Data for doctors?

If there was one topic in the medical curriculum that you wish you could remove what would that topic be? I came across this question not too long ago. A very common answer was (unsurprisingly) – biostatistics.  Many believe that this time could be used to learn other useful things. I can see where that angst is coming from. The medical curriculum is crowded. We do miss out on teaching several things. From that perspective is biostatistics or even epidemiology really needed in the undergraduate curriculum. Not everybody becomes a researcher anyway?

Data Use in the larger context

Lets look at the “non medical” world. The value being given to “data” seems to be rising every day. The Economist published a famous piece declaring “Data the new oil”. Billion-dollar companies like Facebook, Amazon, Instagram make their money with their prized commodity – Data. Massive advances are being in the fields of Machine Learning and Artificial Intelligence (The more celebrated older siblings of old school data analytics). “Data experts” seem to believe that AI replace a lot of what doctors are doing. Many doctors seem to detest technology . The middle ground seems elusive.

Using Data in Medicine? Is it new?

In medicine, we have been using data long before data science became a thing. That is in fact the foundation of “Evidence-based medicine”. How do we know that 140 /90 is the cut off for hypertension? Why do we use CURB65 scores to decide management in Pneumonia? Why do we use the GCS Score in Trauma? We conducted studies, looked at the data and predicted that people with prolonged elevated BP / High CURB65 Scores / Low GCS / High Respiratory Rates tended to have poorer outcomes if they were not treated immediately. Pediatricians have been using “Z Scores” for years to classify nutrition status. (A Z Score refers to standard deviations which is a direct statistics term)

It is said that “Medicine is a form of art built on the foundation of biostatistics”. The idea that Data Science (including Machine Learning and Artificial Intelligence) and Medical Science are at odds with each other is a faulty assumption that many physicians hold. The heart of data science is problem solving. When a clinician pieces together several sheets of prescriptions and investigations to understand the past history of the patient I would call it a type of data science! Each prescription is a piece of raw data. When put together with what the physician knows it can provide valuable information. For large populations you need computers, software and programming but those are only tools.

Decision Making in medicine

In medicine we have the difficult job of taking decisions and giving advice. Decisions that are extremely hard while making them. Do I operate or manage conservatively? Do I admit or send home?   Start Antibiotics or wait and watch? After the outcome it is ridiculously easy to turn back and judge. What genuinely seemed right at the time can seem so wrong in hindsight. Tools like CURB65, Glasgow Coma Scale etc. help make difficult decisions. They are by no means the only thing we base decisions off . Spotting a sick child in a busy casualty is definitely more than just counting a respiratory rate. Clinical experience matters. Counting the respiratory rate definitely helps the process. Spotting a sick child with a normal respiratory rate takes experience but relying on the respiratory count will prevent us from discharging a baby breathing at 66/min!

Research for everybody?

Doctors may not necessarily be creators of research papers but ALL doctors will be consumers of research. Learning the foundations of bio-statistics and epidemiology and being able to interpret the basics of a study is important now more than ever. In this day and age when there is a relentless onslaught of fake news, propaganda and psuedo-science this becomes important not just in medicine but in life as well. We need to build a culture of promoting scientific temper. Let us work with data science, not as a magic bullet to solve all problems , but as one of many effective tools to guide clinical decision making. The heart of medicine will always remain the doctor – patient relationship and rest assured nothing can replace that.

Rational Medicine!

The social determinants of health – too much idealism?

Somewhere in the pages of Community Medicine, every medical student has learnt about the “Social Determinants” of health. Health does depend on various factors like the conditions where a person lives, how much he can afford to spend on health, education, food, etc. If the person does not have money to eat or pay rent then his health becomes the least of his priorities. Many diseases disproportionately affect people who cannot afford care and this makes things worse.

So what? Its life and life is not fair is it? Doctors and healthcare workers in India are already scarce and it’s not like we can go around solving all these issues. It’s not like doctors are charging a bomb themselves. Doctors rarely get to decide how much the patient pays. (Some hospitals do let doctors write off charges at least partially but that is the exception and not the norm). Doctors are employees themselves. We like to stick to the medical side of things and not concern ourselves with payments and other things. Many doctors wish they could do more and there is often a lot of frustration.

What can we do?

My personal take is that something can indeed be done. The best intervention that you can possibly do for your patients is to get better with your clinical skills! You may never be able to solve all the poverty problems in the world or feed all the hungry but 3 very powerful things you can control are the prescriptions you write, the tests you order, and the procedures you do. They cost money and affect the patient financially.

Use drugs rationally

The most expensive drug in the market is usually not the most effective. Ranitidine (~Re1/tablet) or Pantoprazole (~Rs7/Tablet) can be quite effective in managing gastritis. Yet we often see fixed-dose combinations of Rabeprazole+Domperidone (Rs 20 /tablet) being used. The cheaper alternative would have worked just as well. That is NOT to say that newer drugs should not be used. They may even arguably be more effective or have fewer side effects. But we have to ask ourselves if the patient can afford to spend that much more money for a marginal increase in efficiency. What is the cost-effectiveness of Ranitidine vs Rabeprazole? These are just examples obviously but they illustrate a larger point.

Order investigations wisely

The good rule of thumb is “Order investigations only if the results will change the course of management”. You do not always need an MRI for every low back pain. Of course, you will have certain conditions where an MRI is indicated. You do not need a Dexa Scan to suspect osteoporosis and start calcium in a 60-year-old woman! You DO need a Total Blood Count and blood cultures before starting an IV antibiotic. Be careful while placing the order. If you need only Haemoglobin, WBC Count, Differential Count and platelets, you don’t need to order the whole Complete Blood Count Package which may be more expensive. It may have values that you will not even look at! Investigations are a powerful tool and should certainly be used when necessary. At other times go with clinical sense.

Use Procedures only when appropriate.

The dictum is that “a good surgeon knows when to operate, a great surgeon knows when not to operate”. Not every knee that has the slightest ache needs to be replaced. Not every gall bladder stone needs to be removed! In some cases like end-stage cancer etc, i would even argue that not every patient who desaturates needs to be intubated! Pick the patients you choose to do procedures on wisely. I once saw a very poor, morbidly obese woman who had been immobile for over a year due to severe Rheumatoid Arthritis be offered a hip replacement! What are the odds that a hip replacement would be beneficial in this scenario? Next to zero! It gave her so much hope that she would walk again! She desperately went about trying to arrange funds for the surgery. It eventually got canceled.

Most things mentioned here are just good clinical practice. Yet time and again we forget to practice them. An estimated 63 million Indians are pushed into poverty every year because of healthcare-related expenses. We may not be able to go out and remove all the poverty in the world but if we consciously decide that we will keep the patients paying capacity somewhere at the back of our heads when we order investigations, prescribe medicines and plan procedures I think we can go a long way in helping out.

Hutchison’s Prayer

There is a famous piece that is on one of the first pages of Hutchison’s Clinical Methods. First published in 1897 this book is still one of the most-read clinical manuals in the world. This is as relevant today as it was when Sir Robert Hutchison wrote it all those years ago.

‘From inability to let well alone
From too much zeal for the new and contempt for what is old
From putting knowledge before wisdom, science before art, and
Cleverness before common sense;
From treating patients as cases;
And from making the cure of the disease more grievous than the
Endurance of the same, Good Lord, deliver us.’ – Sir Robert Hutchison

The “practice” of medicine!

Medical students who finish their last round of undergraduate medical exams face a strange mix of happiness and anxiety. Happiness because they have finished the exam and are now almost certified as doctors, anxious because they don’t feel like they know enough to manage complex cases independently.

Medical students don’t seem to know enough of anything! Anesthesiologists feel that medical students don’t know enough about spinal anesthesia and central lines, Radiologists feel students can’t read an x-ray well enough. Cardiologists feel that students should be reading ECG’s better, Palliative Care feel pain management should be taught better. Why is it that every specialty flat out believes that nothing from their field is being taught in medical school?  Is it fair to say that nothing is being taught in medical schools?

However, this notion cannot be further from the truth. In India, students join for Undergraduate Medical Training in medicine straight after high school via an extremely competitive exam. They are arguably some of the brightest students in the country. MBBS covers the basics of over 19 subjects with more subjects beating on the door to be let in. A fundamental knowledge of Anatomy, Physiology, Bio-Chemistry Pathology, Pharmacology, Pathology, Microbiology, Forensic Medicine, Community Medicine, ENT, Ophthalmology, Internal Medicine, Pediatrics, Obstetrics, Gynecology ,General Surgery, Psychiatry, Orthopedics and Dermatology are covered. (phew…. you skipped the list didn’t you?). That is a LOT of knowledge – in a very short period of time! – Time is a luxury.

Theory classes in medical school are usually designed to spark an interest in students. Classes are ONLY for signposting and what is absolutely essential. The rest is expected to be read by the student in their own time. They are usually free to read any book of their choice.  

Real learning happens in the wards. From second year on, students spend time in the wards. “Shadowing” interns and residents and professors. Learning the basics of collecting a history by talking to the patient, learning to examine a patient, learning to put theory and practice together, make a differential diagnosis and order relevant tests. This is almost a sacred process where skills are passed over from one generation to another. Many clinicians love teaching and passing on their knowledge, many couldn’t care less about teaching. It is variable and depends on how much the student wants to learn and the teacher wants to teach. A good teacher makes all the difference.

The ward is where attitudes and skills are picked up. These interactions at the bedside make the difference between good clinical skills and bookish knowledge. An extension of this practical learning process is internship. Procedural skills – starting IV lines, ascitic taps, conducting deliveries, catheterizations, managing an emergency room, breaking bad news etc. are all learnt by doing. However, it may be difficult to quantify everything learnt in internship. For procedures students sometimes keep a log book but how do you quantify the learning you get after you watch death for the first time?  Break bad news for the first time? Face a mob in casualty for the first time (so common that is quickly becoming a rite of passage)? All these experiences teach so much!

If you are a medical student reading this. – Relax! You have made it so far crossing many tough exams. Keep working hard with honesty. Get your basics right. If your attitude towards your subject and your patient is right your skills will improve. Keep hustling. Mastery will come with time.

The idea of MBBS/undergraduate medical training is to make a physician who is competent with basic skills. You HAVE to meet a minimum standard. You may not be able to solve every problem but you must be able to identify red flags and refer. You may not be able to characterize a cardiac murmur but you MUST be able to identify that it exists and refer! Spend time in the wards. Do as many procedures as you can during internship. Don’t throw away the opportunity to be in the ward to solve MCQ’s. The pressure of the upcoming postgraduate residency entrance exams may be massive but the opportunity to spend time in the wards and rotate through all the specialties is unlikely to ever come again. In the future you may choose to work in one specialty but the broader your overall view is the better it will be when you specialize later.

When in doubt – Call for help! There is NO shame in calling for help.

MBBS certification is not an endpoint in itself. Learning will go on – during residency and further practice and then for rest of our lives – that is why it called “practice” to begin with. Because you keep learning and getting better.