off record
Shaukat Ali Jawaid

The Death of
Clinical Medicine

A young man thirty six years of age feels some discomfort in the chest and fearing he may not be having heart attack and to rule out its possibility goes to a private tertiary cardiac care facility. The medical officer in the emergency after completing the necessary paper work asks him to deposit the necessary charges so that the essential investigations are undertaken. On enquiry he is told that the consultant will see him with all the laboratory and angiography report. He rang up his physician friend, who obliged him to come over only to find out that there was no need for an angiography, thus he is saved of any intervention. This is just an example as to what is happening in Pakistan. One does not know how many un-necessary angiographies, endoscopies and other interventions are performed every day most of them driven by commercial interests since we lack a primary healthcare set up and proper referral system.

What we are now seeing is death of clinical medicine. A vast majority of the healthcare professionals have become slave of modern gadgetry. Clinical skills i.e. good history and proper physical examination are neither taught in most of our medical schools nor are they practiced. Late Dr.Ali Muhammad Chaudhry a renowned cardiologist and former President of Pakistan Cardiac Society used to say that with good history and comprehensive physical examination one can diagnose almost 80% of the cardiac diseases and the rest 20% can be confirmed with the help of some investigations. Clinical dermatology has been replaced with Cosmetic Dermatology as laser treatment brings more money and similar is the situation in most other specialties. In the absence of comprehensive primary healthcare set up which provides satisfactory treatment to the patients and lack of proper referral system, patients tend to approach directly to the tertiary care teaching hospitals in the big cities or other secondary care, tertiary healthcare facilities. The rush of patients is so much that it is virtually impossible for the doctors working there to concentrate and give time to each and every patient they are supposed to examine. In the OPDs they are surrounded by dozens of patients and since confidentiality cannot be ensured under such environment, patients cannot express themselves freely. The patient has hardly started explaining his symptoms that they are handed over a list of investigations and prescription and this goes on.

While communication skills are extremely important for the physicians, they also need to be trained in “Listening Skills”. Unless they listen to the patient’s complaints patiently, it will neither satisfy the patient nor will they be able to make correct diagnosis but how it is possible when they are expected to see hundreds of cases daily. Frustrated and dejected, these patients then go to the quacks who make the disease worse and eventually these patients again land up in the hospitals with serious complications making the treatment much more expensive and in some cases the disease by now has advanced so much that very little can be done to help the patients.

We need to put more emphasis on preventive measures, health education, establishing a good primary healthcare set up, introduce some referral system and start with Filter Clinics at tertiary healthcare facilities so that serious patients who need specialized care are entertained on priority basis and looked after properly. Specialized investigations, facilities can be shared by different healthcare facilities which apart from providing the much needed facilities, will also prove to be cost effective. If a cardiologist buys an Echocardiography machine, he or she will be tempted to recover the investment by subjecting more and more patients to echocardiography irrespective of the fact whether they need it or not thus indulging in all sort of unethical practices. Teaching and Training in clinical skills should be given due importance and efforts should also be made to inculcate the spirit of ethical medical practice among the healthcare professionals for which good role models play a very vital role.

Tail Piece: While talking to a senior cardiologist from interior of Sindh and a faculty member from NICVD Karachi during the Pakistan Hypertension League Symposium held at Lahore, one of the senior faculty member from Punjab Institute of Cardiology was heard saying that “We have sent back Mian Nawaz Sharif to Jail. He is not sick and does not need any treatment”. This is a typical mindset. Hence it is not surprising to note that Mian Nawaz Sharif has refused to suffer any more humiliation in the name of treatment being sent to one hospital after the other. Looking at the comprehensive unanimous report by the Special Medical Board, it is evident that MNS suffers from multiple diseases and might need some cardiac intervention with full surgical back up. It is a very serious and high risk case. Pakistan has not yet fully recovered from the after effects of “Judicial Murder” of Zulfikar Ali Bhutto and assassination of Benazir Bhutto. God forbid if something happens to Mian Nawaz Sharif while in custody, it will have serious repercussions. Pakistan will be in for political instability for another two decades and our rulers will keep on visiting world capitals with begging bowl in their hand because we as a Nation have never learnt any lesson from history. Economic development and prosperity is vital for the security and existence of the country and for economic development, political stability is a pre-requisite. The Supreme Court has done well to free Mian Nawaz Sharif on bail for six weeks so that he can get treatment of his choice.

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