|Year : 2014 | Volume
| Issue : 1 | Page : 1-3
Wither clinical skills and humanism?
Bhaskara P. Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||4-Jun-2014|
Bhaskara P. Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. Wither clinical skills and humanism?
. Arch Med Health Sci 2014;2:1-3
"The human spirit must prevail over technology"-Albert Einstein
On the science of history taking and art of listening, Osler indoctrinated the philosophy of learning from experience, "In what may be called the natural method of teaching, the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end." The Oslerian dictum "listen to the patient, he is telling you the diagnosis" should be resurrected in today's bedside clinical-skill development. Such art of history taking and skillful-targeted clinical examination would go a long way to foster humanism, professionalism, and would ignite the healing encounter and build doctor-patient relationship. Formulation of a diagnosis through the mastery of clinical skills and higher-order thinking in the Bloom's cognitive taxonomy is akin to the detective work of Sherlock Holmes at the clinical bedside. The mastery of clinical skills is central to the transformation of a medical student into a competent health professional fit for medical practice. Clinical medicine, clinical-skills attainment, bedside clinics, and the ward have been a subject that I call as "clinical poetry." I reminisce how my 1985 outgoing class of MBBS of Kasturba Medical College (KMC) Manipal gave me a nickname of 'clinical poet' befitting my name and altruistic dedication that I had to clinical medicine. For me, to hone clinical skills from my mentors was a great learning experience that I cherish and revere even today. Mentors and the vastly experienced colossus of doctors at the bedside painstakingly taught us in such meticulous details of cardiac sounds, its variations, murmurs, observation of the jugular venous pressure (JVP) waveforms, breath sounds, arterial bruits, venous hum, bowel sounds, and many invaluable bedside skills. Indeed, they grounded that 75% clinical diagnoses can be achieved with astounding precision by listening to the patient as echoed by Lord Platt at University College Hospital, London in 1949. Today there is a paradox that physician's reliance on the stethoscope has fallen to unbelievably low levels and replaced by pocket-size miniaturized handheld bedside echocardiographic devices. As Hippocrates advised, it is more important to know what sort of person has a disease than to know what sort of disease a person has. We need to re-train our medical students to listen to and talk with the patients, be great communicators, possess two qualities i.e. imperturbability and aequanimitas in order to preserve humanistic medicine, all of which would foster 'whole-istic healing' encounter through psycho-neuroendocrine-immunologic network activation.
Through my unconditional clinical commitment during my formative years, I would salute at the wisdom of Sir William Osler famous quote, "for the junior student in medicine and surgery, it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself." However, I see a vital quintessence vanishing from our healing profession that is a progressive demise of bedside clinical skills termed "hyposkillia"  where we have become servants to technology rather than its master. Is clinical skills and acumen a dying art today? Are we witnessing the death of clinical medicine at the expense of these hard-learnt essential clinical bedside skills? Is clinical medicine with emphasis on Oslerian spirit a bygone era superseded by high tech medicine? Has the time dawned to write an obituary note for the declining clinical skills, humanism, and professionalism? Does India need high-tech medicine or clinical medicine? This editorial will attempt to seek answers to my reflective and provocative thoughts and questions sighted above.
I certainly do not deny that modern medical technology has greatly enhanced our understanding of medical disorders and our ability to diagnose and treat diseases. However, undue reliance on these technologies has resulted in "disuse atrophy" of cognitive and metacognitive thinking skills in our brain. The high-tech modern medicine essentially bypasses the medical history and physical examination and thus weakens the healing encounter by preventing the patient-doctor bond, thus treating the disease and not the patient who has the disease. I feel remorseful that over the last few decades' technologic marvels has crippled physicians' use of the mind and the five sensory faculties, critical thinking, inductive and analytical reasoning to problem formulation, hypothesis generation, and inquiry strategy to generate provisional and differential diagnosis. Instead physicians today circumvent the former, and rely on an armamentarium of tests and procedures with numerous consultations. I would reiterate that technological advances are not to be blamed; instead the deficiency of clinical skills has resulted from the indiscriminate and habitual over reliance of high-technology diagnostic devices and tests by the modern medical technicians. Technology has become a surrogate for history taking and listening. At the heart of medicine, this has led to a medicine that is not compassionate, and it has lost that special trust that once bonded the physician-patient relationship. Healing is replaced by treatment, and the art of listening substituted by technological advances.
The increasing dependence on the trillion dollar high-tech driven 21 st century medicine coupled with lack of clinical competence and humanism has caused the dehumanization  of patient care, making medical practice reductionist than holistic. It's a calling now to revive the spirit of Oslerism and to conceive a paradigm shift in our healing orientation from a physician-technician axis to "a physician-healer0" perspective. Technological shortcuts should not replace a mind willing to think, instead be prepared for an unhurried interview, and pay careful attention to numerous details derived from painstaking inquiry. In the words of Hippocrates, " For where there is love of man, there is also love of the art; many patients recover from perilous health simply through contentment with their physician, as the then physicians had the art to talk to patients, and listened, hearing to the patients and to their illness behavior."
Hyposkilliacs are physicians who lack logical thinking, inductive reasoning, unable to think critically and clinically, have poor clinical reasoning, and unsound in the process of clinical decision making. Thus hyposkillia results in the culture of flourishing technological overuse. Such atrophy of clinical skills resulting from the lack of clinical-skill development and training ends up in producing clinicians unable to pick up simple clinical diagnoses with basic knowledge and skills. I feel it is a high time to revisit the clinical-skill training, clinical-skills assessment and performance outcome methods for doctors, and explore what doctors don't get to learn in medical schools in India.
Can we do an autopsy to find the etiology that resulted in the withering of clinical skills and humanism? I feel the solution to the problem of hyposkillia and the lack of humanistic medicine would lie on the need to restructure our medical school teaching faculties, teaching facilities and methodology, work-based assessments, performance evaluations, clinical-skills assessments, and to restructure the Indian undergraduate curriculum. We need teachers who are ardent role models of the Oslerian spirit who teaches the invaluable role of clinical history taking, possess astounding clinical examination skills, formulate clinical impressions, and those who know when and which investigations to request for and to refrain from the habitual reliance on of sophisticated battery of tests. As educators, we need to use cognitive learning theories such as experiential learning cycle in clinical teaching to promote thinking at higher cognitive levels and to develop new understanding. Faculty development is necessary to improve the current clinical skills of medical school faculty and provide proper instruction on the teaching and evaluation of clinical skills. Current emphases on classroom teaching and lectures have taken away the essence of clinical bedside teaching. Quoting Sir William Osler, " Medicine is learned by the bedside and not in the class room. Let not your conception of manifestations of disease come from work heard in the lecture room or read from the book: see and then research, compare and control. But see first." Innovative teaching-learning methodologies to develop critical thinking on the higher levels of Bloom's cognitive taxonomy, creative and reflective thinking, problem-solving and decision-making, clinical judgment skill development, self-regulated and self-directed learning, appreciative inquiry and learning styles, problem- and case-related learning, reflective learning and reflective practice, experiential learning, and transformative learning are pivotal. There is absolutely an urgent need for the early introduction of training clinical skills in the curriculum, organized in a cascade of logical sequences at the very beginning of medical study so as to produce a final product of a competent physician with all prerequisite skills mastered. We need to not only test their knowledge base but also medical students need to demonstrate not only they 'know' and 'know-how' but can also 'show-how' they can do based on the Miller's pyramid of assessment of clinical competence. 
Clinical skills' training is arguably the weakest point in medical schools' curriculum. We need to bring back into the medical curriculum and clinical practice the art of observation, listening, clinical reasoning, and focused and targeted clinical examination of the patient. Phases of clinical-skill training should include the rationale of clinical skills, training in clinical-skills laboratory (clinical-skills lab), demonstration of skills in a clinical setting, execution of skills in a clinical setting, and the final assessment of proficiency. Performance evaluation/clinical competence assessments/workplace-based assessments by way of objective structured clinical examination (OSCE); objective structured practical examination (OSPE), clinical performance examination (CPX), mini clinical evaluation exercise (mini-CEX) will certainly provide not only concrete evidence of clinical competence but also drive doctors' learning. These paradigm reforms in Indian medical curriculum and teaching faculties would pave way to develop a "high-touch" medicine that is soundly constructed on the principles of Oslerian medicine and shift away from habitual reliance of high-tech medicine.
Lastly, the lack of clinical-skill acquisition and humanism would also have their underpinnings on the phenotype of students selected/entering the portal of various institutions for a medical career. In this respect, I believe there should be certain admission criteria during interview such as Thematic Apperception Test, Sense of Coherence Scale, Rosenberg-Self Esteem Scale, Career Motivation Questionnaire, and 16 Personality Factor Questionnaire that would analyze the various non-cognitive personality attributes. Assessments of these personality and character traits would ensure selection of candidates who would be torch bearers of future compassionate and humanistic medicine. 
In a country with a mammoth population where India's "Bharat," the "soul of India" live below the poverty line, I would reiterate that the Indian medical graduate as stated in the Vision 2015 document should be extremely skilled in clinical bedside medicine. Furthermore, there are large gaps in health-care accessibility in many parts of our country. India's ever-growing Bharat needs clinical and not high-tech medicine. Furthermore, the downside of such high-tech medicine in India and developing nations will only contribute to "iatrogenic poverty." The academic scenario in India needs to be revamped and weed out the dangerous and crippling malady of hyposkillia characterized by vanishing clinical skills. Our current medical curriculum across the country is graduating a growing number of these "hyposkilliacs." These reforms in our medical curriculum and teaching faculties would pave the way forward to develop a "high-touch" medicine that is soundly constructed on the principles of Oslerian medicine and shift away from habitual reliance of "high-tech" medicine.
To conclude, it is my opinion that we could "put the toothpaste back in the tube" if medical educators are trained for a fundamental attitudinal change on the part of academic medicine. This shift in thinking would encourage a renaissance in the art of clinical medicine, skill training and competence, and bedside clinical diagnosis, which will ultimately embrace humanistic medicine. This will include a framework for curricular reforms, horizontal and vertical integration of medical curriculum between disciplines, bridge the gaps between theory and practice, between hospital-based medicine and community medicine, role-model teachers to indoctrinate the science and art of clinical bedside medicine, innovative approaches to teaching clinical skills and metacognitive skills, teaching patient-centered care with real patients as well as simulation-based medical education, and cultivating the habit of humanism that would be the holy grail to prevent the malady of hyposkillia, the atrophy, the deficiency, or the startling decline of clinical skills in tomorrow's physicians. This approach will certainly ensure the return of the heart and art of medicine to its Oslerian and Hippocratic roots, rivet humanities and the bedside, and preserve humanistic medicine.
"An inquiring, analytical mind; an unquenchable thirst for new knowledge; and a heartfelt compassion for the ailing-these are prominent traits among the committed clinicians who have preserved the passion for medicine."-Lois DeBakey, Ph.D.
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