Practicing Medicine: Blend of Intuition, Intellect and Science- Dr Chandrika Kambam

The primordial question 'Is the practice of medicine a science or art?' has been a subject of furious debate and discussion over the years. No wonder, all leading journals of the world have published numerous articles on this subjective issue. Here, I attempt to outline my own perspectives, stemming from my personal experience as a practicing physician.

At times, I have seen patients being misdiagnosed, overtreated, or undertreated in the course of their treatments. Consequently, many patients are left perplexed about their health problems and solutions, unable to make sense of the doctor's therapeutic advice in the exact context of their illness and wellness.

What could be the root cause of this issue, I often wonder! As a prerequisite to qualify as practicing doctors, we all undergo a fool-proof selection process, comprehensive training, and rigorous exit examinations. Then why should there be a stark variation in the degree of skill, competency, and acumen from doctor to doctor. That is precisely why I believe medicine is much more than the scientific knowledge of disease and disorder; it is also the art of applying that knowledge in line with the specific needs of the patient, which obviously differ from case to case. A doctor should be guided as much by intuition as by intellect. The former is largely a function of art, and the latter heavily draws from science. Art and science should come intertwined in a judicious blend when it comes to medical practice.

The art of medicine, more often than not, thrives on the varied experience of seeing several patients with the same condition again and again. Often, we find that patients do not present the classic symptoms mentioned in the annals of medical literature. However, this does not mean that young physicians cannot acquire the art of pre-empting the exact disorder from the apparently different symptoms. All one needs is dogged determination and an adequately inquisitive mind. The latter has a direct correlation with the knowledge one has about the disease, which comprise the key facts and figures. The more you know, more questions you will ask and ultimately help patients help you with a differential and appropriate diagnosis.

The other key aspect of art is observation, keenly watching patients while recording history; their body language, expressions, gestures, sense of awkwardness in the presence of other people in the examination room, apparent fears and inhibitions, as also their inability to grasp the relation between the varied disease aspects and their signs and symptoms. It is extremely important to comprehend the 'unsaid' and give the patient more space and confidence, the reassurance that you are there to help and keen to know the truth and only the truth.

Technology, whether diagnostic tools, or lab and radiology reports are all enablers at best, helping us with the diagnosis but not replacing our clinical judgment. The defining impact of an incomplete history is more than what meets the eye. The cost of over prescription or under prescription of medicines or inappropriate medications are an unfortunate sequel of the incomplete history. In consequence, patients suffer not only from the disease, but also from the devastating effects of misdiagnosis. Suffering goes beyond the physical realm to drain them emotionally, and the whole family suffers from the growing uncertainty and financial burden.

The science of medicine is essentially the combined knowledge of the past, present, and future. The pivotal significance of knowing the facts and iteratively improving the skills cannot ever be overemphasized. I do not know of any other profession that thrives on continuing medical education to the extent the medical profession does. Given that science is evolving rapidly, it is very important for us to keep abreast with the latest developments and breakthroughs that shift the therapeutic paradigms faster than we can imagine.

Continuing medical education also helps fine tune the art of medicine on an ongoing basis. Let me substantiate with a few examples. It's my daily routine to go to the gym in the morning. I often meet a housekeeping lady there, and we exchange pleasantries before moving on to our respective regimen. One day, I observed that her face had a sullen expression while she was talking to me. I checked her conjunctiva and it was pale. I told her she could be suffering from anemia. She confidently replied she has always had low blood count and asked me to prescribe her iron supplement. I told her that her low blood count did not appear to be stemming from iron deficiency. I suspected some minor traits of hemoglobinopathies and advised her to go for a checkup. Her reports showed her positive for minor hemoglobinopathies. There are many instances where the root cause of anemia is not probed and patients are blindly recommended iron tablets and infusions which only make their condition worse. If I had not delved deeper, I would have also probably ended up prescribing her iron treatment.

In another instance, a young lady came to me complaining of leg pain and mild swelling which had persisted for a few days. I sent her to a surgeon for a venous doppler to rule out any clot in her legs. The report was normal but after a few days, she again complained of a variety of aches and pains. In the course of our conversation, she made a passing mention that she had the responsibility of a dependent child under her care, which kept her on her toes morning till night. This crucial information set me on the right diagnostic path. Had I not encouraged her to speak her mind, I would have treated her symptoms based on empty conjectures, ignoring the root cause of the issue.

A regular practice that has immensely helped me is to ask the right questions and keep mulling over the different possibilities. Often, this introspection has helped me reach the 'Aha' moment. A case in point concerns the father of one of my friends, who was admitted to a hospital for suspected heart failure. He also happened to be a diabetic with chronic renal failure. She kept saying, "Something is not right, he doesn't look good, he is in great discomfort" but she was unable to pin point to anything concrete. I got the details of his heart rate, saturation, temperature, blood pressure , everything seemed normal. In this situation, the usual reaction would have been to reassure my friend with comforting words. But I chose to give her concern the benefit of doubt, and kept thinking what else it would be. Suddenly, I recalled a typical presentation of myocardial infarction in elderly, diabetic patients. I asked her to tell the duty doctor to check the troponin level, and it came back positive for Myocardial infarction. He was rushed to the Cath lab and had a timely intervention. He was back to normal and lived on for many years thereafter. Had I not thought of that differential diagnosis at that decisive time, my friend could have lost her dad long back.

There are so many instances like the three shared above. The list is endless. For whatever reason we are in this profession, we need to acknowledge the magnitude of responsibility we carry on our shoulders. We cannot afford to take any case lightly, as we could end up playing with a life as a direct consequence of our ignorance. We have to execute the same degree of efficiency, curiosity, empathy, and care to each and every patient. We need to continuously work on enhancing the art of practicing medicine; we need to sharpen our intuitive abilities backed by solid scientific evidence. Not to forget, many of the medico-legal cases can be avoided by appropriate application of this and powered by documentation.Medical practice is undoubtedly a judicious blend of intuition and intellect.

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