Monday, August 25, 2014

The side room laboratory

 When I was a final year medical student, many years ago, we used to have a side room laboratory in every medical ward. It was the job of the final year student to do the simple laboratory tests needed by the patients like urinalysis, stool exam, blood counts etc. We used to spend a considerable time in that laboratory which also served as our meeting place to discuss medical issues and also chat about various subjects. When I became a resident doctor I also used to spend a significant time during afternoons and nights in the side room laboratory doing simple tests that were needed by newly admitted patients. That was part of the job of the resident doctor. Even in my membership examination in London, when I was given my long case I was shown the side room laboratory and asked to do, if I want to, whatever test I thought useful in reaching a diagnosis. When I was training in kidney disease, they used to say: a good nephrologist is one who looks at the urine himself.
Things gradually changed. By the time I was on the teaching staff, medical students were relieved from this duty although some hospitals retained a simple side room laboratory used by the occasional keen student or resident. These also gradually disappeared. All tests came to be sent to the general laboratory of the hospital.

Was that a change for the better?
If you are working in a place where a reliable laboratory is available and easy to reach all the time, then clinicians probably do not need to involve themselves in doing laboratory tests. That will save them more time to spend with their patients. Laboratory people are also more skilled and experienced in laboratory work and their results should be more reliable.
But, do all clinicians work in such convenient circumstances?
Many do not, especially in less developed countries. For these, some simple laboratory tests done on the patient's bedside or in a small side room laboratory can be immensely useful. Examining the urine can be done in minutes in the presence of dipsticks that test for various chemicals like protein, sugar, ketones, hemoglobin, bilirubin, urinobilingen etc. Vital information about the state of the urinary system and the whole body can then be obtained. Looking at a urine drop under the microscope searching for various cells gives important information about the urinary system. Seeing bacteria swimming in that drop may be more reliable in diagnosing urinary infection  than a urine culture done by a laboratory of a questionable quality. It also gives a rough idea about the number of bacteria (knowing that one bacterium in a high power field corresponds roughly to 30,000 bacteria in a milliliter of the urine sample). Looking at a drop of cerebrospinal fluid under the microscope in the middle of the night when the hospital laboratory is not open yet, can be sufficient to start treatment of meningitis and probably save life. Many more examples can be cited.

Clinicians' performance of simple laboratory tests still has a place in medical practice and medical education especially in less developed countries.

Wednesday, August 20, 2014

نقاش بلا صراع

ما الهدف من الدخول في نقاش؟
الهدف الامثل هو تبادل الرأي للوصول الى الحقيقة او الى افضل الطرق لحل مشكلة او خلاف. في احيان اخرى يكون الهدف هو الترويج لراي واثبات انه الراي الصحيح وان الراي الاخر خطأ وهو ما نراه في المناقشات التي تجرى في وسائل الاعلام في السياسة على وجه الخصوص ولا يكون الامر تبادلا للرأي وانما صراع يسعى كل طرف ان يكون الفائز فيه. ما يعنيني هنا هو النوع الاول الذي يبدؤه المتناقشون بقصد تبادل الراي والوصول الى الحقيقة ولكنه قد يتحول الى صراع يطلب فيه كل طرف الفوز على الطرف الثاني.  كل طرف له رأي مسبق يصبح هدفه الدفاع عنه وليس الوصول الى الحقيقة. سلاحه في ذلك الكلام ولذا يحاول ان يتكلم اكثر الوقت وكثيرا ما نرى المتناقشين كلهم يتكلمون ولا احد يستمع واذا اضطر الى الاستماع فانما يستمع ليرد وليس ليفهم  (على حد قول الكاتب الامريكي ستيفن كوفي) وكثيرا ما تدخل العاطفة والحماس وتطغى على الفكر والتدبر. تختلف قوة عنصر الصراع باختلاف مستوى المتناقشين وتقل كلما زادت ثقافتهم وتحضرهم ونضجهم الفكري.

ان نجاح النقاش يعتمد الى حد كبير على نزع عنصر الصراع منه. وذلك باحترام راي الطرف المقابل وتجنب وصمه بالخطأ وابداء الراي بهدوء وتواضع وعدم الالحاح في الجدل منتظرا ان يرفع الطرف الاخر الراية البيضاء ويسلم بانك على حق فانك حتى لو كنت فعلا على حق فان تغيير الراي كثيرا ما يحتاج الى وقت فاترك المقابل ليتمعن مع نفسه في ما قلت له. واذا لم تتوصلوا الى اتفاق ثم حدث ما يدلل على انك كنت على حق فلا تظهر بمظهر المنتصر المنتشي بانتصاره وتذكره بما قلت له فان مثل هذا قد يدفعه على الاصرار على رأيه حتى مع اقتناعه بخطئه حفاظا على كرامته.