions of his immediate family to the illness, as also his faith in alternate systems of medicines ( find out if the patient is taking any of those “innocuous” medicines at the time) as also her/his anxiety about the future should all be assessed indirectly though without directly asking probing questions. Most, if not all, of the above could be gauged while observing him/her talk with the physician, if the latter is a good listener. Every student should learn the art of listening which consists of the listener’s interest in the talker, his ability to give a keen ear to the talk while displaying no sign of hurry. The doctor should appreciate what is being told by the patient in all sincerity. Here the family physicians score over the sub-specialists. The latter only come into the picture at the eleventh hour but the family physician knows the patient very well. Studies have shown that where there are more family physicians compared to specialists as happens in Japan vis-à-vis the US, the health indices as well as the longevity are markedly better.

Medication history:

Every single drug, from the simple baby aspirin to the most complicated anti-cancer chemotherapeutic drug, will have side effects. In fact, the adverse drug reactions are the largest cause of iatrogenic (doctor induced) diseases resulting in significant mortality and morbidity all over the globe despite all the studies that go into prior to drug release to the market. It is the last stage of drug testing, after the drug is released to be used by millions all over the world, that the real dark face of the drug is brought out. An alert physician with a high index of suspicion alone could spot the new adverse reactions. In fact, that could clinch the diagnosis in some instances. So it is mandatory that every student learns to take a detailed history of all the drugs that the patient is having at the moment as also those that he/she has had in the recent past as well. This is very simple in countries like the UK and Canada with their National Health records available for every patient. It is the most difficult part of history taking in any other country especially where there is the fee-for-service system in place and patients go shopping from doctor to doctor not maintaining their drug records carefully. To cap it many of the doctors’ prescriptions are almost totally illegible. 

Many new discoveries of great significance are made by ordinary doctors who are careful observers and take a detailed drug history from patients as each Adverse Drug Reaction (ADR) could be a new disease syndrome. One example will suffice. SMON (sub acute myelo-optic neuropathy) was a new disease that broke out in Japan first and killed many patients in short time span. Since there was to be the Olympic Games in the near future the authorities brought strong pressure on the scientists to find out the cause. As is the usual case in such situations the scientists came up with a viral cause and claimed that SMON is caused by a slow virus akin to Kuru, an African disease! Credit should go to an observant family physician in the outskirts of Tokyo, Dr. Kano that observed that this syndrome was seen only in those patients of his that took a quinoline derivative for diarrhea in the past one year. Thus was the final curtain drawn on SMON when the said drug was banned. In the interim period it had claimed many lives both in Japan and elsewhere. The authorities were relieved and the Olympic Games were held with full fanfare.

Individual system examination will have the history taking of each system separately in a nutshell in each system review. 

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