The lost invisible touch!

Sir Robert Hutchison
Father of clinical methods

A friend, during our stint as house officers, told me about an incident that happened during his medical student days when he was studying in Manipal, India. An American elective medical student had joined the group's ward rounds. The old Professor of Medicine was showing them the correct technique of examining the respiratory system. He laboriously punctuated the teaching rounds by asking basic science questions and snarling occasional sarcastic remarks, for not understanding the basics. He was showing the green medical students the art of inspection, palpation, percussion and auscultation.

The American student, failing to see the point of such a laborious examination of a single patient, raised his hand.

"Professor, wouldn't it be better if we just send the patient for a chest X-ray?" he quipped.

That is the state of medicine now. We have lost the art of practising medicine. It is just about diagnostic procedures and laboratory results. Clinicians no longer use clinical methods to diagnose. If it used to be that laboratory and auxiliary tests were used to confirm or disprove our differential diagnoses, now it is the primary modality of the approach of a patient. 

Pretty early in my training, I did an attachment in a Gynaecological Oncology unit. Its head, an old-timer Professor, once was in a dilemma. As part of the staging of cancer in his patients, he would perform a CT scan. This, he would do after carefully performing a complete clinical examination. The outcome of the scan would enable him to decide on the operability of cases. There was this particular cases where he was in limbo. He was unsure of the stage of cancer. After much discussion, argument and reevaluation, he was convinced that that individual patient had an early operable cancer even though scans were reported as otherwise. After much deliberation, he went ahead and assessed the patient under anaesthesia on the operation theatre. It turned out that the old Professor was correct after all. He proceeded with the surgery, and final histopathological specimen confirmed his clinical findings too.

That was how it used to be. Clinical acumen took precedence over laboratory and auxiliary investigations. Now, lab tests take precedence even over a good history taking. The recent Covid-19 pandemic is evidence of the above. Do the swab test first, then the clinician (or perhaps the technician) would decide the next course of action; whether to operate, treat conservatively or even see the patient. Just quarantine and see the outcome later - If he pulls through what was perceived as a death warrant. 

A recent case that came to my attention recently during my work made me realised that perhaps we are too dependant on lab results. Maybe it is fueled by patient expectations of wanting an instant resolution (diagnoses) and fear of litigation. The need for an instantaneous gratification in all human dealings has permeated all social activities. We do not want our results now, but yesterday.

A 30-year-old lady presented with a two weeks delay of her periods. A urinary pregnancy test showed positive findings (i.e. pregnant). The couple presented at their doctor for a pelvic ultrasound scanning. The examination did not reveal much. As she was asymptomatic, she was told to show up in two weeks for reassessment but to return earlier if she felt unwell.

Just three days later, she returned with slight discomfort over her lower belly. HCG levels revealed 2000 IU/L. This time, a vague mass was seen just right of the uterus. A diagnosis of possible ectopic pregnancy was made and referred to a tertiary centre.

Based on the above findings, at the tertiary centre, Methotrexate was administered intramuscularly to medically treat the ectopic pregnancy. 

Follow-up HCG five days later was 5000 IU/L; adnexal mass still present, uterus empty. After the first episode of pelvic discomfort, she had been symptom-free except for the anxiety caused by the turns of events. 

Another three days later, HCG was 3000; still, uterus was empty, and the adnexal swelling persisted. The patient was well otherwise. 

© George Condous

Seven apprehensive days later, i.e. three weeks after her first consultation, much to the puzzlement of everyone, a small shadow was seen in the uterine cavity of what appeared like a gestational sac with a yolk sac in-situ. A diagnosis of heterotopic pregnancy (concomitant intrauterine and extrauterine pregnancy) was considered, and laparoscopic evaluation was considered.

Being confused with the whole turn of events, the patient decided to opt for 'wait and see' policy. A day after that, she passed out blood clots. She was diagnosed as had a complete miscarriage and was monitored periodically. 

So what happened here? Did the clinicians place too much trust on biochemical results over clinical findings? Perhaps not. When the HCG levels are significant, with the presence of extrauterine shadows and an empty uterus in imaging, it would be negligent to just sit on it. Did the methotrexate cause miscarriage? Possibly not. A high HCG with an absence of visible pregnancy is itself a hallmark of abnormal pregnancy, including impending miscarriage.

In anything that the Covid-19 had taught us, it would be that everybody can be an expert. Armed with statistics and articles to support the assertions, anyone can insist on having found the elusive cure for the ailment. Clinicians, who by nature, like to err on the side of caution, had been accused of selling out the whole human race for self-interests. It seems PhD doctors got the panacea for all woes. Their data analyses and textbookish method of approaching disease make them excellent armchair critiques of what is wrong with the medical services in any country. We all know what happens in the field is not what is shown in laboratory experimentations. But still, it is a free world. Anyone can say what they want. The more one delves into a subject, the less he is cocksure about anything.

Perhaps the demand for wellbeing makes medical services a lucrative business. If before, in the Jurassic era, the doctors would call the shots in the management of patients and the running of medical facilities. The ever increasing expense and the need for state of the art medical equipment make healthcare revolve around breaking even and paying the stockholders rather than being patient-centred. Law of Attraction dictates that the smell of money draws characters of reputable character. Hence, vultures and hyenas of various ferocity started flocking around. Referring to the clinical practice guidelines as their holy grail, these creatures of the dark forces scream medical negligence or even manslaughter whenever an adverse outcome ensues. In hindsight, everyone has 20/20 vision. They think that treating patients is like cooking chicken vindaloo referring to a cookbook.

Like the 1927 movie Metropolis, everyone is just a cogwheel in the big machinery of modernisation. We are mere technicians doing our designated duties for the greater good of mankind as decided by the powers that be - the businessman. The future is not bright, either. After breaking down and digitising our individual tasks, our jobs may be assigned to artificial intelligence (AI). We will be redundant and irrelevant.

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Save lives or your skin?

Courtesy: Zee News

Stemmed a mob in Kolkatta cracked the skull of a 
doctor when his 76-year-old patient with myocardial
ischemia and arrhythmia succumbed to his ailment. 
Incidentally, the victim is from a minority group. 
That makes it difficult for politicians to make the 
'correct' decision.

There was a time when it was noble to treat the sick and downtrodden. People who had 'failed' in life, i.e., failed to live up to the expectations beset by the society, would find solace is serving the infirm. It was considered virtuous to live amongst and care for sick. Father Damien cared for lepers, contracted leprosy and was canonised. Florence Nightingale spent sleepless nights holding vigil in her ward to minimise morbidity. Mother Teresa left the comforts of her hometown to answer her call among the poor of Calcutta.  

In public life, many non-religious individuals sacrificed time and energy to establish medical services in many newly independent countries of the East. More often than not, personnel in the medical profession do not work 9 to 5 but start early and finish late, not anticipating remuneration but the thankful nod and warm handshake from grateful patients (mind you, not clients!)

The turn of the century saw a change in lay people's expectations and outlook of the medical fraternity. They were no longer held up on a pedestal but treated as another spoke in the cogwheel of machinery that kept the civilisation going. In other words, they were looked upon as technicians to perform specific tasks. There was nothing divine in their calling. The roll call is the jingling of the cash-machine, they say, Ka-ching!!! 

With the spread of anecdotal reports of cures and treatment modalities, the perception is that immortality is real and achievable in this lifetime. With the increasing litigation risk and corresponding growing medical costs, both care providers and recipients look at each other with much scorn. The doctor views every patient as a potential liability and a possible litigant. Hence, he practices defensive medicine, taking care of all differential diagnoses are not overlooked. He must ensure that if God forbid, any unforeseen malady should strike, he must have a watertight case to keep the swarm of prancing sharks in robes at bay.

The patient views their care providers as money-faced mercenaries out to make a kill on others' miseries. They jump at the term of medical negligence at the first instance any medical intervention go south or as uncharted.

In jumps the businessmen who envisage a future in this distrust. They portray the image of a fair middleman who would promote fair trade. In reality, he is just a wolf in sheep's clothing tasked to guard the chicken coop.  His eyes are squarely on the chicken and the pearly white eggs as well. Like appointing Colonel Saunders to act as the spokesperson for the 'Society Against Cruelty to Chicken'!

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The past will present the future!

Malay Magic

Walter William Skeat (1900)

There was a time many years ago when the Malaysian National Museum in Kuala Lumpur decided to go all out to make their exhibits draw more viewers. They curated an exhibition themed along the lines of 'Magic in Malay Land'. Just a few days into its starting, it had to be discontinued. The powers that be were not too comfortable as the reception was too overwhelming. Before this exhibition, the National Museum building was like Siberia; everybody knew where it was, but nobody wanted to go there. Rows and rows of hired outstations express buses were seen parking around the vicinity of the museum on a daily basis. The religious bodies did not realise that the interest amongst our community in knowing our ancient animistic past believes ran that deep. 

So, as what a true-blue beholden of belief would do, to avoid confusions among its confessors, the religious authorities decided that the best thing to do would be to cancel the whole show. Never once after that was such a display ever held. The leaders thought that ignorance is bliss, curiosity would make believers dabble in the supernatural and occult practices and that they would probably doubt the teachings of the Book.

Maybe, as a knee-jerk reaction, the religious bodies decided to tighten the screws on what can be exhibited to the impressionable public. The broadcasting companies and moviemakers were reminded that subjects delving on the supernatural or religions were out of bounds.

It is remarkable that a Western anthropologist of the 19th century would go through such lengths as to produce a 700-page treatise on the cultural practices of the natives if the Malayan peninsula. Even though the writer admits that his records are no means exhaustive of all the traditions of the natives, the book is definitely encyclopedic in nature, detailing into most of the day-to-day concerns of an average agrarian Malay of the late 19th century. He managed to venture into their psyche, spirituality and esoteric practices. 

There are many ancient practices in the Malay world that a modern Malay person would like to forget. Many of the rituals outlined in this book may be considered as un-Islamic, polytheistic in nature.

                       Some gadgets used to determine auspicious times. After the spread of Islam

                       to the region, these practices became unnecessary. Every day is good as 

                       decided by the Almighty. Traditionally, the first Wednesday on the Islamic 

                       month of Safar was deemed as the day of mishaps. To cleanse and to protect

                       one from misfortune, people believed that they had to immerse themselves 

                       in seawater. People congregated around the beaches around Malaya for this 

                       occasion. As the fiesta-like atmosphere reached fever pitch, the religious 

                       authorities put a stop to it, deeming it un-Islamic. This practice called 

                      'Mandi Safar' only remains in the annal of Malayan history.

The population of the peninsula mostly depend on the goodwill of Nature for their survival. Living in the vicinity of ferocious beasts, they develop a system to appease the spirit of the jungle and its occupants. They believe every being has a soul that needs to be respected. Sometimes the spirit of the tiger is also invoked to combat human malady like illness.

The Malays have their interpretations of the origin of animals in the jungle. Many of them seem like a mumbo-jumbo of folklores and pseudo-sacred tales with a twist of Islamic flavour sprinkled upon it. Many jungle produce like fruits, incense, camphor and medicinal leaves are used in ceremonies before any life-changing task is commenced. Many practices also tell of the role that Hinduism played in the civilisation of the region.

Pawangs are shamans who are gifted with extraordinary powers to communicate with and ward off evil spirits. Their services are indispensable in treating the sick and initiating rituals.

One important tradition that stays on till today in the remote areas of the padi planting areas of Malaysia is the worship of the rice spirit. The rice spirit has to be feted to assure good yield, protection from pests, and to ensure favourable weather for planting and harvesting.

Superstitious customs go beyond the spectrum of forests and its dwellers - tiger, crocodiles, snakes, owl. The natives have various fascinating stories about ghosts. Ghosts play essential roles in their lives. A well-known spirit, known as pontianak, involves a mother who died in childbirth. There are great taboos related to pregnancy, birth and puerperium because of this.

Even though Mohamedan men are discouraged to don ornamental appendages, many Malay men traditionally wear rings. The rings usually carry a stone. Most of these stones are not precious ones but are bezoar stones, polished undigested droppings of monkeys, porcupines or other animals. They are said to bring aphrodisiac or medicinal properties.  Amulet and talisman are frequently deployed as love charms or to ensure conjugal fidelity. They have their own non-scientific ways to prove the authenticity of the stones.

The author goes on to discuss the various dances performed in leisure hours. The natives spend many hours in multiple games. Cockfighting is particularly favoured. He goes on to tell about its intricacies, preparations and the madness that surround the pastime. Dice games, cards, top spinning, kite flying, checker and sepak raga are played too. Children create their own games with sticks, sand and stones. Like children elsewhere, they play hide-and-seek also.

Theatrical performances with dancers or puppets (shadow play) are reserved for the noblemen. Here again, rituals take centre stage before any performance. Many of the input into this book also comes from Frank Swettenham and Hugh Clifford. The exciting thing about the writing is that the author is respectful of the natives' beliefs. He does not look at their ritual with his condescending judgmental eyes, like a real anthropologist. 

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