Saturday, July 31, 2010

Medical practice: Is the textbook always right?

Most practicing doctors in developing countries feel the gap between their practice and the book. They usually regard what is in the book as the correct thing and anything short of or different as incorrect or inferior. Textbooks are usually written by doctors working in highly advanced institutions in developed countries, which frequently provide tertiary care. The situation in most hospitals and clinics in developing countries is quite different.
The aim of the doctor is to do what is in the best interest of his patients in the environment he or she is working in. This should be the yardstick by which a certain behavior is judged as right or wrong. What is an appropriate decision in one place may be inappropriate in another. Sticking to the book is not always the proper behavior. Here are examples of this at various stages of the relationship between doctor and patient.

Physical Examination
Examining women is a special problem in our community when the examiner is a man. They frequently resist exposing parts of their body. Some may request to be examined with their clothes on. The doctor has then two choices. One is to refer the patient to a female doctor. The patient frequently does not like that either because she trusts the doctor she has come to and wants to be treated by him or because of the inconvenience of having to go to a different place and have another appointment. The second choice is to do what the patient wants and examine her with clothes on.
The doctor has to judge whether such an examination is acceptable in the circumstances. Examining the abdomen for example with a thin internal cloth on does not interfere significantly with palpation, percussion or auscultation but it interferes with inspection. In some cases, it may be reasonable to assume that this is unlikely to affect your judgment and doing it should not be considered wrong. Taking blood pressure with a thin sleeve on usually does not interfere significantly with measurement(1) and doing it to a patient who wears a sleeve that cannot be rolled up is another example.

Many tests done in our laboratories are not as accurate as they are in the place of the writer of the chapter in the book. The values given to them in the book in the form of sensitivity, specificity, predictive values and likelihood ratios may be quite different from the values they have in our actual practice. Their weight in the diagnostic and management process may consequently be considerably less than the weight given to them in the book. In other words, their value compared to the information obtained by history taking and physical examination may be considerably less than what is stated in the book. This should always be kept in mind in making a final judgment on diagnosis and management. It should also reflects on the decision to do the test in certain situations when the probability of a diagnosis or a management action built on clinical criteria (pretest odds) is high and the likelihood of it being affected by the test result is low. For example, if you have a very strong suspicion of typhoid fever on clinical grounds and the reliability of your laboratory is questionable, it may be prudent to treat the patient without wasting time and money by asking for a Widal test.

A certain treatment, especially complicated procedures, is advised when it is judged that its possible benefits outweigh its possible harms for the patient concerned. Consequently, it should be judged according to the situation in the place of practice. It should not follow the instructions of the book blindly. Those who write book chapters usually work, as stated earlier, in advanced institutions with higher expertise and better facilities. The results of various therapeutic procedures and their complications are not the same as they are in less developed places. Consequently, the balance between benefits and risks is different. So, a treatment, which according to the book is indicated in a particular situation, may not be indicated for the same situation in the place one is working in. Dialysis is an example. In a place where maintenance dialysis is good with few complications and a reasonable quality of life of patients, one may advice patients with chronic renal failure to go on maintenance dialysis when their creatinine clearance comes down to 10m./min. One would expect their life on dialysis to be better than it is without it and their long-term prognosis better. In another place where the quality of maintenance dialysis is poor and complications are many, one tend to wait longer until the patient's condition becomes severe enough so that their life on dialysis in spite of its poor quality and frequent complications represents an improvement on their life without it. The policy may then be to wait until creatinine clearance comes down to 5 ml/min. before putting the patient on maintenance dialysis as it is indeed the case in less developed parts of the world(2).

I. Hoysrpian R, AI-Haddad M, and Abdulla K: Comparison of blood pressure measurements in bare arm, clothed arm and forearm. J Fac Med Baghdad, 1996; 38: 221-4.
2. Swyter J: International ESRD experience: An anthropological perspective. Dialysis and Transplantation, 1985; 14: 328-38.


  1. As you ever been Sir, brilliant.
    What you had mentioned about the textbook, was describing our situation during my Arab Board fellowship 1998-2002. However many textbooks were fair enough to mention 2 or 3 points of view toward a diagnosis and/or management dilemma.
    Nowadays, medical students, post graduate fellows and practicing physician, facing the arising concept of applying and following Guidelines published by the international bodies, which are more unified and sharp in decision making, and many times difficult to be applied literary. Any deviation in applying them, may be perceived as mal-practice which may lead to disciplinary action against the practitioner.
    These guidelines were basically meant to reduce the gap between the intelligent physician and the average one, by helping the average to behave just like the intelligent, but they should not oblige the intelligent to behave in an average manner?


    Ahmed Mohammed Ali Kadhim
    fellow - arab board of internal medicine 1998-2002, Al Kadhymia Hospital.

  2. Yes Ahmed, guidelines are indeed very helpful but they are also subject to the effects of varying local practice factors. Thank you very much for the comment.