OLD AND NEW – MAKE THE BEST OF THE TWO

Chapter 6. Old and new – make the best of the two

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

Old is gold but new may be a diamond but don’t forget it is the gold that holds the diamond â€“ Igeenell Timmons In modern medicine we have a name for everything but cure almost for nothing â€“ Charles Coleman

Introduction

Modern medical science is advancing rapidly and newer technology attracts everyone’s attention. It has made a significant impact on health care but also is vulnerable to be misused. This is because majority patients in the community can be well treated by time-tested old methods of basic medicine and do not justify use of modern technology. Modern technology also has limitations and hence it should be used selectively only after proper counselling. Though it has widened our understanding of diseases, present knowledge lacks ability to offer significant advantage to majority patients. Level of clinical suspicion and probability of a given test result can be correlated, higher the degree of clinical suspicion, more likely the test result will confirm the diagnosis. Therefore, it is time that present generation of doctors must learn when to avoid use of modern technology, instead excel in use of basic medical approach of making a provisional diagnosis. At the same time, older generation of doctors must be continuously updated to know where modern technology can benefit the patient.

Old not entirely gold but all that glitters is also not gold

Science has changed but—-

Over last six decades of my medical career, I have seen a drastic change in understanding of diseases and their management strategies. This has been possible only because of modern technology. I recall the days when simple chest xray was also not freely available and fluoroscopy was used routinely with its inherent dangers and subjective interpretations. Today we have many imaging modalities that depict not only structural but also functional changes. Infections can be diagnosed with precision and with the development of Immunology and genetics, it has been possible to get deeper insights into causation and progression of diseases. Invention of newer drugs and therapeutic interventions have revolutionised treatment strategies. Thus, “old” ignorance in science has been replaced by “new’ understanding. Previous generation of doctors must keep updated and take help of technologically trained newer generation of doctors. It is important to realize that part of the present-day advanced knowledge will be obsolete by next decade as medicine is ever changing, hopefully for the better. It calls for continuous learning.

Science has changed but not art of medical management

Art of history taking and physical examination as well as art of communication and behavior with the patient has been time-tested and so remained the same over centuries. Ethics, empathy, concern for the patient, honesty, transparency, responsibility, accountability, communication and counselling made patients feel better, even when science had not much developed. Physicians always cared for the patients if not able to cure and patients showed gratitude and faith in doctors. Present generation of doctors have largely ignored this aspect of patient management in pursuit of modern science. It has made patients feel unhappy and lose faith in doctors. Thus, image of medical professions has been maligned. Present generation of doctors must reverse this trend and follow this part of “old” while using “new” selectively and rationally.

Limitations of modern technology

While taking history, an uninterrupted and patient listening to what the patient has to say is an exercise in developing a rapport between the doctor and a patient. It is a measure of doctor’s empathy and concern about the patient and it makes the patient feel assured. Further, physical examination establishes a bond with appropriate human touch â€“ “hightouch” technology. This sets the tone for developing faith in the doctor and helps in recovery of a patient. Misuse of modern technology lacks such opportunities and thus misses an important factor in the management of a patient.

Diagnostic technology has also many inherent limitations Peripheral blood smear is the most important part of blood investigations and modern technology is of no use as it needs an experienced and committed pathologist to examine the same. Similarly, treating physician has to corelate test results with his clinical judgment. In fact, every technology has inherent issues that come in the way of correct interpretation. Today, most laboratories perform CBC on automated counters that differentiate blood cells based on the size of cells, smallest size is a platelet and largest size is a leucocyte and size in between is an erythrocyte. If erythrocytes are of smaller size as happens in commonly prevalent iron deficiency anemia, automated counter includes them in platelets and platelet count goes higher than actual. If a child suffering from thrombocytopenia also has iron deficiency anemia, platelet count on automated counter may be normal and diagnosis can easily be missed.

Besides the issue of interpretation, technical error in performing the test can give erroneous results as happens in case of a small blood clot while loading the sample. Commonly available counters can differentiate polymorphs and lymphocytes but not monocytes, eosinophils and basophils that are all clubbed together in one common category. So, in spite of automated counter, a pathologist must see the peripheral smear to assign relative value to these three types of cells included in another category. This means that a pathologist must have good basic knowledge.

Of course, now latest generation of counters are being invented to overcome such difficulties. Further, CBC results by themselves are not diagnostic of any disease and even a simple difference between an infective and non-infective disease or between viral and bacterial infection are also not possible. This brings in a point that basic knowledge of medicine is required for right interpretation in spite of modern technology. If it is true of a simple test, then it must be more problematic in complex tests such as genetic or immunological tests. Even in case of monogenic genetic defects (for example, cystic fibrosis), more than several hundred mutations are known and as all mutations cannot be tested, negative test does not rule out the disease. In such a situation, physician has to fall back on clinical approach and treat the patient. In case of oligogenic or polygenic defects, problems are further compounded even though newer tests such as microarray or gene sequencing are invented. Finally, positive genetic test has very little relevance to the index patient and theoretically may be useful for prenatal detection. Immunology plays an important part in causation, progression and outcome of diseases. However, such tests merely suggest the probability but are not diagnostic of autoimmune or infection induced immune disorders and need correlation with clinical profile.It is clear that modern technology cannot replace basic clinical approach and competence. Technology must be used as a servant (summon whenever required but ignore if necessary) and not as a master (to dictate actions). Besides, the cost is a concern.

Rational use of modern technology

Diagnostic technology must be used judiciously with primary aim of offering direct benefit to the index patient. It is important to estimate pre-test probability of usefulness to a patient before ordering the test. It helps to decide whether to order a test or not. However, there could be indirect benefit of diagnostic tests to the family or community, even if not to the index patient and also could improve scientific understanding for doctors. For example, genetic tests in an index patient may be useful to predict recurrence of same defect in the next pregnancy and similarly RT-PCR test for covid helps monitoring epidemiology of the disease. In such a situation, patient and his relatives need to be well communicated and counselled before ordering the test so that they understand the advantages and limitations of these tests. Therapeutic technological advances have been much more useful to patients. Interventional radiology and cardiac procedures, minimal invasive and robotic surgical techniques and organ / stem cell transplants have definitely benefited patients though often not affordable or accessible. In such situations, communication and counselling play very important role to explain risk-benefit ratio and long-term implications that are inherent with some of these advances.

Personal notes

I have often seen patients complaining about doctors ordering multiple tests and interventions. This is true more when the results of tests are negative, suffering continues and diagnosis is at bay. When desirable outcome is achieved, even irrational use is mostly condoned. It is not wrong on the part of doctors to use modern technology only if its use is rational, can be justified, patients are adequately counselled and explanation is properly documented. Doctor should be accountable to his own conscience about rationality, justification and proper counselling. This is found lacking in many present generations of doctors. It is not rare for doctors to pursue final diagnosis even when final outcome is known to be poor and in absence of pre-test counselling, parents feel cheated in spite of doctor’s good intensions to arrive at a final diagnosis. In such cases, patient must be given a choice of making a decision regarding further testing. What concerns the patient most is the present benefit and not future of science. I saw a bird watcher focusing at a distance through his high-tech binoculars but the bird was sitting just behind him and it must be wondering whether to alert the bird-watcher to look behind. Many times, physician focusses at a distance but misses what is near.

Take home message

There is a need for intergenerational learning. Doctors of previous generation must at least be acquainted with newer developments and direct patients appropriately to seek better advice. They should therefore keep updated by attending CMEs and through interactions with the highly trained present generation. This alone will offer the advantage of modern science to patients. At the same time, present generation of doctors must attempt a provisional diagnosis before ordering tests and avoid misuse of modern technology by judicious selection. Art of medical practice is most essential part of patient management and will remain so irrespective of modern technology and this fact should be born in mind by present generation of doctors. This is the only way to make old and new work best together.