Physician or medical technocrat?

B Ashworth

SMJ 2003 49(2): 39-42

THE CLINICAL CONSULTATION is a special meeting between patient and doctor. During the last century two major developments have modified consultation. The increase in knowledge has led to specialisation and as a consequence a team of experts may be involved. More recently, information technology has provided both a database and the potential for networking.

It has been suggested that information technology might replace the doctor. This ignores the humanitarian, social, ethical and personal aspects of consultation. A better informed public makes increasing demands of medical practitioners and an ageing population swells the need for medical help. A further point is the change of emphasis from paternalism to autonomy so that the patient takes more responsibility for his or her own illness. These various developments raise complicated issues of confidentiality, consent and compliance. They tend to undermine trust.1

Functions of the doctor

The traditional doctor serves as diagnostician, therapist, provider of prognosis, teacher, judge, and communicator.  Other related functions include researcher, health care manager and economist.

The early physicians were concerned primarily with the expanded to include a physical examination of the patient, radiology, laboratory tests, and other investigations. Areas of ignorance remain but the volume of medical knowledge continues to increase. This expansion has made it difficult for doctors to retain medical information and keep up to date, but specialisation has helped to spread the burden.  The capacity to store and integrate medical knowledge using computer programs is a significant advance. There is a continuing need for sympathy towards the sick and disabled and improvement in communication between the doctor, patient and the other people involved. Effective medical work requires knowledge, intelligence, experience, judgment, clinical skills, the ability to communicate, appreciation of the background and personality of the patient, with awareness of the broader issues and prevailing culture. All of these characteristics can be assessed and some of them can be measured. There is a tendency to attach more importance to features which can be measured as is emphasised by the recent publicity about league tables relating to examination results or hospital waiting lists.

Clinical judgment

Clinical judgment is difficult to measure or teach but generally recognised as important in medical consultation.

It emerges as a component of the personality and influences the whole area of practice. Those who are familiar with medical work recognise the doctor who is able to evaluate a situation rapidly when others are lost in a plethora of information. A related factor is that doctors who seek help from colleagues to deal with illness of members of their own families would seem to be recognising a combination of qualities which are significant although hard to define.  Good judgment requires assessment of the relative contribution of various factors together with ability to decide that further information will not help and a clear decision about a course of action. It also implies an appreciation of values, including those held by the patient.  The capacity for judgment does not necessarily correlate with high intelligence or distinguished performance in examinations. It has been suggested that an undergraduate course in literature or philosophy may help to widen the humanitarian outlook.2 The importance of judgment in general and more particularly in the medical setting has been emphasised by various writers. Sir Robert Hutchison3 summarised the place of judgment in clinical diagnosis:

“Every doctor must be a judge. He has to weigh the evidence of symptoms and signs, and allot each to its proper value in making a diagnosis. Now we have Hippocratic authority for the belief that judgment is difficult, and indeed medicine has been defined as the art of coming to a conclusion on insufficient evidence...  We can increase our powers of observation by training and practice, and we can extend their range by instruments and methods. We can increase our knowledge by study and experience, but can we improve our powers of judgment? I greatly doubt it. Judgment seems to be an inborn faculty, the result of union of mind and character, which a man either has or has not, and it is almost as difficult for him to increase it as to add a cubit to his stature.”

This quotation stresses the cognitive aspect of diagnosis but makes it clear that values should enter into the judgment as well.

Mistakes are , of course, inevitable in medical practice as in any other form of human activity. Errors may indicate incompetence and this can be divided into three categories: body, mind and moral. Physical inability to perform or communicate is the most easily recognised. Incapacity of mind may result in inability to manage affairs or take decisions and may extend to legal incompetence. Moral incompetence may be manifested as failure to control urges and blindness to moral values. The psychopath lacks respect for himself and others and is uninfluenced by shame or guilt.4 Medical teaching, in the past, has emphasised the importance of a detailed clinical history and a full physical examination. In practice, most stress is put on the clinical history obtained from the patient. As the story unfolds a hypothesis is formulated in relation to the likely diagnosis.  This is checked as the history evolves and by specific questions. This method is economical of time but requires judgment of what should be accepted or rejected.

Probability

Probability is the measure of a chance event. Subjective probability is used to add weight to a diagnosis. This is illustrated in the analogy that a bird resting on a gatepost in Britain is more likely to be a sparrow than a canary.  Appreciation of the significance of probability is difficult to convey to patients who are often looking for certainty.

In medical work statistical probability is used in clinical trials of drugs and comparison of their effects. A clear distinction must be made between subjective probability and statistical probability.5

Science and art

Science is based on observation and experiment. It leads to the formulation of hypotheses which have to be modified in the light of new findings. Observation gives rise to description but it is influenced by past experience so that the prepared mind becomes aware of features which would be missed by the general observer. Experiment provides an opportunity to modify the circumstances of observation by isolation of single factors to determine their influence on the outcome. Science does not provide a final statement at any given time but is a means of gradual advancement of knowledge. The same methods are of use in medical science. Observation is vital but experiment on the human subject is restricted. The science of medicine has advanced rapidly in recent years and underlies not only diagnosis but also treatment.

“Art is based on experience, subjective, incapable of precise analysis, not reproducible and impossible to measure”.6

The art of medicine consists in the application of scientific knowledge to the problem presented by the patient. This has many facets. First, is an attitude of mind. This must cover more than curiosity and lead to empathy with the patient which implies an element of compassion and a positive desire to help in the relief of the condition. If this approach is lacking the patient may reject any conclusion and it is likely that facts will be overlooked and therefore not recorded. Second, there are skills in obtaining information about the history of the illness and making a physical examination of the patient. Third, are the means of communicating conclusions that are reached about the nature of the illness in language that can be understood, with appropriate emphasis, but without conveying undue alarm or pressing details that the person involved does not want to hear.

Clinical consultation

“Given the condition here and now, that judgment of relevance and applicability is essentially one for the person who best understands the individual’s history” 7.

The consultation begins with an enquiry about symptoms.  Sometimes the account is clouded by interpretations or resistance to facing the facts. A child of 10 may be able to provide a better history of the symptoms than his mother whose feelings are dominant and overshadowed by anxiety.  The clinical history therefore requires interpretation.

This vital part of the investigation can only be done by a person with medical knowledge because it requires more than a narrative provided by the patient. Pertinent questions are asked to confirm or refute hypotheses concerning the nature of the illness. For example, a patient with fever for which there is no apparent cause may have returned from a country where malaria is prevalent. If that is not revealed the diagnosis of malaria may not be considered at all.  As a further example genetically determined conditions may be mentioned. The fact that a close relative has suffered a similar illness (or died previously with an undiagnosed condition) may point to a diagnosis. Quite often information of this kind is not volunteered by the patient and only comes in response to specific questions. The medical history alone frequently leads to a suspected diagnosis. It is followed by a physical examination which demands skills including a gentle approach and respect for the feelings of the individual.  The practice of medicine requires both a background of medical science and acquisition of the art of dealing with patients. The relative contribution of these two parts has been debated at intervals. Although there has been a major growth in medical science in recent years the art of dealing with patients is no less important. A general method of helping ill people may be taught but it requires modification according to the needs of individual patients.  The extent of this modification will depend on the doctor and is not based on a fixed and universal routine.  Variations on the general theme may be equally effective and it would be wrong to conclude that there is only one response to a particular problem. There is inevitably a personal component in consultation which has to be considered if a satisfactory conclusion is to be reached. A conflict may arise between the needs of the patient and of the community. The community will determine the resources available for patients using a national service and decisions are called for in applying these to individual patients. But clinical judgment is primarily concerned with the welfare of the individual in a personal relationship.

Epistemology

The bio-psycho-social model takes account of these factors and uses a systems approach. The emphasis is on humanitarian aspects and the need to relieve the patient of distress. The distress may be due to some form of physical disease or be related to social or psychological adaptation.  Systems theory offers a framework.8,9 It proposes a continuum extending from sub-atomic particles through molecules, cells, and organs to the person. The hierarchy continues as the patient relates to other individuals, family, community, culture, and nation. At each level of the system there may be interaction and response. In this way there is integration between levels but centred on the patient. For example, a physical disturbance at cellular level frequently affects psychological function. This conceptual model incorporates a range of factors which have some impact on illness.

Clinical judgment is mainly concerned with the art of interpretation. It rests on an appeal to evidence-based medicine and medical narrative including knowledge of the patient and his views. But it must take account of probability and theories of disease. A good clinical judgment leads to the best therapeutic outcome. This may rest on the choice of a drug or other treatment or in some instances the withholding or withdrawal of a particular regimen.

Insistence on evidence-based medicine and randomized trials may undermine the autonomy of the physician. It is assumed that the most rigorous investigation is superior to the multifaceted knowledge of the physician. There are standards of perceptiveness and coherence in all professional practice. The greatest harm arises from the notion that certainty has replaced probability and the devaluation of clinical expertise. Pauker has noted that ‘Even the ideal model cannot replace clinical judgment, it merely contributes and additional perspective from which high quality clinical care can be delivered.’10

Narrative and interpretation

Narrative provides a bridge between patient and doctor and also helps to link with relatives and other parties concerned with the illness. There is an urge on both sides of the divide between individuals to formulate a narrative or story of the illness. The narratives interact but they reflect different concepts and interpretations based on accounts of what was experienced. Narrative gives coherence to the sequence of events. In the more acute conditions changes take place from day to day and the sequence of decisions becomes a cascade.

The presenting complaint may be misleading. In a discussion of pain narratives Bayliss stresses the importance of allowing the patient to speak without interruption, listening to the words used and also taking note of the body language. He quotes the case of a middle aged woman who appeared smiling and said ‘I’m happily married but I have the most terrible headaches’ Bayliss at once suspected that the explanation was more likely to be found in the domestic environment than intracranial disease and was able to confirm this later. He suggested that the patient was unaware of the impression conveyed. However, it seems likely that somebody had raised the possibility with her at an earlier stage and was confronted with a firm denial which led to the order of presentation.11 The training of doctors in the past has tended to emphasise a structured method of taking the history. In its extreme form this may be reduced to asking a series of questions.  While there is a place for questioning about matters that arise from the history a great deal is lost by a rigid approach.  As Bayliss says, the history should be received rather than taken.

Family and confidentiality

Members of the family are usually involved when serious illness threatens a patient. The link is even clearer when hereditary disease is known to affect some members.

Difficult issues arise between husband and wife in relation to Huntington’s chorea now that a test is available to detect predisposition. The male patient, for example, may not want to know the result while his wife is anxious for a prognosis.  This dilemma may be surmounted by preliminary discussion of possible outcomes.

Epilepsy often involves the family. The diagnosis carries a stigma and efforts may be made to conceal it. As the warning of an attack is brief the situation may be revealed at any time. Epilepsy also leads to constraints over employment and driving a car. The majority of subjects are well apart from the attacks. The impact on the patient is often one of continued insecurity.

A recent trend towards a more open approach has increased general awareness of the disease but community attitudes are slow to change. Confidentiality on the part of the doctor is a professional requirement. It can be overruled in cases of notifiable infectious disease or in a Court of Law. Patients and families are not constrained in this way but may decide to preserve secrecy concerning illness. Again, the situation is changing and serious conditions such as cancer and dementia are now discussed more openly.

Conclusion

The computer is not a substitute for a physician. Good clinical practice requires a broad appreciation of scientific knowledge, psychological considerations and the social environment, combined with value-laden appreciation of the humanities. This depends on narrative and communication which cannot be conveyed by an automated system. Computer networking is useful in the manipulation and storage of information. The computer may be programmed to answer some basic questions but is unreliable in providing a diagnosis or directing treatment. It is also time-consuming. Patients are likely to be uncomfortable when confronted with a machine. Personal communication and trust between patient and doctor are likely to remain central in the medical process of dealing with serious disease.

B Ashworth

Consultant Neurologist (retired) 

13/5 Eildon Terrace

Edinburgh EH3 5NL

ACKNOWLEDGEMENT: I am grateful to Professor Z.Szawarski for much helpful discussion.

REFERENCES

1. O’Neill O. Autonomy and Trust in Bioethics. Cambridge University Press. 2002:16–18.

2. Downie R.S. and Macnaughton J. Clinical Judgment: Evidence in Practice. Oxford University Press. 2000; 186–196

3. Hutchison R. The principles of diagnosis. Br Med J 1928;28:335 – 337.  

4. Szawarski Z. Impaired capacity and the medical knowledge. European Philosophy of Medicine and Health Care. 1996;4 :89.

5. Wulff H.R., Pederson S.A.,and Rosenberg R. Philosophy of Medicine.   Second edition. Oxford : Blackwell Scientific Publications. 1990;89–104.

6. Ridderikhoff J. Methods in Medicine. Dordrecht : Kluwer. 1989.  

7. Toulmin S. Knowledge and art in the practice of medicine; Clinical judgment and historical reconstruction. In Science, Technology and the Art of Medicine.  Delkeskamp-Hayes C. and Cutter M.A.G. eds. Dordrecht ; Kluwer 1993: 243.  

8. Canguilheim G. The Normal and the Pathological. New York: Zone Books 1966 reprinted 1991.

9. Brody H. The systems view of man: Implications for medicine, science and ethics. Perspectives in Biology and Medicine. 1973 17; 71–92.  10 Pauker S.G. Comments by the representative of the Medical Society for Decision Making. Journal of the American Society of Cardiology. 1989;14 no.3 11 Bayliss R. Pain Naratives. In Narrative Based Medicine. Ed. Greenhalgh T.  and Hurwitz B. London : Br Med J 1998 75–82.

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