Doctors’ Instinct

          Our friend fell down some steps, then couldn’t move because the pain in his hip was terrible. His wife took him by public ambulance to the closest, very new hospital, partly owned by a semi-retired orthopaedic surgeon. He gave the friend a pain-killing shot and took an x-ray. Later, the wife found him (doctor, not friend) poring over the film, palm on forehead, mumbling, “… the neck should be broken, must be broken..” She wondered whether the semi-retired doctor was also semi-stupid.

“How was I to know,” she told me later, “that he meant neck of femur (thigh bone)? To me, a neck is something that attached one’s head to one’s shoulders.”

The only way to prove the neck-was-broken was by doing a CT-scan. The closest CT machine, this was in Noida, UP, was some kilometres away, even in an ambulance an agonizing ride. Friend’s wife did some sms homework and was assured that doctor had a good ‘hand’. So without ‘photographic’ evidence, she signed the consent for the surgery. In a couple of days, the friend’s hip was fixed and functioning. Opinion-based diagnosis had saved the day.

During my recent back-pain episode, my Goan doctor DB, sensing agony in my phone-distilled voice, recommended: “Complete bed-rest.” The Mumbai consultant who saw my MRI via Picture Archiving and Communication System on Everest Base Camp, sent realtime instructions via smartphone to his registrar sitting by my bedside: “Complete bed-rest.”

When I mentioned opinion-based versus evidence-based practice to someone, this is what he said: “Without doubt, evidence-based. How can anyone say I think the patient has fever? You check the thermometer, read the value and you have proof of temperature.” (Healthcare professionals reading this, hold your giggles; that’s how lay people perceive it.)

Even the brightest physicians are thankful to ultra-sound inputs to pass judgement on ‘pottanth khubba dukhtaan’. Who might be responsible for the painful crime: gall-bladder stone/ renal colic/ appendix/ secret tumour?

Experience versus modern technology, that’s the debate. Can skills (l)earned over 18 hrs/day x 11 months/year x 25 years of practice be superior to blood tests done in a laboratory? There are times when an opinion-based practitioner won’t wait for a typhoid result, but start treatment pronto, not wanting to waste time/ lose patient.

But… in evidence-based practice there is no guesswork. Therefore less chances of making mistakes when one depends on lab-tests. Think blood-sugar levels, typhoid/ dengue detectors.

There are those who don’t believe in modern technology, who believe that doctors must use their heads and hands alone. But should the doctor made a mistake, they say: aaj-kaal beshta suvidhaa aastana kitya upyog karap na. Would they include stethoscopes and blood-pressure checking gadgets as ‘modern’ things?

(I know people who believe landline phones are acceptable technology, but mobile phones are not. It’s ok to have a fridge, but no micro-wave. No one complains about cars, air-conditioners and electricity. No one even realizes that technology goes into the manufacture of office-chairs, sliding-windows and shaving-gear. Where does one draw a line regarding ‘modern’?) 

When it comes to curing our ailments, we want both, experienced doctors with great instinct plus state-of-art technology.

Experience crawls. Young doctors lack it and benefit with the evidence-based method. What doctors of my age learned through their MBBS and PG years, the youngsters cram into a short period because the amount of knowledge they need to know is more.  Cutting-edge stuff is cold, distant, without the human touch. And expensive. If we were to depend only on it, we’d need diagnostic centres next to every other biscuit stall and even then we’d have long queues, so dense is our population.

Leave aside serious road traffic accident cases or those with bleeding in the brain, where no surgeon would touch a scalpel without following the protocol of checking on blood-clotting time, exact location of ‘trouble’, etc, there are many illnesses that can be prevented by modern methods. Dyes injected through arteries and the presence of higher-than-normal levels of creatinine in the blood can detect heart/kidney troubles. Same with some kinds of cancer.

Evidence-based practice is here to stay. To prevent thoughtless prescriptions, to know how and when to use which tests, how to interpret the results correctly, doctors will have to fall back on Experience. Those who have insights through medical humanities, who recognize the importance of the natural history of a disease, will be more accurate in their dealings with different diseases/ ailments/ injuries/ illnesses. At the end of the day, opinion-based practice will still have higher value. Doctors’ instinct develops over time.