1. PHILIP JOHN, M. D. PEEJAYS CHILD GUIDANCE CLINIC COCHIN, INDIA www.peejays.in DOCTORS’ DAY ORATION : JULY 1 st, 2012 CUTTING-EDGE TOOL IN MEDICINE: THE CLINICIAN’S HAND

2. A highly respected Physician, C.M of W. Bengal for 14 years. Alumnus of the Medical College, Calcutta. Completed both F.R.C.S. and M.R.C.P. simultaneously in two years National Doctors’ Day is celebrated on July 1 date of his birth, death. HOMAGE Bidhan Chandra Roy, (1 July 1882 – 1 July 1962) TRIBUTE Dr. Abraham Vargheses DOCTORS’ DAY ORATION : JULY 1 st, 2012

3. Mind is generated by the Brain. Psychiatry is the Application of Basic Neurosciences to man’s day-to-day problems. Psychiatry is a Branch of Medicine. Psychiatric Disorders are Physical Disorders. Psychiatrists are primarily Physicians. NEW SCIENCE OF MIND THE CLINICIAN’S HAND

4. CUTTING - EDGE TOOL IN MEDICINE: THE CLINICIAN’S HAND Surgeon Joseph Bruner "Fetal Hand Grasp"“Reassuring Hand Grasp” Any Physician like us Hand of HopeGift of Life

5. THE CLINICIAN’S HAND The clinician’s cutting-edge tool : THE HUMAN HAND Quarter of motor cortex in human Brain devoted to Hand. Homunculus: hand in the brain. Hand is a Cognitive Organ, working in coherence with the brain’s Frontal Lobe.

6. THE CLINICIAN’S HAND Cutting edge tool : rough tasks like pelting to delicate micro-precision, like a surgeon’s. And Language… Thus, hands useless without the Mind in the Brain. Hand, a perfect functional Tool, when applying the Mind. A functional Hand can accomplish tasks impossible even for advanced robots. And for more – Hands to Touch, thereby, to Talk. The clinician’s cutting-edge tool : THE HUMAN HAND

7. THE CLINICIAN’S HAND Hand and Mind together : Touch Touch to Connect Touch to Comprehend Touch to Diagnose Touch to Reassure and Touch to Heal… The clinician’s cutting-edge tool : THE HUMAN HAND

8. THE CLINICIAN’S HAND MIRACLE OF THE HUMAN HAND The only Diagnostic technology till recently was this Human Hand ! Even today, the most powerful comprehensive tool in the Doctors’ arsenal. Hands need the Head to Diagnose. And the Hands and Mind to Heal – ‘the Miracle’. Hands, therefore, must become the Culture of Medicine.

9. THE CLINICIAN’S HAND MIRACLE OF THE HUMAN HAND TOUCH : TO DIAGNOSE, COMFORT AND TO HEAL

10. THE CLINICIAN’S HAND HANDS AND THE MIRACLE TOUCH Determine quality of Doctor-Patient interaction. The Clinical Touch that examines, undergoes ‘Parivarthan’ – to progress to a Reassuring Touch. If thus optimal Rapport builds up, it results in Interpersonal Trust. Trust enough that helps the patient to instantly confide his secrets and even to disrobe himself ! Each of us Clinicians is keenly aware of this ‘Healing Energy’. This is the Healing Hand, the Healing Touch.

11. THE CLINICIAN’S HAND Hands : The Heart of ‘Doctor-Patient’ Relationship Bygone Clinical Era - spontaneously connected these two. Presently, Physical Examination and Clinical Diagnosis is “Dying Art”. Scoffed at. Old-generation Physicians shudder if examination-skills atrophy and die. And the younger ones these days look at P/E as an archaic curiosity ! In this process of decay, the Doctor-Patient Relationship has been the casualty. In a true Doctor-Patient relationship, Physical Examination must not be compromised. It is a powerful tool not for Diagnosis, but also for Relationship

12. THE CLINICIAN’S HAND MEDICINE & TECHNOLOGY ‘Victory of Technology upon Wisdom’ Medicine as Science – exponential growth. Information (overload) and Knowledge. Knowledge may not have ‘Wisdom’ ( eg: internet ). ‘Scientific Paradox’ : reductionism ( eg: chest pain: “thonnal”) ‘Victory of Technology upon Wisdom’. Medical gizmos and gadgetry have sunk the ‘Art of Medicine’ and the ‘Trust of Patient’. Current trends : Practice of Medicine has lost the ‘Human Face’. Patient ‘care’ often without ‘caring’ (Prof. Gilvaz). Without the old bonding.

13. THE CLINICIAN’S HAND MEDICINE : ART OR SCIENCE ? Fulfillment in Clinical Medicine used to be proving your intelligent guess ‘right’ - by the outcome. Medicine always was known as the tricky ‘Art of Conclusions on Insufficient Evidence’. Therefore, William Osler wisely named Medicine “the Science of Uncertainty, and Art of Probability”. The balance between the Art of the Right Brain and the Science of the Left Brain. A good Clinician is this balanced combination, and the Clinician’s Hand, the successful delivery tool – to Diagnose and to Heal. (cabg)

14. THE CLINICIAN’S HAND DEMISE OF CLINICAL DIAGNOSIS The restoration of that most powerful and cutting- edge technology of the ‘Human Hand connected to its Brain’ can resurrect the balance between Art and Science. Technology in Diagnosis and Intervention may have permitted a perfect ‘Diagnosis from a Distance’, bereft of Empathy from the Doctor, and of Trust from the Patient. Lack of Clinical Diagnosis can also precipitate the overlooking of simple diagnoses, and send the patient on investigation trips. Harrison’s TBM : “no examination of the chest is complete for chest pain……”

15. THE CLINICIAN’S HAND DEMISE OF CLINICAL DIAGNOSIS i) Patient from USA: Diagnosed with CA Prostate. On Tesla 3 MR Spectroscopy, high choline and low citrate levels suggesting CA. Diagnosis from a Distance, and the resultant angst ! Simple PR exam by Urologist here unremarkable; and biopsy normal. ii) Mr. V, 74 yrs. Father of a Physician. Investigated extensively with imaging, for Depression. Referred for opinion. Glabelllar tap +. Thumb fingers bradykinesia. Clearcut Parky..

16. THE CLINICIAN’S HAND Compelling need to restore Clinical Diagnoses. An MRI or CT cannot detect Cerebral Palsy. And computer-generated Questionnaires cannot diagnose Autism! Technology cannot replace Physical Examination and a resultant Doctor-Patient relationship. ‘Get up from the chair’ - to touch the patient for Physical Examination and Therapeutic Relationship. DEMISE OF CLINICAL DIAGNOSIS

17. THE CLINICIAN’S HAND RETURN TO THE PHYSICAL EXAMINATION The writings of Dr Abraham Varghese, Professor at Stanford, and Dr. Sandeep Jauher in NEJM. Dr. AV developed the ‘Stanford 25 Initiative’ to showcase and teach 25 fundamental P/E skills for Diagnostic & Therapeutic benefits. Evidence, that Physicians lack P/E- skills (Jauhar, 2006). P/E maneuvers have as much Sensitivity and Specificity as investigations in the final diagnostic round. P/E enhance skills and opportunities to strengthen Clinical Outcome in practice (Janicik). Most importantly, learning Humanism and sanctified Professionalism at the bedside.

18. THE CLINICIAN’S HAND PHYSICAL EXAMINATION: A RITUAL Dr. AV (Stanford) jokes that the current breed of Physicians need a scan to locate a limb missing, because they shortchange the physical examination! For my generation, P/E has been a RITUAL. Inspection yields awesome information which NO investigation can replace. Palpation and Percussion in bedside medicine generate Relationship too. The Stethoscope still best symbolises my practice of medicine. The passion for my Profession is when I find the thrill in the ‘Investigation-results agreeing with my P/E diagnosis’ !

19. THE CLINICIAN’S HAND PHYSICAL EXAMINATION: THE RITUAL History-taking and P/E establish Therapeutic Relationship; thus the Physician earning many rights with the patient. Something sanctified occurs in this exchange. That is the RITUAL, like a Prayer. THE CONNECT. That instantly enables the patient to confide, to disrobe, to swallow your chemicals, to allow anesthesia. It is incredible! P/E and the relationship kindle the patient’s Hope and Faith. Even when your ‘Science’ fails, the ‘Art’ of Medicine makes the caring Physician walk with the patient till the end. Kindling his Faith: “I will always be there with you; I will never abandon you. I will be with you through the end.”

20. THE CLINICIAN’S HAND NOW, OUR SIDE : DOCTORS AS TARGETS ALL ABOUT RIGHTS. NO RESPONSIBILITIES! The NGOism sweeping from the West has become a fad for the media and some policy-makers. For them, it is all about ‘Rights’. Many of these ‘Rights’ are one-sided. The soft-target Physician, of course, has “no rights”, only responsibilities. So, he can even be attacked ! Patients are not usually the litigants. We know the instigators.. Local vested interests, certain one-sided journalists, aggrandising relatives.. All of which make us do ‘Defensive Practice’. Nevertheless, ‘Trust’ may withhold even ‘litigants’.

21. THE CLINICIAN’S HAND NGOism has thus now led to this emphasis on “Patient-Doctor Interface” ! Not P/E.. (Educating, and talking to the Patient and the Family !) NGOs advise - “get your doctor to spend time with you – ie. talking !” Therefore, there is compulsion for us to short-cut P/E and ‘blindly investigate’, in order to ‘bluntly talk’ to them about our confident findings! DOCTORS AS TARGETS

22. THE CLINICIAN’S HAND DOCTORS AS TARGETS ‘Evidence based Medicine’ is another fad… ‘Research’ studies that are either not understood, or manipulated to ‘score’ above your experience. So, litigants may not spare you now, even if you used your ‘experience and good faith’. And,society and the media seem to find the worst in us to make all of us appear as cut throats. Even the “reality-shows” would concentrate only on that other side…

23. THE CLINICIAN’S HAND PHYSICIANS AS TARGETS OF PHYSICIANS Listen to our own colleagues : “How could he have missed this..”, “this should never have been done”, “if only you had come early…” etc. We know, we all have to together curb these tendencies of one-upmanship. Specialists function as ‘water-tight-compartments’, and do not communicate with each other, but mis-communicate to the patient and his relative. Lack of inter - specialty communication gets both Physicians and Modern Medicine into trouble.

24. THE CLINICIAN’S HAND “NOBLE” PROFESSION If it comes to the ‘rights’ of the poor Physician, or to his ‘reward’, suddenly everyone goes.... “the noble” profession should not do this! Other than teachers, Medicine is the only profession which Society need not have gratitude for, and need not remunerate. “Noble.. The Society needs to start looking at this differently- our media to judges to political leaders. Governments, politicians allow Crores to pass hands for a medical seat - consciously. But the Doctors who pass paying those crores are expected to do Social Service !

25. THE CLINICIAN’S HAND CURRENT SAD STATE Entrances, Admissions, even Examinations have become playing grounds of disproportionate money. To pay back loans and keep up a decent life-style, what is the Physician expected to do ? Why are our younger doctors training to become procedure-oriented Specialists, and not GPs or Physicians? The Society does not reward us Physicians for their Listening to, or Examining the patients. There is no reward for a smart Diagnosis or a Medical-treatment or a healthy Outcome……

26. THE CLINICIAN’S HAND CURRENT STATE On the other hand, income can be indiscriminately generated by a procedure, or through blind, investigation-based medicine. This social system too needs change where “Clinical Diagnosis, Physical Examination and a Medical Outcome are equally rewarded” professionally. This will also reduce Health costs for everyone, and Physicians who do not investigate disproportionately too will earn a decent income. And the cutting edge tool - the ‘Clinicians Hand’ - may recoup a decent place in our Profession.

27. THE CLINICIAN’S HAND THEREFORE, ON THIS DOCTORS DAY… As Trousseau, the French Physician implored – “ For mercy’s sake gentlemen, let us have a little less SCIENCE and a little more ART.” - using the cutting-edge tool in medicine that we now deliberated on.

28. Thank you