Back to the bedside.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” – so saidWilliam Osler, and I must humbly agree. Sir Osler was one of the four founding professors of Johns Hopkins Hospital.[1] He is credited for creating the first residency program to bring medical students out of the lecture halls and to the bedside for an intensive clinical training.[1] Sir Osler unshakably believed that in a natural method of teaching, “the student begins with the patient, continues with the patient and ends his study with the patient, using books and lectures as tools, as means to an end.”

The fervent power of bedside teaching is that it makes patients and their illnesses tangible, thus helping the student to comprehend the disease in its entirety.[2] History-taking, physical examination, logical reasoning, clinical diagnosis, communication, professionalism, touch, respect, empathy, and most importantly, what it takes and means to be a doctor are best taught, exemplified, role-modeled and learnt in the presence of patients, and not in a conference room or a lecture hall.[3]

In clinical medicine, over half of the patients’ problems can be diagnosed by a comprehensive history and about 75% can be diagnosed with a good physical examination.[456] In a myth-shattering book, “How Doctors Think”, Groopman pinpoints that a doctor interrupts a patient describing symptoms within 18 seconds on an average.[7] In that short time, many doctors, it seems, decide on the likely diagnosis and treatment. In the 1900s, clinical training was predominantly imparted by bedside observation and surgical apprenticeship. About 50 years ago, three-quarters of clinical teaching was still at the bedside[89] that has currently declined to less than 20%.[10] This lopsided exposure to a very critical aspect of training seems to be responsible for suboptimal clinical skills among the present-day physicians.[11]

Bedside examination and teaching seem to have declined for a variety of reasons including increased patient volume,[12] and increased emphasis on electronic medical records (EMR) and investigations.[1314] In a survey of thoracic surgeons conducted in 2015, over 50% responded that lack of time was their major limiting factor to impart bedside teaching.[15] Some physicians fear that bedside teaching compromises patients’ satisfaction with their care, despite evidence to the contrary, whereas others are limited by their own suboptimal bedside teaching skills.[15]

While technology has become an inexorable component of clinical practice, total dependence on technology and using it as a surrogate to a good clinical examination has become a malady of modern medicine. The computer seems to have become an “elephant in the room”.[16] Abraham Verghese, a strong proponent of bedside skills aptly terms the current-day EMR-documented patient an “iPatient”.[1718] He goes on to state that “the iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record”.[1718] Professor Verghese firmly believes that “Patients have deep expectations of a ritual when a doctor sees them, and they are quick to perceive when he or she gives those procedures short shrift.”[1718] Rituals are about transformation, the crossing of a threshold and in the case of the bedside examination, the transformation is the cementing of the doctor-patient relationship, a way of saying “I will see you through this illness. I will be with you through thick and thin.”[1718] Professor Verghese uses the iconic painting, “The Doctor” by Luke Fildes, to exemplify the wholeness and the holiness of bedside presence [Fig. 1].[19] He observes “The gravely ill child is in the center and draws the eye immediately. The doctor, to the left, the table with medicine, and the parents in the shadow to the rear create an atmosphere of vigil and sadness. The father is looking intently at the physician, who is gazing at the child. The mother's anguish is evident from her bent head. In this era of Victorian England, the doctor is not a tradesman but a gentleman master of an art. There are no new-fangled tools of the trade, such as a stethoscope, thermometer, ophthalmoscope in this painting. Nor does the doctor look at any one part of the body. He considers the whole being.”[19] As Dr Verghese nails it, “The importance of an attentive, thoughtful presence at the bedside by the physician cannot be overestimated - one might cure without seeing a patient, but to heal a patient requires presence.”[19]

Figure 1

Artist Sir Luke Fildes, “The Doctor,” oil on canvas, 1891, © Tate, Tate Britain, London, UK, CC-BY-NC-ND 3.0 (Unported), available at https://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522; This painting was inspired by the death of the artist's son and the professional care of Dr Gustavus Murray who treated him. The character and bearing of their doctor throughout the time of their anxiety, made a deep impression on Sir Luke Fildes. Dr. Murray became a symbol of professional devotion which inspired the painting. Professor Verghese interprets the painting as follows: “The gravely ill child is in the center and draws the eye immediately. The soft light shines on the child and the doctor, the two central figures. The doctor, to the left, the table with medicine, and the parents in the shadow to the rear create an atmosphere of vigil and sadness. The father is looking intently at the physician, who is gazing at the child. The mother's anguish is evident from her bent head.”[19]

Unlike many other specialties, Ophthalmology is highly privileged—we have fairly healthy patients who can narrate their history quite well, we can see almost all the parts of the eye and around (unlike chest and abdomen which one can only palpate, percuss and auscultate or image) and come to a clinical diagnosis with relative ease. Teaching in an ophthalmic clinic need not be very elaborate and at the expense of efficiency. In just a few minutes, a good clinical teacher can direct students’ attention to what is important while simultaneously providing clinical care.[3] It is sad that in their enthusiasm for “throughput” and fascination for instrumentation, many of the modern ophthalmologists demand to see the patient only with a topography, specular microscopy, visual fields, ultrasound biomicroscopy, ultrasound B-scan, computed tomography (CT) scan, magnetic resonance imaging, optical coherence tomography (OCT), optical coherence tomography-angiography, or the current fad—multimodal imaging, or all of that, and a clinical impression is often already made before the patient encounter. Even when they see the patient finally, it would be only for a few seconds, that too, concentrating only on the part of the eye that they are “specialized” in. We end up treating topographies, visual fields, OCTs and CT scans, not eyes and not patients. Patients’ primary symptom often remains unaddressed in our enthusiasm to diagnose the “disease” and treat it. It is not too uncommon for a “cataract cowboy” to miss a florid diabetic retinopathy or a melanoma, or a cornea “specialist” to miss glaucoma, or a retina “expert” to look through a corneal ulcer, or an oculoplasty surgeon to miss all of that. Forget about the esoteric “eye being a mirror of systemic diseases”—we have no inclination, interest or time for all that! This changed attitude has slowly but surely percolated into training of our fellows and residents. Conversion of ophthalmology into a day-care specialty with fewer overnight admissions and the use of optometry work force and superficially trained paramedical staff for the so-called “patient work-up” have only made it difficult.

We have ended up training generations of excellent “ophthalmic technicians” but not complete—skillful, analytical and compassionate, ophthalmologists who value and practice ophthalmology with the three “H”s—their hand, head and heart, as Dr Gullapalli N Rao puts it [personal communication], and treat the patient as a whole.

Herbert Fred calls this modern medical training malady hyposkillia—deficiency of clinical skills.[20]“Residency training programs are graduating a growing number of these hyposkilliacs, who cannot take an adequate medical history or perform a reliable physical examination, or critically assess the information they gather, or create a sound management plan; they also have little reasoning power, and communicate poorly. These individuals, however, do become proficient at ordering several tests and procedures—but don’t always know when to order or how to interpret them. They also learn to treat a number or a test result rather than the patient to whom the number or test result pertains.”[20] Contributing to this mindset, incidentally, are the organizations that force physicians to care for maximum number of patients, in minimum time, at the lowest cost.[20] Dr Fred goes on to say, “High-touch medicine is based on a carefully constructed medical history coupled with a pertinent physical examination and critical assessment of the information thus obtained. One then determines which studies, if any, are indicated. And if studies are deemed necessary, the simpler ones are ordered first. In comparison, high-tech medicine essentially bypasses the medical history and physical examination, and, primarily based on the patient's chief complaint, goes directly to a slew of tests.”[20] And the fault, of course, lies with us, the teaching faculty. Why, then, do we allow such deficiencies to develop, persist, and grow?

The wise sayings of Sir Robert Hutchinson seem to ring very loud

From inability to leave well alone;

From too much zeal for what is new and contempt for what is old;

From putting knowledge before wisdom, science before art, cleverness before common sense;

From treating patients as cases; and

From making the cure of a disease more grievous than its endurance,

Good Lord, deliver us.

As we are just about to observe the death centenary of William Osler (12 July 1849–29 December 1919), we should grieve the slow demise of bedside skills and patient-centered teaching and pledge to readily put it back in the place where it rightly belongs—right at the heart and soul of patient care and clinical training of our fellows and residents. We must go back to the bedside and find a sweet spot between traditional teaching methods and technological advances.

“I fervently hope that current teachers of medicine can somehow recapture the Oslerian spirit and strive diligently to restore the very core of doctoring - humanism. Reaching that goal will require teachers with commitment, compassion, candor, and common sense. Teachers who understand and believe that medicine is a calling, not a business. Teachers who can look at, listen to, and talk with patients. Teachers who will work as hard and as long as it takes to ensure patients’ welfare. And teachers who always put patients first.” —Herbert Fred.[20]

Amen.