What I say to medical students and paediatric residents

“A Letter to my Younger Colleagues” is a series of essays written by selected senior Canadian paediatricians, who were named as outstanding mentors by a prominent group of their younger peers. I hope you enjoy and treasure the rich pearls of wisdom that each author offers, based on a lifetime of professional practice and personal reflections. Andrew Lynk MD Assistant Editor, Paediatrics & Child Health Having trained in paediatrics in the late 1950s at a time when subspecialties were just beginning and in gastroenterology before it became procedure intense, I can look back at over half a century of extraordinary progress, which has revolutionized health services and has dramatically improved patients' outcome, quality of life and longevity. Back then, we were literally ‘flying by the seat of our pants’ because technology at the service of medicine and therapeutic options were very limited. Descriptions of diseases and of their varying phenotypic manifestations were exhaustive and have not changed. However, we knew very little of their ‘why’ and ‘how’. Training was focused on how to do the following: use your ears, eyes, nose and hands during patient encounters; develop analytical and intuitive skills; manage uncertainty and ignorance; and transform experience into expertise under the mentorship of exacting clinicians and clinician scientists with encyclopedic knowledge and exceptional clinical skills. The lessons learned and the thoughts generated should not be interpreted as the nostalgic musings of an ‘old fart’. The good old days were not that good after all. Because history and physical examination (H + P) lead to the correct diagnosis in 70% to 90% of cases, it is, by far, the most powerful technology at the service of clinicians and the least expensive. Besides, it is endowed with remarkable therapeutic properties when carried out in an empathic fashion. One wonders why H + P is neglected. There is little in terms of narrative, because problems have become a series of symptoms labelled yes or no. Young trainees are taught to perform physical examinations using an organ-based or system-based sequence. Descriptions of the whole patient, such as his or her attitudes, behaviour, level of understanding, and ability to tell his or her story and respond to questions, constitute a key clinical skill that has been lost. I worry not only about the consequences of the lost art of H + P on clinical decision making, but also about its negative impact on the learning of clinical medicine. Hearing and being part of patients' stories is how learning really occurs, the lasting kind that stays with us forever and on which I continue to build my clinical knowledge. The revival of medical education has not responded to the decline of clinical skills. An announcement at my institution of the purchase of simulators and of sophisticated computer technology was saluted as progress. It is change, but certainly not progress. Let us keep in mind Osler's admonition: “…it is a safe rule to have no teaching without a patient for a text and the best teaching is that taught by the patient himself”. I also lament the ‘buffet style’ and fleeting contact of medical students with patients and faculty, thereby stifling the apprenticeship of productive patient-doctor relationships and of a rewarding participation in care, decision making and patient advocacy. Let me illustrate this with a personal anecdote. During patient rounds on an internal medicine service, a flamboyant cardiac surgeon proposes an operation to a young lady with mitral stenosis secondary to rheumatic fever. The surgeon agrees with her that her physician should be consulted on the matter. When asked who her physician was, she responded, “Dr Roy”, and pointed to the lowly fourth-year medical student at the back of the room. Innovations in technology have greatly contributed to our understanding of diseases and have created new tools for clinical medicine. Their contributions to improved health outcomes have been impressive, but their overuse and misuse are said to be the largest culprit for spiralling health costs. Moreover, it is estimated that one-third of diagnostic technologies are inappropriately used. Furthermore, little effort is made to reassess old technologies that continue to be used and are seldom abandoned in favour of new ones. Technology pulls the wagon of medicine and has greatly contributed to the erosion of clinical skills. This is the era of high-tech medicine, where tests and procedures are no longer ordered to rule in (ie, to confirm a clinical diagnosis) but to rule out a long list of improbable diagnoses. In my own specialty as well as in other procedure-intense subspecialties, it is a shame that the time spent with patients and with trainees is being reduced because of the pressure for procedures. I get particularly incensed with physicians or physicians-to-be who convert people with minor symptoms into patients by a prodigal list of investigative technologies. “Will medicine become a trade?” is now a legitimate question. Curtailing or bypassing history-taking and the physical examination in favour of tests and procedures threatens clinical reasoning, which constitutes the only professional activity that will never be transferable to other health professionals. When I ask trainees why a diagnosis has been missed, the answers commonly are as follows: “I didn't listen enough to the patient's story”; “I forgot to do a rectal”; or “I paid too much attention to a lab result”. With the fragmentation of paediatrics into subspecialties (19 at the most recent count in the United States), students and young physicians often lose sight of the fact that the clinician's responsibility is to treat the sick person, not merely his or her disease. The changing epidemiology of children's health care needs toward chronic diseases and developmental/behavioural problems calls for a patient-centred integrative approach. Managing diseases rather than people and their health problems is no longer an option. Patient-centred care addresses needs, concerns, expectations and cultural differences. It presupposes a solid patient-clinician relationship, assessment of patient's beliefs and understanding of their illness, and the sharing of management options. As Richard Smith, former editor of The Lancet, recently remarked, “Improving the quality of health care is still a minority sport”, patient centredness is not new, but it needs to be resurrected. Information overload, defined as having more information than one can assimilate, hinders decision making and judgement. MEDLINE now adds 12,000 articles to its database per week, including more than 300 reports of randomized trials. I remember the days when the flow of information was controlled and limited. Professors had privileged information, which they could dispense parsimoniously to students. We were contemplating in awe the knowledge base of professors. Learning to fly in a world of information overload is a must to counter the sense of frustration and the anxiety associated with the growth of knowledge in the health sciences. Students, residents and young physicians need to develop information skills just as they need communication and clinical skills. My advice over the years has been to concentrate on ‘information pull’, ie, to seek information to answer specific questions raised by clinical encounters. My message is to build clinical knowledge by reading about your patients. There is a long lag between being a doctor and becoming a doctor. The apprenticeship of clinical medicine is a major source of anxiety, frustration and discouragement among our young trainees. Acquiring and maintaining a current knowledge base is increasingly difficult for clinicians in an era of ‘omics’, creating a trough between basic and clinical sciences. This, in my view, is due to the progressive disappearance of clinician scientists from the wards, the clinics and the clinical departments. Phil Gold, a renowned Canadian researcher and clinician, aptly expressed his concern, which I share, with the question: “Is there a clinician scientist in the clinic? Is there a doctor in the lab?” I have grown more and more aware that success in the practice of medicine and in health research comes not necessarily to the most gifted nor to the most knowledgeable, but to the most dedicated and passionate about a profession that is very demanding but so gratifying. I have never forgotten the Quebec City (Quebec) surgeon who turned down my request for a Saturday morning off with these words: “Roy, if you can live without medicine, medicine does not need you.” I know that times have changed and for the better. Nevertheless, I feel strongly that a commitment limited to professional competence is a dead end. Our society expects reaffirmation of the fundamental and universal values of the profession, such as altruism (putting patients' interests first, advocacy), self-discipline, lifelong education and contribution to the generation, and use of new knowledge. Born and educated in Quebec City, he trained at McGill University (Montreal, Quebec), Harvard University (Cambridge, Massachusetts) and the University of Colorado (Boulder, Colorado) where he started his academic career as a paediatric gastroenterologist in the 1970s before his recruitment at Hôpital Sainte-Justine (Montreal). He greatly contributed to establishing paediatric gastroenterology as a specialty through publication of the first textbook and of more than 400 laboratory-based and clinical research papers. He received many international awards and honorary doctorates. He was made Officer of the Order of Canada in 1990.

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