Chapter 15. How to be rational in practice?

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

 

Rational man is guided by his thinking, by a process of

reasoning, not by his feelings or desires –

                                                                        Ayan Rand

Rational practice is to be taught not in a lecture hall but at

the bedside of patients where it is applied

                                                                        Robert Owen

What is rationality?

Rationality refers to judicious and well-reasoned sensible use of resources to offer quality service. Judicious use of resources in medical practice simply means minimal intervention (investigations and drugs) to get maximum benefit (cure if possible, comfort always). Quality service in  medical practice implies holistic care. Holistic care is possible with use of all modalities endowed upon humans by nature – namely body, heart, mind and soul. When translated into medical practice, body is knowledge, heart the compassion, mind the commitment and soul the conscience. If it is done with devotion – love and loyalty, it becomes divine – coming from supernatural powers and it is so sacred that helps ultimately the healing.

Medicine and rationalism are inseparable.

Medicine is the most touching science of all – it involves healing, caring, soothing, reassuring, understanding and offering hope. Medical practice should be a perfect combination of science and art. Rationality of science involves detailed history, keen observation (it is well known that eyes don’t see what mind does not know), focused physical examination, objective reasoning and analysis,

introspection and learning from own mistakes. Rationality of art includes empathy, compassion, communication, counselling and documentation. It is only when judicious use of science and art is combined that rationality is served.

Universal pitfalls in medical practice

There is not enough time spent on detailed history. Proper information is not sought because of lack of time – it is an excuse. Whatever information is obtained, it is not analysed and interpreted due to lack of thinking. Once this habit is lost, thinking itself becomes a disuse atrophy. This leads to unfocused physical examination likely to miss abnormal findings. It sets in a vicious cycle of unnecessary tests, empirical therapy often with multiple drugs. It is obviously not conducive to communication, counselling or documentation. This is irrationality at its height. However, ironically, it may still work and gives false sense of competence to a doctor. Unfortunately, patient may not know about poor quality of service but the doctor should introspect.

How to ensure rational practice?

Care always For whatever complaint patient may come to you, offer advice on preventive health issues such as growth monitoring, developmental screening including vision and hearing, ideal diet, proper hygiene and life style.

Use clinical Skills

Try to arrive at provisional diagnosis by analysis of detailed history and focused physical examination. Order investigations only after provisional diagnosis and that too if necessary.

Be a good listener

Every parent of a child or child himself may give you a clue to a diagnosis only if you care to listen to them carefully and allow them to express what they wish to say. Most illiterate persons also know enough to express though one must have a skill to get relevant information and to filter out what is not relevant.

Test a test

Before you order a test, think what way such a test would help you to arrive at a diagnosis. Don’t order a test because you don’t know probable disease and if so, then youalso don’t know which tests to order. There are no routine tests.

Be a rational prescriber

If you don’t have any provisional diagnosis, decide whether it is safe to wait for disease to evolve. Empirical therapy is justified only in serious situations and that too after ordering relevant tests. Prescribe minimum number of drugs. Symptomatic therapy is necessary only if symptoms are very discomforting to a patient and that too it should be employed only at the time of intolerable symptoms. This should be explained to the patient and left himself to decide when to use. Doctor should not advise the timing of such symptomatic therapy, though frequency has to be limited.

Communicate, counsel and document

Inform patient about his illness and therapy in simple words which improves compliance of treatment. Counselling is an art that guides the patient to go through his illness which instils confidence in a patient. Document in brief relevant facts that signifies transparency and accountability. It also helps to be legally safe.

Choose your own way

You have to set your own goals in practice and pursue them. Let your goals be professional credibility, peer acceptance and social respect. To achieve this goal, be rational in practice and once you adhere to rationality, it becomes a habit that is sustained throughout life. It may take time to begin with but spending time for rationality is worth. It leads to happiness and promotes your own health.

Personal notes

I formed a habit of documenting my provisional diagnosis with supporting facts that ensured rational drug prescription and advice. Even when I could not come to any provisional

diagnosis, I would mention “no clue to any specific diagnosis” and add “it is safe to wait and observe any new symptoms and inform”. I would end with “no specific medicines except symptomatic therapy”. Such a commitment was accepted by most patients as it signified not only honesty but also confidence and it helped me to be rational in my approach. This is the best way to inculcate rationality. Unfortunately, most prescriptions contain only the drugs without any preceding justification and hence rationality is never monitored. Once a parent of my patient requested me to see their neighbor’s child for whom their pediatrician had prescribed an antibiotic. When I saw the child and confirmed the need for an antibiotic, child’ s parents exclaimed saying “Oh, you also write an antibiotic” because I had never found the need to prescribe an antibiotic for their neighbor’s child. They thought antibiotic use is irrational. Such beliefs must be countered and corrected. Rationality can’t be stretched to irrational level. One of my junior colleagues said that if everyone around him prescribed an antibiotic without reason, he could not afford to be rational. I told him a story. There was a vasectomy camp in a village where every eligible person underwent the procedure. When organisers were about to close down, an old man of 80 years came in and wanted to undergo vasectomy. He was told that he did not need it. He explained “if any lady got pregnant in the village, he would be blamed” Old man had a valid pointbut it should not apply to medical practice. Hence practice rationally, it will give you happiness and community will recognize it eventually.

Take home message

Rational practice is possible if you set your goal to achieve it.It does not take time and with repeated practice, it becomes a habit. It offers satisfaction to a patient, happiness to a doctor and promotes good health in both.

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