TREACHERY OF IMAGES: DECODING THE SIXTH SENSE
Final year, MBBS
Grant Govt. Medical College
“I see dead people!”, whispers Cole Sear to Dr. Malcolm Crowe in the movie ‘The Sixth Sense.” Not unlike the movie, a physicians’ job involves seeing ghosts, struggling at the threshold of life and death, “walking around like regular people, not knowing they’re dead.” Would then one depend on the famed doctors’ intuition, a term used to describe the unconscious, reflexive thinking developed by physicians, a sense of unease that makes physicians seek hospital admissions irrespective of the patient’s presentation, or on the cutting edge technology of evidence based medicine?
What roughly holds the same for most medical consultations? The same approach to the patient, conditioned by years of vivas at the examination table and personal choice. A patient arrives, with an approximate idea of the various symptoms, pains, aches that he/she may have experienced in the past few days, accompanied usually by, but not always, by an overbearing relative. A volley of questions ensues between the doctor and patient, punctuated by infrequent interruptions and not so frequent exaggerations, aimed at making sense of the patient’s unease from a wide variety of pathologies.
Further, the physician figures in the patient’s various physical and demographic parameters, and summarily churns out a response. What exactly went physicians head, and would it not be just as easy to order a summary of diagnostic tests and pray for a divine sign?
“Technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty”, is a quote often associated with the professors of Stanford Medical School, highlighting the unease amongst even physicians to jump into the rabbit hole of evidence based pure data, regardless of considerations of logic.
Holmes, the eponymous hero of Arthur Conan Doyle novels, is said to have remarked about a particular feat of logic by simply stating, “From long habit the train of thoughts ran so swiftly through my mind that I arrived at the conclusion without being conscious.” Arthur Conan Doyle himself, a physician, likened the work of a doctor to that of a detective, eliciting an illness from a set of mystery diagnoses.
The medical world, for all its idealism, suffers from basic deficits at the logistical level, with doctors facing prohibitive cost considerations, ethical dilemmas stemming from subjecting the patients to a wide variety of probing, and the struggles of finding the right resources at the right place at the right time. In this regard, the reflexive intuitiveness spoken about earlier plays an important rule in distilling further treatment regimes.
Recently, at a student conference, I had the privilege of presenting a rare case on behalf of my hospital’s department. A young male patient, presenting with complaints of reddish discoloration of urine and impending renal failure, with pallor, was classified as haemolytic anaemia secondary to an infectious cause, a finding extremely common in a country like India. However, further analysis of the case in the view of negative serum titres for most infections pointed to a more insidious and poorly understood autoimmune cause, with the diagnosis clinched with atypical haemolytic uremic syndrome. The fascinating part, in the whole discussion, lay in the fact that the particular syndrome may have a set of varying aetiologies, itself overlaps in signs and symptoms with different syndromes, and is a death sentence in due to the expenses incurred in the drug regime, deemed to be the most expensive medical management in the world. Further, confirmatory diagnosis is near impossible, hinging on the non-availability of specific tests or their non-feasibility. The patient, managed symptomatically, lived to tell the tale.
At the same conference, a colleague of mine presented a slightly different case with a radically different moral. Initially diagnosed as a textbook case of aseptic meningitis, a young patient was later classified as a case of SLE vasculitis, not on virtue of the clinical presentation, which was highly atypical, but by the wonders of a MR angiogram.
Two cases, yet two different viewpoints. The first, demonstrating the beauty of an intuitive, reflexive, unconscious thinking pattern that does not rely on set regimes, the latter demonstrating how technological interventions have radically altered and improved on our typical presentations and diagnoses.
When doctors admit patients in defiance of strict guidelines, defying the eagle eye of insurance companies set to impose cost cutting algorithms, they often are regarded as a source of mirth. Admitting the patients when their physical findings and inconsistent with complaints, or when the patient is seen to be stoically at peace, may in itself be considered less of an intuition and more pattern recognition. However, in the same breath arguments from the other side of the fence deem evidence-based medicine as big interpretations out of clinically insignificant data, yet ignoring recently developed guidelines which exhort the importance of small changes. For example, keeping the blood pressure in tight control instead of telling the patient it’s a ‘little high’ makes the life and death difference between getting and not getting a stroke.
Ultimately, the modern physician treads on a tight rope. In a future that will get more “evidence based” as the years progress, society needs to find a way to put the art back in medicine and reverse the onset of mechanized assembly lines. Educational attempts, especially at the psychological level, aimed at decoding the mystery art of intuition may ultimately be the solution.