Clinical examination nowadays

The Lancet 

Vol 388, No. 10044 p 559-560  6 August 2016.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31211-9/fulltext?elsca1=etoc

Correspondence

Clinical examination nowadays

Khalid Abdulla MohammedPress enter key to Email the author

DOI: http://dx.doi.org/10.1016/S0140-6736(16)31211-9

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I am a retired physician and teacher. I studied medicine and taught it with a strong emphasis on taking the history of patients and physical examination before diagnosis. I have told my students that in more than half of patients, the history is the main determinant of the diagnosis. With the gradual shift of emphasis towards technology, I now see doctors facing the patient with a laptop in front of them, asking few questions then, with a limited or no physical examination, handing the patient a long list of tests to be done in the laboratory and various imaging facilities. I realise that the information obtained from properly chosen laboratory and imaging tests can be more accurate and more objective than information obtained through interrogation and physical examination. But, the proper choice of tests depends on a good differential diagnosis based on a good history and physical examination. Irrelevant tests are a waste of time and money, place an unnecessary burden on the patient, are a possible cause of side-effects that can sometimes be serious, and a cause of delay to other patients who actually need these tests. Moreover, interpretation of the test results depends on the probability of the condition you are testing for. The predictive value of a test varies with the pre-test probability of the disease, which in turn depends on the information obtained from the history and physical examination.

Moreover, careful questioning and examination strengthens the doctor–patient relationship, builds a patient's confidence in their doctor, and makes them feel that their doctor cares. The importance of doctor–patient communication for a person whose life and wellbeing depend on this relationship cannot be overemphasised.

I declare no competing interests.

Hypertension treatment. What is the target?

The recent publication⁽¹⁾of the results of SPRINT (Systolic Blood Pressure Intervention Trial) was received as an important news. It showed that lowering systolic blood pressure in hypertensive patients to a target of less than 120 mm. Hg. produced better results than the generally recommended target of less than 140 mm. Hg.

(More than 9000 patients who were hypertensive and not diabetic, were randomized into 2 groups: one treated to a target systolic pressure of less than 140 mm. Hg. and the other to a target of less than 120 mm. Hg. After about 3 years, the lower target group had a 25% lower relative risk of the primary composite end point of myocardial infarction, acute coronary syndrome, stroke, acute heart failure, and cardiovascular death. In addition, the lower target group had 27% lower risk of all-cause mortality. However, this group also had higher adverse events such as hypotension, syncope, and acute kidney injury or failure. The trial was stopped by the safety monitoring board before completing its planned 5 year period when the difference between the two groups became obvious.)

Interestingly this represented a move in the opposite direction to the last hypertension guidelines of the Joint National Committee (JNC 8)⁽²⁾ published early 2014, which suggested that the target systolic pressure can be relaxed in people 60 y. old and above to 150 mm. Hg.; a suggestion received with scepticism by many at the time.

Blood pressure is a continuous characteristic in the community with a unimodal distribution curve. There is no clear separation between hypertensive and normotensive people.

(This point was the subject of a well known debate in the forties and fifties of the last century between two British physicians, George W. Pickering who held the idea of a unimodal distribution and thought that primary hypertension represents the pressure of people on the high side of the distribution curve and Robert Plat who claimed that the distribution is bimodal and that primary hypertension is a separate disease entity carried by an autosomal dominant gene. Pickering idea prevailed. It conforms with the present thinking.)

The complications of high blood pressure are the results of the physical effects of blood pressure on the arterial wall and the heart and as such are proportional to the height of blood pressure (correlating more with systolic pressure). They constitute a continuum without cut off points above which complications occur and below which they do not. The lower the pressure, the less are the possible complications. On the other hand lower pressure may impair tissue perfusion and may predispose to thrombosis. The optimum level is that which produces the most benefit and least risk. If going down to 120 mm. Hg. produces a better risk benefit balance then it will be reasonable to make it the target. But one would like this to be confirmed by further studies. The other important point is that every patient is unique and advices based on studies of groups of patients do not necessarily apply to every individual patient. You will have to decide in each patient whether the advantages of further lowering of systolic pressure outweigh the possible risks.

_____________________________

(1) The SPRINT Research Group; A Randomized Trial of Intensive versus Standard Blood Pressure Control; N Engl J Med 2015; 373; 2103-2116.

(2) Report from the panel members appointed to the Eighth Joint National Committee (JNC 8); 2014 Evidence Based Guideline for the Management of High Blood Pressure in Adults; JAMA 2014; 311(5):507-520.

مساعدة أم فضول؟

مساعدة الاخرين شيء جميل وفضيلة محمودة.

ترى شخصا يحاول عملا أو أنجاز مهمة. تقدر ان الامر يصعب على شخص واحد فتعرض المساعدة. يقبلها شاكرا فتعينه في تحقيق ما يريد بالصورة التي يريدها أو تقترح بديلا فيستحسنه وتعينه عليه. يشكرك وتمضي في سبيلك مرتاح الضمير. صورة جميلة لما ينبغي ان يكون.

ولكن هل هي دائما كذلك؟

هناك صورة اخرى.

ترى شخصا يحاول عملا أو أنجاز مهمة. تقدر ان دخولك في الامر مطلوب. تذهب وتساهم في العمل دون اذن. يشكرك ويقول بادب ان الامر سهل عليه ولا يستدعي المساعدة ولكنك لا تأبه بما يقول وتمضي في العمل حسب ما ترتئيه أنت. يعترض بلطف ويبين انه يريد ان ينجز العمل بالصورة التي يرتئيها ولكنك تصر انك تعرف اكثر منه. يتحملك على مضض ويتمنى في قرارة نفسه ان يتخلص من هذه المساعدة!

هناك خط يفصل بين المساعدة وبين التدخل في شؤون الاخرين. ولكن بعض الناس لا يرى هذا الخط!

PSA screening: A public health disaster?!

1. A friend of mine had an elevated PSA (Prostate Specific Antigen) level some years ago. He was naturally worried. He had some prostatic symptoms, so he underwent a transurethral resection of prostate which was found to be negative for cancer. Another friend also had an elevated PSA. After few years of worry and repeated tests he had a needle biopsy of the prostate which was negative. He decided not to do the test again. A third friend, a pathologist, also had an elevated PSA and decided to ignore it. He said too many prostates had been removed unnecessarily because of the test, sometimes with tragic consequences like incontinence and impotence.
2. Dr. Richard Ablin, who discovered the prostate specific antigen in 1970, recently published a book about it titled "The great prostate hoax"⁽¹⁾. In the book and prior to that in an article in the New York Times⁽²⁾ he described screening for prostate cancer using PSA as a "public health disaster"!
3. In a thought provoking interview with Dr. Ablin on Medscape on  August 8, 2014⁽³⁾ he told the story of the test, a story that makes one scratch his head:
1. In 1970 he, an immunologist, was working with two urologists studying freezing prostates (cryosurgery) as a treatment of prostate cancer. They noticed that cryosurgery in animals induced an immune response which increased when freezing was repeated. They also noticed that in some patients with metastasizing prostate cancer who underwent cryosurgery of prostate, metastasis were reduced in size which may have been, they thought, due to antibodies induced by the surgery. Dr. Albin could then isolate the antigen responsible for the immune response. He thought first it was a cancer specific antigen but later realized it was a tissue specific antigen (i.e. prostate specific) and not cancer specific because it was also present in normal prostate tissue and in benign prostatic hypertrophy. He also noticed that in cancer patients its concentration decreased with treatment and increased again with recurrence which makes it suitable for following patients and detecting recurrence. In 1986 the test was approved by the FDA (Food and Drug Administration) as a harbinger of recurrence.
2. In 1989, Schering-Plough Company paid $1.2 million to a marketing firm to promote PSA screening in asymptomatic men to detect prostate cancer. Primary care physicians were brainwashed that they needed to order PSA tests for patients. Many doctors started to use the test, off label, for detecting prostate cancer!
3. In 1994 it was approved by the FDA as a test to detect cancer in spite of the fact that it was pointed out to the group discussing its approval that the test has a false positive rate of 78% i.e. it is wrong in nearly 80% of the time!!
4. The latest statistics show that the annual budget for the National Cancer Institute (of the USA) is about $5.1 billion; of that, approximately $300 million goes for urologic research. Compared to this, every year $3 billion are spent, in the United States on PSA screening in asymptomatic men!⁽³⁾

                                                                                                                                

1. Ablin RJ, Piana R. The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster. New York: Macmillan Publishers; 2014.
2. http://www.nytimes.com/2010/03/10/opinion/10Ablin.html
3. http://www.medscape.com/viewarticle/828854?src=

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.

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.

Using guidelines? Think carefully

1. Guidelines are meant to help the doctor deal with an individual patient but they are based on information obtained from groups of patients. Description of groups has to rely on statistics using averages to describe various characteristics and results.
2. When you apply the results of various medical interventions obtained in a group (frequently in the thousands) to your individual patient, you are presuming that your patient is similar to the patients in the group so that you expect him to respond to the treatment in a similar way to that of the group. But the response of different patients in the group is not the same. You do not know the characteristics of various individuals in the group and how each one responded. What you may know is the averages of their characteristics and the averages of their responses. Those who wrote the guidelines for you based their guidelines on these.
3. The critical question then is whether your patient is sufficiently similar to the average of the group (or the groups) studied so that you can reasonably apply the guidelines to him.
4. This can best be explained by an example. Guidelines on the treatment of non valvular atrial fibrillation using CHAD or CHADS2 score lump together patients with permanent atrial fibrillation and patients with paroxysmal atrial fibrillation. Treating the two types similarly is based on studies that showed similar prognosis regarding their liability to develop strokes. The cause of this is not clear but it may be related to the fact that the patient with paroxysmal fibrillation is more prone to develop a stroke  when fibrillation reverts to sinus rhythm and this may offset his decreased risk when he is in sinus rhythm. The vital question is this: are we justified to treat a patient who has two or three attacks a year each lasting several minutes in the same way as a patient who has daily (or every few days) attacks each lasting many hours because both patients carry the same label of paroxysmal fibrillation?!
5. Applying guidelines to your patient without considering his individual characteristics and circumstances is like a tailor who, when asked to make a suit for an Iraqi man, does not take his measures; instead he makes the suit relying on statistical figures describing the physical characteristics of Iraqi men. If the man happened to be much taller (or shorter) than the average Iraqi, it is just bad luck!
6. This does not mean that we should not use guidelines but that we should take into consideration the individual characteristics and circumstances of the patient we are treating. You should ask yourself whether your patient is sufficiently similar to the average patient with that condition to justify applying the guidelines in his case. If not, you should modify your application of the guidelines according to your judgment of the magnitude of the difference.

No News is Good News

"No news is good news" is not always right.

If you were among the relatives of the passengers of the Malaysian Airlines flight 370 waiting for the daily news conference to update them about the search and rescue operation of the plane that went missing last March and you say "no news is good news" you would likely have been kicked and beaten by the angry crowd.

If you look for a situation in which the proverb is right, you do not need to think long or go far. For years we have been used to the daily news of killing and destruction in our country. When I listen to news bulletins or ask family members or relatives about the news of Iraq and the answer is no news, I breathe a sigh of relief and say "no news isgood news."

Should we combine ACE inhibitors and Angiotensin Receptor Blockers?

1. Theory: The Renin Angiotensin System plays a pivotal role in sodium metabolism and blood pressure regulation. It also affects the function of the endothelium, induces inflammatory changes, growth and fibrosis in various target organs like the heart and the kidney. Its hyperactivity is responsible for many of the deleterious changes in these organs that occur in hypertensive and diabetic patients. Blocking the system should therefore reduce blood pressure and delay the progress of cardiac and renal disease. Blocking can be done at different sites. Direct Renin Inhibitors (DRI) block the action of renin. Angiotensin Converting Enzyme Inhibitors (ACEI) block the transformation of angiotensin I to angiotensin II in the lungs. Angiotensin Receptor Blockers (ARBs) block Angiotensin II (type 1) receptors. Aldosterone antagonists block the action of Aldosterone on target tissues.
   Practice: ACEI, ARBs and Antialdosterone drugs are established hypotensive drugs and have been in use for a long time. ACEI and ARBs have been shown in various studies to delay or prevent the progress of hypertensive and atherosclerotic cardiovascular disease decreasing the incidence of myocardial infarction and heart failure. They have also been shown to delay the progress of chronic kidney disease in diabetic and non diabetic subjects leading to a less rapid rise of serum creatinine and delaying or preventing the onset of dialysis or death from renal failure. These beneficial effects are independent of the effects of these drugs on blood pressure.

2.Theory: Blocking the system in one point results in a feed back response leading to an increase in the production of renin by the kidney and the production of other angiotensin converting enzymes in tissues other than the lung. These changes can result in a significant reduction in the effects of the blocking agents over time. It sounds logical to block the system at more than one point to get a more pronounced inhibition of the system and stop or reduce the rebound increase in angiotensin II with time (angiotensin escape).
Practice: Combining the two drugs has not so far been shown to produce the expected results.

1. In hypertension the combination did not produce a better control of blood pressure than either of the two alone and led to more side effects. The recent American and European hypertension guidelines advised against it.
2. The effect on cardiac disease progress was similar in patients receiving ACEI, ARBs and in patients receiving both. Some studies showed some additional benefit in patients with advanced heart failure receiving the combination.
3. In diabetic and non diabetic patients with chronic kidney disease some studies have shown mild beneficial effects of the combination over the use of monotherapy on the progress of proteinuria but these effects were not translated into beneficial effects on clinical outcomes (rate of rise of serum creatinine, onset of dialysis or death).

In all of these studies side effects (hyperkalemia, decreased GFR) were more in patients receiving the combination.

The issue of combining ACEI and ARBs is still unresolved and awaiting further studies.

Guidelines, calculators and clinical judgement

http://www.iasj.net/iasj?func=fulltext&aId=83477

Hypertension guidelines

In 2003 the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure published its seventh guideline on hypertension (JNC7). The committee had published guidelines on hypertension every four or five years since the seventies. The eighth guideline (JNC8), however, was long delayed.

In June 2013 the ESH/ESC (European Society of Hypertension/European Society of Cardiology) published its guideline on hypertension. In Dec 2013 ASH/ISH (American Society of Hypertension/International Society of Hypertension) published a guideline on hypertension. One day after, members of the Joint National Committee published their long delayed JNC8.

Now we also learn that ASH/AHA/ACC (American society of hypertension/American Heart Association/American College of Cardiology) intend to publish a guideline on hypertension during 2014.

This plethora of guidelines appearing within a short period of time may produce some confusion for the practicing doctor as the various documents agree on points and differ on others.

Agreements and differences:

Some of the main points of agreement and difference are:

1. JNC7 classified blood pressure into: prehypertension, stage 1 and stage 2 hypertension. The new ESH/ECC guideline was more elaborate and classified blood pressure into optimal, normal, grade 1, grade 2 and grade 3 hypertension. JNC8 and the ASH/ISH guidelines did not address the issue.
2. JNC8 guideline increased the treatment threshold (level at which to treat) and treatment target (level you aim at) of blood pressure in adults over 60y of age to 150/90. The other guidelines kept it at 140/90.
3. JNC7 advised a threshold and target of 130/80 for people with diabetes and people with CKD (Chronic Kidney Disease). All new guidelines advised the same figure of 140/90 for these patients as it is for other patients (except in certain specified situations).
4. JNC7 ­­­advised initiation of treatment with a thiazide like diuretic except when there is a compelling reason to choose a drug from one of the other three groups of drugs, namely: ACEI (Angiotensin Converting Enzyme Inhibitors) or ARB (Angiotensin Receptor Blockers), CCB (Calcium Channel Blockers) and Beta Blockers. The new ESH/ESC accepted any of the four groups to start treatment with. JNC8 dropped Beta Blockers from the list and advised to choose any drug from the other three groups. The ASH/ISH advised to start with ACEI or ARB.
5. All new guidelines advised ACEI or ARB in patients with diabetes or CKD.
6. All new guidelines advised against combining ACEI and ARB (because of increased possibility of side effects of these drugs).

So, what will a practicing physician treating a specific patient do in the face of different advices?

He has to remember that guidelines are based on studies done on large number of patients with various characteristics in different countries. They depend on averages of these various characteristics and averages of results. They are not talking specifically about your patient and they cannot include in their calculations all his variables. They are a great help in throwing light on the general picture but do not make decisions for the doctor. What you exactly do with each patient in his specific circumstances will ultimately depend on your clinical judgement assisted by these guidelines.

نظرية المؤامرة

هل قابلت أشخاصا كلما ذكر أمامهم حديث عن ما يجري في دول المنطقة من أحداث جسام قالوا بنبرة الخبير ببواطن الامور: انها مؤامرة امريكية غربية صهيونية؟ واذا حاولت أن تشير الى عوامل اخرى تخص المنطقة وشعوبها، تاريخية وثقافية واقتصادية وغيرها، نظروا اليك نظرة استخفاف وعطف على تفكيرك الساذج الجاهل بخفايا الامور مما يدركونه هم؟؟

ان الانسان يميل الى تفسير الاحداث التي يراها ويعيشها. ويستند التفسير عادة الى ما يتوفر من معلومات. وتفسير الاحداث السياسية، الكبيرة منها خصوصا، يستند الى أمور كثيرة تخص بلدان المنطقة (ثقافتهم ومستواهم الحضاري، أعراقهم، أديانهم وطوائفهم، تاريخهم وما تعكسه أحداثه على حاضرهم، حالتهم الاقتصادية، عاداتهم وتقاليدهم وغيرها) والى أمور تخص الدول المجاورة وامور تخص الدول الكبرى والعالم بأسره.

لكن بعض الناس يعفون انفسهم من عناء التفكير والتحليل ويفسرون كل شيء بانه مؤامرة من قوى خارجية. وهم بذلك يصورون هذه القوى كقوى لها قدرات خارقة ويصورون شعوب المنطقة كاناس بسطاء ليس لهم قدرة على التفكير، لا يملكون أرادة وتقودهم مجموعة من المتآمرين. ويتحدث هؤلاء المتمسكون بنظرية المؤامرة بلهجة الذكي العالم ببواطن الامور الذي ينبهك الى ما انت غافل عنه ويغلق عقله تماما عن كل شيء اخر يخرج عن نظريته في تفسير الحدث.

ان من صفات نظرية المؤامرة التي تستهوي المتمسكين بها:

1. السهولة: بالغاء التفكير المتعمق واراحة الدماغ من عناء التحليل والتفسير فهناك سبب جاهز يلائم كل حدث!
2. الراحة النفسية: بالقاء اللوم على العدو والتنصل من المسؤولية.
3. الظهور بمظهر الذكي الذي يعرف بواطن الامور ولا تنطلي عليه الألاعيب.

قد يحاول بعض منهم ايجاد أدلة على نظريته في المؤامرة ولكنه يبقى محصورا في داخلها ولا يفكر في أية أدلة لا تؤدي اليها. يغض الطرف عما يتوفر من أسباب للحدث واضحة للعيان معروفة للكثير من المفكرين ويبحث عن أدلة غامضة مشكوك في صحتها ومصادرها. انه لا يستعمل الادلة للتوصل الى قناعة وانما هو مقتنع بالفكرة مسبقا ويبحث عن أدلة تسندها! عكس المنطق السليم الذي يصل الى القناعة من الادلة.

لا أنكرأن للمؤامرة دورا في الاحداث وان التامر كان وسيبقى وسيلة من وسائل الصراع بين المتخاصمين والساعين الى بسط النفوذ. ولكن هذا الدور، صغر ام كبر، كان من البداية ام دخل فيما بعد، انما هو عامل مع عوامل اخرى كثيرا ما تفوقه في الاهمية يغفلها المولعون بنظرية المؤامرة ويرفضونها أو يستهينون بها عندما يذكرها الاخرون.

Time the healer

They say "time heals all wounds". Does it?

It certainly heals a lot of wounds, sometimes very efficiently. Grief, anger, hate etc gradually subside and may eventually disappear. At other times scars are left. You stop hating somebody but keep avoiding him. Your grief disappears only to be aroused when memories are brought back.

Problems may be solved by the mere passage of time. A bad neighbour may decide to move away for his own reasons. Financial hardship may be solved by unexpected inheritance or a job coming into your way without you planning for it. The ancient Chinese proverb: "If you sit by the river long enough, the body of your enemy will float by" may sometimes be true but certainly not all the time and not even most of the time.

In spite of the immense healing power of time, it certainly does not heal all wounds. As someone commented sarcastically, "if time heals all wounds, why the hell am I paying for health insurance?" Waiting is prudent in some situations, but action may be needed to solve a problem, improve relations between opponents, ameliorate severe grief or intense anxiety. Actions may be effective, may not be and may even worsen situations. When to wait and when and how to act needs a lot of wisdom which not many people are endowed with.

In medicine:

Many illnesses recover spontaneously. Infections like influenza, sore threat, various diarrhoeas may recover with time merely as a result of the natural defence of the body. Many obscure symptoms come and go without being diagnosed and without treatment.

Diagnosis of an obscure illness may become more obvious with the passage of time hence the well known saying by physicians: "wait and see". Acting too early or interfering too much may bring unnecessary suffering and may itself produce complications. I remember one of my teachers saying during a clinical round: Patients do better the less you interfere with them! His saying was not intended to mean exactly what it says, but rather to stress that decisions to interfere should not be taken lightly and should be restricted to what is necessary and be on a good ground.

On the other hand waiting for time to cure an illness or to help in making a diagnosis carries the risk of development of complications or making a diagnosis too late for treatment to be effective. Decision to wait or to act depends, like all decisions, on weighing the benefits against the risks. This is at the core of good clinical judgment.

لا تصدق كل ما ترى

"لا تصدق كل ما تسمع" قول مألوف. "لا تصدق كل ما ترى" ليس قولا مألوفا فقد أعتاد أكثرالناس أن يحصروا شكهم على السمع ويعتبروا الرؤيا دليلا قاطعا يقولون: رأيت ذلك رأي العين أو رأيته بأم عيني ويقصدون بها عادة رؤيا الواقع التي كانت هي الغالبة. أما الان فان كثيرا من الناس يقضون ساعات من يومهم يحدقون في شاشات التلفزيون والكومبيوتر يشاهدون كما هائلا من الصور وافلام الفديو تنقلها الانترنت والفضائيات ويسهل بالتقنيات الحديثة التلاعب بها وتشويه حقائقها وتضمينها أمورا كاذبة لا وجود لها. كثيرا ما نرى في هذه الافلام أمورا يصعب على العاقل تصديقها يدعي عارضوها انها حقائق. يعمل ذلك احيانا لغايات بريئة واحيانا اكثر لغايات سيئة. علينا الان ان نقول ونكرر: لا تصدق كل ما تسمع ولا تصدق كل ما ترى.

Active passivism

In dealing with patients doctors decide on certain management actions when they judge that the probable benefits outweigh the probable harms. The same is true in life in general. However in some situations the only available course of action that promises significant benefits carries also significant risks of harm that may exceed the benefits. Pure objective thinking may favor avoidance of the action creating a difficult situation in the absence of a good alternative. One is left with the much less satisfactory option of trying to ameliorate symptoms, explain and support psychologically and hope for the best.

A subjective factor is sometimes added to the risk benefit equation. That is the tendency in all of us to do something significant to help. Consequently an action may be attempted (a drug is given or an operation is advised) to satisfy this impulse in spite of the improper balance between possible benefits and harms.

Resisting this tendency in such a situation is not easy and makes one feel and appear passive. This resistance is an active process though it results in an apparently passive stance. I like to call it active passivism!

The same thing occurs outside the field of medicine, in general life. Sometimes you do something not because you are convinced it is the proper thing to do but because you feel you must do something significant and obvious and that other people expect that from you. Abstaining from this is active passivism.

A right answer to a wrong question

“Judge a man by his questions rather than by his answers.” ―Voltaire

“The scientist is not a person who gives the right answers; he's one who asks the right questions.” ―Claude Levi-Strauss.

When I was a medical student, we started studying internal medicine in the fourth college year. This changed later and students started to learn their internal medicine in the third year. A meeting of medical teachers of the various Iraqi medical colleges was arranged one day in Baghdadto discuss which of the two ways is better and whether we should go back to starting in the fourth year. The discussion concentrated on the training of fourth year students and whether having studied medicine in their third year has benefited them. In other words the assembling teachers were trying to answer the question: Are fourth year students better in internal medicine if they have started studying the subject in their third year? The meeting was convened early during the academic year. All attendants agreed that the level of fourth year students is better when they have studied medicine in their third year; an obvious finding that should go without saying! Students who had some training in the previous year should be better than those who are starting afresh. The teachers went on from this to conclude that it is better to start training of internal medicine in the third year. Nobody tried to answer the right question: Are students who start their training in the third year better than those who start in the fourth when they graduate or at least at the end of the fourth year? It is quite possible that during the fourth year (or the years after) students starting in the fourth can catch up with (or even pass) those starting in the third year especially if they have more hours during the fourth year as is usually the case if training starts in the fourth. I pointed out that the meeting was addressing the wrong question but no body seemed to care or to see the difference!

I am not claiming that starting in the fourth year is better than starting in the third or vice versa. The answer to this is to be left to specialists in medical education and should be built on properly designed studies. I only wanted to say that asking the right questionis more important than knowing the right answer of a wrong question.

BASICS OF ACID BASE BALANCE 1

(To our junior colleagues and students)

كاتب عدل مرة أخرى

أذا كنت عزيزي القارئ قد قرأت المقالة السابقة المعنونة "وكالة" فسوف تفهم ما أقول بصورة أوضح وأعمق. أحتجت الى كاتب عدل مرة اخرى ولكني كنت هذه المرة في مدينة اخرى في بلد اخر. دخلت على الانترنت من حاسوبي المحمول في غرفتي وطلبت اسماء كتاب عدول في منطقتي. أجابت الانترنت بعدد من الاسماء مع ارقام هواتفهم وعناوينهم وخارطة اماكنهم. أخترت احد القريبين من سكني وادخلت عنوانه على موقع الانترنت لأحدى وسائط النقل العام فشرح لي الموقع كيفية الوصول اليه: رقم الحافلة ومن اين استقلها واوقات وصولها والفترة التي تستغرقها.. ألخ. ذهبت الى مكتب الكاتب العدل فأستقبلني السكرتير وكنت محظوظا حيث لم يكن لدى الكاتب العدل أحد في ذلك الوقت فدخلت عليه. ألقيت التحية وجلست فرحب بي وسألني بعض الاسئلة عن بلدي من باب المجاملة ثم سأل عن سبب مجيئي فأخبرته أن عندي تعهدا ينبغي أن أوقع عليه أمام كاتب عدل ويصادق عليه. سلمته التعهد فقرأه ثم طلب مني بعد ان تأكد من هويتي أن أوقع في المكان المحدد لي وأخذه وكتب اسمه في المكان المحدد له ووقع وختمه بالختمين الخاصين به وسلمه الي. سلمته المبلغ المطلوب (ولكي أكون عادلا ومتوازنا فان المبلغ اكثر بكثير من المبلغ الرمزي الذي ندفعه في دوائر الكتاب العدول في بلدي). شكرني وشكرته وانصرفت عائدا الى بيتي. لم أجد في الطريق بائع رقي ولم أكن في حاجة اليه!! ولكنني تذكرت معاناة الوكالة التي عملتها عند كاتب عدل في بلدي فابتسمت وقلت لا حول ولا قوة الا بالله.

Measuring blood pressure

(To our junior colleagues and students) 

1. Patient should be comfortable, lying or sitting with the arm supported. Actively holding the arm up by the patient raises blood pressure. The patient should avoid smoking or drinking coffee or tea shortly before measurement as this may raise blood pressure.

2. Mercury sphygmomanometer is reliable. Aneroid sphygmomanometer is reliable if calibrated against a mercury one.

3.   Apply the cuff neatly around the upper arm well above the cubital fossa (to leave a place for the stethoscope). Any of the two arms may be used. However if the pressure is measured for the first time, especially in an elderly patient, it is advisable to measure it in both arms and consider the higher one as the true representation of the patient’s blood pressure. It is not uncommon, especially in elderly people, to get a lower reading in one arm as a result of atherosclerosis in the arteries supplying that arm. Subsequent measurements in such a patient should use the arm with the higher pressure.

4. The arm should be at the same level as the heart. The pressure inside the brachial artery decreases when the arm is raised and increases when it is lowered. The position of the sphygmomanometer is not important because the cuff and the tubing are filled with air and the pressure in a container filled with gas (unlike liquid) is the same at any point regardless of its position.

5. If you find (more often in women) that rolling up the arm clothing will constrict the upper arm and it is not practical to ask the patient to undress, then it is better to apply the cuff over the clothing provided it is not thick. Thin clothing does not significantly impair transmission of pressure from the cuff to the arm or transmission of sound from the arm to the stethoscope.⁽¹⁾

6.  It is advisable to develop the habit of measuring blood pressure by palpation first. It has the following advantages:

a)      It gives an idea about the systolic pressure so that when you take it by auscultation you only raise the pressure to a little above the systolic before starting to deflate. In this way you avoid raising it too high which is painful and may result in a reflex rise of blood pressure.

b)      It avoids the possibility of raising the pressure in the cuff to a point in the silent gap (in patients who have a silent gap) and starting deflation. You will then wrongly consider the reappearance of sounds (phase three Korotkoff sound) as the systolic pressure.

c)       It makes you check the pressure twice which is advisable. The second measurement has been found to be generally lower than the first and more representative of the real.

7.     Apply the stethoscope over the brachial artery in the cubital fossa and avoid inserting it between the cuff and the arm. The hard structure of the stethoscope may interfere with the even distribution of pressure on various points of the arm circumference.

8.  Deflation of the cuff should be slow to give time for the mercury column or the dial pointer to change position as the pressure drops. Too rapid deflation gives a higher reading as a result of inertia of the mercury or the pointer causing it to lag behind the decreasing pressure inside the cuff.

9. Diastolic blood pressure (as measured intra arterially) falls between phase four (sudden muffling) and phase five (complete disappearance) of Korotkoff sounds but nearer the latter. So it is better to take disappearance of sounds as the diastolic pressure except in the occasional case when the sounds persist down to a very low level or zero.

(1) Hovsrpian R.,  Al-Haddad M.,  Abdulla K., Comparison of blood pressure measurements in bare arm, clothed arm and forearm,  J. Fac. Med. Baghdad, 1996, 38, 221-224.

Confidence Interval

(To our junior colleagues and students)

Confidence interval is a statistical term frequently encountered in papers describing various kinds of medical research. It is one of the terms that postgraduate medical students need to know.

The following examples serve to explain it.

If you want to find the mean weight of a group of 30 men, you measure the weight of each one, add the figures and divide by 30. The result is the mean weight of the group.

If you want to find the mean body weight of men residents of a big city, it is not practical to do the same because of the large number involved. Statisticians get around this by taking a random sample of the men in question. They calculate the mean weight of the men in the sample and consider it a satisfactory representation of the required mean of the total. They may take e.g. a thousand men, chosen randomly from various districts of the city, measure the weight of each and then add and divide to find the mean. They consider this representative of the mean body weight of the men of that city. Now imagine yourself to be the person who requested that mean because you wanted to assess the nutrition status of the people in the city and you asked a statistician to do it for you. Imagine also that the mean weight of the thousand men was 60 kg. You may then have the following dialogue with the statistician:

·         Are you sure the figure you gave me is exactly the same as the figure you would have obtained had you taken all the men in the city?

·         No, most probably it is not, but it is very near that figure and is sufficient for your purpose.

·         How near is it? How much is the difference?

·       I cannot tell you the exact difference because I do not know the true figure of all the men in the city. We statisticians usually deal with probabilities. I can tell you the probability of the difference being of a certain magnitude. I can work out from the data of the thousand men a figure we call the Standard Error (SE). In fact I have already done that and found the standard error of the mean of the sample to be 2. We know from statistics laws and rules that the probability of the difference being not more than one standard error (1SE) is approximately 67% and being not more than 2SE approximately 95%. In other words I can tell you that I am practically 95% confident that the true figure of the mean weight of all men in the city is within 2SE above and below the figure of 60 i.e. between 56 and 64 kg. That is what I mean when I say the mean body weight of the sample of men is 60 kg. and its 95% Confidence Interval (CI) is 56 - 64.

The 95% probability (or confidence) becomes approximately 67% if you choose 1SE above and below the mean as the limits of your confidence interval and approximately 99% if you choose 2.5 SE. The 95% (i.e. mean ± 2SE) is commonly used and if the percentage is not written it usually means 95%.

I used the mean as an example to explain the confidence interval. The same applies to other parameters like proportions when samples are used instead of the total.

Evidence based medicine

When I came across the phrase “evidence based medicine” for the first time many years ago, I was somewhat bewildered. Was medicine we had learned in the college and practiced since not based on evidence?! Are there two types of medicine, one evidence based and one not?! Shouldn’t all medicine be evidence based?!

The key to the answer to these questions lies in the word “evidence”. Like almost any word in the language (any language), evidence can mean different things to different people or in different contexts. In the field of medicine, evidence can come through reasoning from known (thought to be known) pathophysiological facts. For example, in heart failure the heart does not pump blood to the tissues efficiently. Digitalis increases the force of myocardial contraction. So digitalis should be useful to patients with heart failure. Evidence can be the result of opinions of experienced doctors who obtained it from their practice. It may come from opinions of patients who expressed their satisfaction or dissatisfaction of a certain medical intervention. Evidence can also come from planned scientific experimentation.

During the last century and especially in the latter half of it, a trend towards examining medical interventions (drugs, surgical operations, diagnostic tests, life style changes etc) in a planned scientific way following the steps of the scientific method appeared and evolved. It aimed at properly evaluating the benefits and harms of various medical interventions. The trend became more powerful with the evolution and increasing use of clinical trials (including controlled clinical trials). Doctors, and increasingly the public, are not any more satisfied with the results of mere reasoning or opinions of experts. Reasoning that an intervention should be useful because it sounds logical according to our knowledge of medical facts is not enough. Our knowledge is not necessarily complete or perfect and usually, if not always, it is not. Opinions of experts and patients can be, and usually are, biased. The intervention should be tried on people under strictly controlled conditions and the results interpreted in a proper scientific way to find out if the intervention is really useful. And even if it is, we should make sure that it has no adverse effects that outweigh its benefits.

Medicine based on this kind of evidence is what is called evidence based medicine. This should not mean that the rest of medicine is not based on evidence but it means that the evidence for it is not satisfactory. The phrase does not express this in a clear unambiguous way. But that is language, however meticulous and careful one tries to be, language remains liable to be interpreted in various ways!

Should we conclude that evidence obtained from properly controlled clinical trials is infallible? Certainly not. We regularly hear of drugs withdrawn from the market and processes abandoned after being properly and scientifically evaluated and after years of use. Nothing in life is infallible.

Why Iraqi doctors should be interested in research

In spite of the various research difficulties described in the previous article (Why Iraqi doctors are not interested in research), Iraqi doctors should, in my opinion, be interested in research for the following reasons:

1.     Answers to local problems:

Local research even if it is a simple survey sheds light and may produce answers to some local problems. It does not have to produce important discoveries on a worldwide scale. After all, among the huge amount of research published in thousands of medical journals worldwide, very few constitute really important discoveries.

2.     Experience for the future:

With time, research experience accumulates and results are likely to improve.

3.     Education:

Research is highly educating. Knowledge is gained by reading and discussing the subject of research and related subjects. The researcher also learns the ways of obtaining knowledge like searching the internet and using the library.

4.     Promotion of scientific and critical thinking:

By following the scientific method of making a hypothesis, collecting data and modifying the hypothesis, research promotes scientific thinking. The researcher learns how scientific knowledge is obtained and realizes that so called scientific facts are in fact hypotheses with various degrees of convincing power. They are not certainties and that is why they keep changing. This develops in him a skeptical and questioning mind which is important not only in research but also in practice and in life in general. Knowing how various workers frequently differ about the same subject is a warning that one should not take everything he reads in a book or a journal or hears in a lecture as established facts.

5.     Reflection on practice

a.     The scientific method is not confined to research. It should be the basis of practice too. In fact the clinician is involved in research daily by trying to make a diagnosis of his patient’s illness and find solutions for his problems. Fever in a patient, for example, is a scientific problem. A hypothesis about its cause should be made after the initial information. Data is then collected through history taking, physical examination and various tests to strengthen or modify the hypothesis once or more times. Actions are then taken on the basis of the final hypothesis. This is what the scientific method is all about.

b.     Awareness of observer error and observer bias, common precautions in research, is reflected on interpretation of clinical findings and various tests made during daily work.

c.      Awareness that association is not necessarily causation, a common precaution in research, reflects on clinical work. Jaundice in a patient with a positive hepatitis virus BsAg is not necessarily caused by hepatitis B virus.

d.     Knowing how reference values are obtained makes interpretation of patients’ figures more intelligent. You may e.g. accept a figure slightly outside the reference range because you know that 5% of normal people are so.

e.      Research improves logic and shows its limitations. Treatment of various illnesses is based on trials done on a number of patients somewhere in the world and the results are generalized to include all patients all over the world (induction in logical terms). Why should your patient behaves in the same way as those patients?! In fact induction is the logical basis of most medical knowledge, not only treatment. One should therefore not be surprised to find so many differences between practice and the book. What should be surprising is the presence of so many similarities!