The Bedside Clinician

With the fast-moving development of newer procedures, and new diagnostic techniques and investigations offering a medical diagnosis, physicians now have a significant amount of advanced technology available to them. We are told that the advent of newer diagnostic techniques is meant to augment medical decision-making, not replace clinical judgment. However, when you give the rationale of a clinical exam and use clinical judgment, it is often responded to with “Where is the evidence?”

Medicine is considered a noble profession, and in its best moments, patients are considered as a vulnerable population and treated with the utmost humanity. Yet today, we have “healthcare providers” and their offices for their “business”. We have healthcare entities thriving because of the “business of medicine” and patients are likewise referred to as “clients”. The corporate industry has turned the practice of medicine into the “healthcare industry” and today’s corporate hospitals make physicians dance like puppets for their livelihoods.

Fear of litigation by one’s own patients has also encouraged the dominance of investigational medicine over clinical medicine. While not all litigation is fraudulent, no broad-based system exists to avoid the trauma of nonsensical litigation on physicians. Medical trainees are frequently told of litigation all throughout their training and that to avoid being sued, they need to order and complete certain diagnostic tests and studies, and/or obtain consultations from multiple specialists, whether clinically indicated or not. This is the defensive aspect of medicine, where physicians choose not to rely upon their own clinical judgment, in large part because they are obviously not protected by law or supported by any agency in general. Yes, there are several organizations for physicians, but these organizations lack the unity and authority to help safeguard their members or take a stand on their behalf.

In today’s era of review-based doctor visits, patients can choose the “best-rated” doctor in the “market”. As a result, patients risk losing out on those clinicians who may not be “best rated”, yet are excellent physicians. These doctors may not hold a “best of” ranking for various reasons: for example, because they do not talk to their patients about their pets, are not dressed in a certain way, or do not look or speak in a certain way. In fact, some of the best-rated doctors may not always utilize their best clinical judgment and rather, do more investigational, defensive medicine. The rating of doctors is based on how they present to patients and should generally be taken with a grain of salt, because patients cannot fully evaluate whether their physician has mastery of the vast science of medicine necessary to help heal patients, which is the most important factor.

There exists a need to preserve the aspects of bedside medicine, as no technology, diagnostic test, or study can replace the impact of a bedside clinician. Of note, it is also quite inexpensive for the patient if a bedside clinical exam and judgment is utilized rather than several technology-based studies, which at times may be unnecessary. Medical trainees need to be taught predominantly clinical aspects of medicine and have its importance emphasized to them, without seeding fear of litigation. No chart will tell a physician more than the patient themselves regarding their diagnostic clues. A vast majority of diagnoses can be made just by clinical exam and history, if done appropriately, and this is indeed the most important evidence-based medicine that we can use. Under no circumstances should a bedside clinician be replaced by any amount of diagnostic studies, which should only be incorporated to support your clinical decision. The clinical judgement that is made after a thorough history and clinical exam incorporating all the chunks of clinical diagnostic information that come to the physician from the patient directly, and also can come from nurses and ancillary personnel involved in direct patient care, is of paramount importance for great clinical acumen. This clinical acumen comes from consistently practicing clinical medicine. Trainees need to sharpen this skill throughout their training in order to better utilize this essential tool for excellent patient care.

Let there be a focus on the clinical aspect of medicine for all medical trainees. Let physicians be empowered to remain focused on the real essence of medicine, which is clinical, and let the noise of multiple distractors not bother them, as there is no other thing like a bedside clinician. 

Disclosures: The authors report no conflicts of interests regarding the content herein.

The authors can be contacted via Pradnya Brijmohan Bhattad, MD, at pradnyabhattad20@gmail.com