Changing trends a challenge to the already trained

Chapter 3: Changing trends a challenge to the already trained

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

Is it not a bit unnerving what doctors call what they do is “practice”? – George Courtin It is astonishing with how little reading a doctor can practice but it is not astonishing how badly he does it – Dr S. Venkatesan

Introduction

Medical science is dynamic and fast-changing so much so that some of the prevalent trends a decade ago become obsolete by the next decade. The problem is we don’t know which part of the knowledge would change to be invalid and so we need to keep learning, unlearning and relearning. Time may not be too far when what you read today was accurate when written, but may not be accurate when you read it today and what is used today may become obsolete tomorrow. However, the art of medical practice has been eternal over generations and so, once we learn the art of practice and perfect it, it is useful forever. With advancing modern science, art seems to be forgotten and this is a dangerous trend. It has resulted in patient dissatisfaction and led to the loss of faith and image of the medical profession.

Changes in disease profile

Manifestation of a disease is a result of tripartite interaction between the host, environment and an offending agent. Over the last few decades, all three factors have shown changing trends. Changes in lifestyle have affected the nutritional and immune status of the host. Crowding, international travel, air pollution and many such factors have significantly contributed to changing trends in disease profiles. Offending agents, microbes, in particular, have been smarter than before and have successfully evaded host defense by mutation and acquiring drug resistance. Such changes have resulted in varied presentations of the same disease in different individuals and have been a challenge to the doctor.

Unfortunately, neither of these three factors are easy to assess and hence evaluation of the interplay of these factors is getting more difficult. Standard presentation of the disease as described in a textbook is often not the way disease presents in actual life situations and such problems are a rule more than the exception. There are several such examples seen inday-to-day practice. Changes based on host factors As malaria =became endemic, it rarely presented as fever with rigors and may manifest with any type of fever including low-grade fever or at times even without fever. On the other hand, typhoid may present as fever with rigors. In fact, rigors represent a high rise in body temperature in a short time and would occur in any disease. Classical textbook presentation of tuberculosis is low-grade evening rise of fever. However, tuberculosis may present with any type of fever including a sudden high fever as seen in immune-mediated pleural effusion in a healthy child. This is because host response decides the type of pathology and its clinical presentation. Such changing trends have been observed in all diseases and pose a challenge in the diagnosis. Vaccines offer immunity that may not be fully protective and such a child manifests with a modified clinical presentation that is not easy to recognize. Similarly, a malnourished child presents in a nonclassical atypical way. Even the outcome of therapy depends on the host’s ability to respond appropriately and hence there could be a varied type of progress in a disease treated in the same way. At times, the immune system of the host mounts an inappropriate exaggerated immune response that is responsible for immune complications affecting multiple organs and it happens even after the infection is well controlled. Science does not know as yet how to modulate the appropriate immune response. This is a new challenge difficult to manage. Changes based on environmental factors As the infective disease becomes endemic, the majority of persons including children in the community become infected and many of them develop immunity even without developing a disease. If infected again with the same offending agent, clinical manifestations are mild and often not recognizable. Similarly, exposure to tuberculosis infection that did not progress to disease leaves behind hypersensitivity and if reinfected, manifestations are different, take the form of destructive lesions as compared to first-time infection. Increasing air pollution has resulted in a higher prevalence of respiratory diseases including asthma and allergic rhinitis.

Changes based on offending agent

Number of organisms and their virulence decide the severity of clinical presentation and drug resistance adds to the difference in the outcome. Clinical presentation is different in a child who has developed partial immunity as compared to a child who has no immunity at all against a particular infection. Misuse of antibiotics is universal that has resulted in antibiotic resistance with an increase in morbidity and mortality, Microbes keep on mutating and fooling our immune system. That is how the influenza viral vaccine has to be repeated every year. Lifelong, immunity to natural infection is also likely to wane off necessitating vaccination even in adults and pertussis is a classic example.

Changes in medical practice

High dependency on laboratory tests

There is a widening gap between traditional wisdom and modern science that has been further accelerated with the concept of evidence-based medicine. Availability and accessibility of modern tests have definitely made an impact though only in selected cases but it is unfortunate that is far more misused routinely even in non-affordable populations. Tests are offered without a provisional diagnosis and at times, there is a tendency to treat reports without clinical correlation rather than treating a disease or a person in whom the disease resides. Tests should ultimately benefit a patient and it is possible only when the test is able to define the cause of the disease for which specific treatment is available. Patients are dissatisfied when multiple tests do not result in final improvement. It is important to counsel about the need and benefit of test results before ordering tests so that patient and his relatives understand the implications of tests.

Evidence-based medicine

Evidence is of different degrees, the lowest degree is an anecdotal experience. Evidence and experience are two sides of the same coin. Evidence is based on averages and may not be a fit for all while experience is tailored to individual patients. Evidence depends on external research while experience on internal expertise. Both need to be judiciously used but there is a trend to consider the evidence without experience. With changing host factors, evidence may not be applicable to individual hosts.

Super specialisation – boon or bane?

Superspecialist has to be excellent generalist to be rationally effective. It is ideal if a superspecialist spends 25% of his time with a generalist so that he does not overlook more common diseases with atypical presentation rather than trying to test for rarer ones. After all, several diseases affect multiple organs and it is not uncommon to see each superspecialist sees only through his biased angle.

Profession tuned into business!

Medicine is a profession and not a business. Business has a single motive of earning money while a doctor in the profession has a priority of providing holistic care to his patient while earning money Business involves selling the goods irrespective of their worth whereas profession involves giving the correct advice to the best of one’s knowledge that is likely to benefit the patient. Unfortunately, there exists undisputable depersonalization of patient care with its consequences of patient dissatisfaction, legal suits or violence. It is a challenge to set clear goals of rational practice but it is very much possible with intrinsic motivation. It will bring more happiness in life than mere success. In fact, success lies in happiness.

Personal notes

I witnessed changes in every aspect of life as so-called “development” had made life more complex and one had to adapt to such changes. Medicine is no exception. While it was difficult to keep updated in science, I was lucky to get opportunities to teach while in practice, after all, teaching is the best way of learning. It has taught me how to be careful at every step to avoid mistakes. And even then, mistakes did occur and I hope I learnt from them. I spent 4 hours a day attending my duties during my tenure as an Honorary teacher and many thought I had nothing better to do.

However, it was much more challenging to refrain from unethical practices and conduct rational practices. I was aware when few parents of my patients wondered why I spent so much time on detailed history and considered it as my inability to decipher the problem quickly. I remain motivated to adapt to changing trends, though I am aware it is difficult if not impossible. I have learned to be vigilant to focus on my limitations and seek timely help from others. The community also has changed and so also their expectations from doctors as they have more faith in laboratory tests than on doctor’s clinical diagnosis. I often meet parents who come with knowledge acquired from Google-God and challenge my opinion. In such situations, I end up with “you may be right but this is my honest opinion that is documented and it is to the best of my knowledge” and leave them without further argument. I have learned patient has a choice to follow your advice or not.

Take home message

Changing trends in medicine call for constant updating and the doctor has to be a lifetime student. It is important to find time for continued education even in a busy practice. Changing trends in medical practice demand setting clear goals to achieve rationality and excellence and not fall prey to “rat race”. Once you are motivated, habit sustains it to make life happy and worth living.