Medical education is about the patient in all respects. Sir William Osler emphasized that “the student begins with patient, continues with the patient and ends his study with the patient, using books and lectures as tools, as means to an end.” A student should therefore be with the patient, reading the books about the condition of the patient, coming back to the patient for re-examination, discussing with their teachers the condition and the differential diagnosis of that condition, and then going back again to the patient to elicit further details, all the time communicating appropriately with the patient. Hence, it is the patient all the way who occupies the center stage in medical education.
In recent years, more and more instances of case presentations are happening without the patient in the classroom. The pandemic has exacerbated this situation to an extreme level. Most of the postgraduate medical teaching is now scenario-based. A scenario is where an imaginary patient with a name has a few symptoms and signs pre-described. The student presents it as a case without the need for eliciting the signs. This scenario is repeatedly played out in multiple sessions. Such training grooms a set of students who have no skills in eliciting a proper history or conducting a proper examination. Their teachers are unable to interrupt them to demonstrate a sign that the student had failed to elicit or to take a history that was omitted. The students do not perfect the art of correlating the patient’s signs with the symptoms and thereby providing a differential diagnosis. Furthermore, their familiarity with the scenario prevents the development of touch, respect, empathy, and the art of professional communication.
The increased availability of online classes has greatly helped the students to be up to date with the current standards of care. It has also facilitated exposure to different standards of teaching. The negative is that everybody is forced to believe what the student has presented. The online classes must be used by the student as a resource for advancing knowledge, but learning to elicit skills is equally important. A squint case presentation is taken as an example. The student should be well versed in eliciting the primary and secondary deviations and various types of cover tests, including those with the use of prisms and in the forced duction tests. These skills should be demonstrable during the case presentation. Then only the discussion assumes significance. The relevance lies in repeatedly coming back to the patient for examination. I am sure that there will be proponents of a skill laboratory, but the patient must occupy center stage.
Another important malady in patient education is the “no touch.” The pandemic has increased the propensity of no-touch technique of examining the patients, which was already seeping into the examination culture. This, along with the fear in the minds of the teachers of lesser skills in the students causing harm to the patient, has led to students merely observing the patients. One look at the minuscule number of students eliciting corneal sensation during their routine clinical posting is enough to highlight how much of the “no-touch” technique has crept into the system.
This medical training deficiency, that is, the deficiency of clinical skills, now has a name—hyposkillia—coined by Herbert Fred. He says, “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.” High-touch medicine is best exemplified by the “naming and meshing” technique of Nozik in uveitis, which allows us to make a tailor made of investigations to arrive at a diagnosis. In contrast, high-tech medicine goes for a heavy battery of investigations, almost blindly.
The advances in medical technology have invaded every aspect of medical education. Once upon a time, the physician took great pride in the correctness of the localization of a neurological lesion by clinical examination. The plethora of imaging modalities, which are now available, provides information about the exact nature of the condition without going for a detailed clinical examination. However, the thrill of correct diagnosis through the skill of clinical examination cannot be replicated. In another example specific to ophthalmology, the detailed examination of the optic disc is now taking a backseat, and instead, an optical coherence tomography of the retinal nerve fiber layer is being relied upon more and more. It must, however, be remembered that just as eliciting a sign in a patient requires practice, the interpretation of a report is a complex affair, requiring one to shift through a multitude of likely errors, which can be patient- or technician-, or machine-related. Therefore, an improper interpretation of reports can cause increased instances of mental agony and expenditure and at times lead to medical litigation.
Let us take the example of performing a gonioscopy. This skill is both an art and a science. The art lies in patient communication and making the patient comfortable during the procedure, while the science lies in the right settings for the procedure, the technique, and the process. For example, after attaining the right illumination of the room and the right size of the slit beam and the beam not crossing the pupillary area, if the student identifies an open angle, then it is also necessary that the student examines the angle in detail to know the presence of a condition, for example, angle recession. Failure to do so will label the patient as having a primary open-angle glaucoma, especially if other signs of trauma have been missed or are not present. Such a skill can be learned after repeated examining of patients including normal people and both eyes of the patients in a specific sequence, which includes two types of mirror gonioscopy, manipulative gonioscopy and then indentation gonioscopy using a corneal goniolens, and then examining the angle in detail.
There are many factors that have removed the patient from the center stage of medical teaching. Firstly, it is the lack of time due to the increasing duties of the treating doctor. These duties besides being clinical also include administrative and research duties. A significant number of patients do not seek their doctor for their symptoms alone. They need empathy, reassurance, and physical expression of the skills of their doctor. If a patient perceives that the doctor/ophthalmologist is spending more time in the interpretation of a result or on the filling of the electronic medical record on the computer instead of spending time in examining, educating, or reassuring them, then this neglect will be remembered, and they will search for alternative avenues.
The teachers should get out of their comfort zones, go back to the practice of teaching during the rounds and in the classroom, demonstrate patient communication and the importance of patient education about the disease, and create a balance between the patient load, the lack of time, and minimizing costs for the patient yet order relevant investigations while balancing the tendency for litigation for medical negligence. The institutions with lesser patient load can utilize the skill laboratory facilities, while those with a good turnover of patients can utilize the gold mine of patients for the further education of their students. A balance between traditional teaching methods and technological advances must be made. We should stem this rot of “no touch,” hyposkillia, and poor patient communication.
1. Available from:https://en.wikipedia.org/wiki/William_Osler
[Last accessed on 2023 Feb 10].
2. Fred HL, Hyposkilia:Deficiency of clinical skills. Tex Heart Inst J 2005;32:255–7.
3. Verghese A, Treat the Patient, Not the CT Scan Available from:https://www.nytimes.com/2011/02/27/opinion/27verghese.html
[Last accessed on 2023 Feb 10].
4. Honavar SG, Back to the bedside. Indian J Ophthalmol 2019;67:1789–91.