Karachi: The importance of clinical skills, good history taking and comprehensive physical examination to reach correct diagnosis which are still very important even in the presence of numerous advances in technology were highlighted by various speakers during the Third Internal Medicine Conference organized by the Dept. of Internal Medicine at Aga Khan Univesity from November 10th to 12th 2023. The presentations by the guest speaker Prof. Prof. Andrew Elder President of Royal College of Physicians Edinburgh and Dr. Faisal Sultan Infectious Disease specialist from Shaukat Khanum Cancer Hospital and Research Center Lahore were highly useful and informative. The message they conveyed was that healthcare professionals should never under estimate the importance of these skills which have been used for treating patients for centuries. This was supplemented by a presentation by Prof. Muhammad Tariq who spoke on Physical assessment and applying clinical reasoning on second day of the conference.
Making his presentation on “Physical examination in the era of Artificial Intelligence” in the inaugural session Prof. Andrew Elder from UK pointed out that Power of human hand, Eyes and Ears are extremely important to make diagnosis. These skills are still invaluable to the physicians wherever they are practicing. He discussed in detail why physical examination still matters in the present high technology times in diagnosis and beyond. Prof. Elder said, what do you expect from the physician after looking at the image? One can detect more than one abnormalities. American doctors, he remarked, are losing this skill. One of the studies which included eight hundred sixty faculty members, students and residents had shown that the faculty was no better than students as regards clinical skills. For over three hundred years, physicians have based their practice on observations for gathering clinical information from the patients. Analyzed that information and then collaborate it with the ECG. We have more broad tests in Genomics. We use imaging too much but are we really gathering information and collaborate it with other information and results, he asked. In fact, we are just becoming data analysts, he remarked.
Physical examination is really important. Its value is not based on its diagnostic contribution alone. While examining heart failure patient, you need to use your hands, eyes and ears. Physicians are involved in over investigations all around the world and use too many medicines. Over use of drugs is very common. A study which included twelve hundred doctors revealed that almost 20.6% of medical care was un-necessary, 22% of drugs prescribed were not needed. Similarly, 24.9% of tests and 11.1% of procedures were un-necessary. All this is done because of fear of litigations and patients expectations. Clinical skills are in decline. There is too much pressure on physician’s time. Models of physician’s reimbursement was also responsible for too many over investigations. Patients, Prof. Elder remarked value physical examination. However, these days the physicians spend over 50% of their time on computers and 9% interact with the patient. They are burnout. US Residents see ipatients. Physical examination takes you to the bedside that is where the patient is, he added. During bedside teaching one takes old history and the teacher teaches students how to do physical examination. He also talked about contemporary bedside teaching. One learns a lot from Echocardiography but one can still learn a lot more as the clinical skills are complementary. Physical examination is a vehicle for teaching diagnostic thinking. There is more to diagnosis than reassessing and data analysis.
Physical examination Prof. Elder opined also ensures patient safety. It helps avoiding surgical and prescribing errors, delayed and missed diagnosis. Another study involving eighteen million patients showed that there were 76% delayed diagnosis, 27% incorrect diagnosis and 18% un-necessary treatments. These were the errors in simple observations.
Medicine in Digital Era during Internal Medicine Conference held at AKU.
He then talked about a stroke patient. This forty-two years old female had headache, CT brain was normal. She was referred to the OPD from the Accident and Emergency department. The trainee from the geriatrics department was worried. Detailed examination showed there was a left carotid artery dissection. Trainee should be commended for the clinical skills. If we do not do physical examination, we are bound to make mistakes. While referring patient for investigations, we must give complete information to the radiologists, otherwise they will make mistakes. We must remember that most of the diagnosis are not made by technology but it is the history which makes the diagnosis in majority of the cases. Complete history and comprehensive physical examination can make diagnosis in almost 61% of patients. Some diagnosis remains beyond the reach of technology. His advice to healthcare professionals was take time to gather information with comprehensive observations. Analysis are the essentials of Medicine. He concluded his presentation by stating that physical examination remains invaluable, offers numerous benefits and if you don’t do it, you are most likely to make mistakes.
career level physicians. Panelists included Dr. Nosheen Nasir, Dr. Nighat Murad,
Dr. Muhammad Wasay and Dr. Amara Zafar.
Responding to questions during the discussion, Prof.Elder remarked that Artificial Intelligence does not make any worthwhile addition to physical examination. It all depends on the quality of studies that go into the database from where AI learns. Learn AI it will help in physical examination and you will become better doctors. Let us get involved with GhatGPT3. Ask questions and try to understand them. AI can be used for training of Residents. In case of simulated patients, ask questions and they will respond to you on the basis of information they have in the database. Why we are training students on computers because it is difficult to do bedside teaching, Prof. Elder remarked.
Prof. Khalid Masood Gondal President of College of Physiains & Surgeons Pakistan was the chief guest on this occasion. He also highlighted the importance of clinical skills and opined that physical examination will be extremely helpful in making the diagnosis. One should not forget to sit with the patient and ask all relevant questions. Detailed symptomatology investigations will also help you. Clinical examination and body language is all very important for correct diagnosis. Sympathy and Empathy will also support us.
He then traced the history of establishment CPSP and pointed out that we are collaborating with a large number of national and Internaitonal institutions. CPSP has also been collaborating with AKU since many years. In fact, CPSP was currently collaborating with 415 institutions in Pakistan and overseas. We at present have 35,570 trainees enrolled. We have eighty-six FCPS programmes. We are now planning to start re-certification of our Fellows. He also referred to Work Based Assessment, Certification of Fellows with good academic standing, training of trainers, revamping the curriculum. CPSP also plans Re-accreditation and De-accreditation of institutions after self-evaluation, provision of facilities of advanced skills at distant collaborating centers. At the recent meeting of IAMRA held at Bali in Indonesia, we had detailed meetings with world regulatory bodies and collaboration with world leaders in the field of medical education. He then also showed the glimpses of the Convocation the CPSP organized for the Fellows in UK recently. It was organized by the CPSP UK Center. As part of our collaboration with UK and Ireland, so far 567 Pakistani doctors have got training there and 95% of them have returned to Pakistan after completing their training. The performance of our Residents have been commended by the authorities in UK and Ireland and we are now being requested to send more residents but we wish to move carefully in order to ensure quality training, he added.
