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Clinicopathological conferences: The fading art of playing Sherlock Holmes
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_83_17
Sir, “When you have eliminated the impossible, Whatever remains, however improbable, must be the truth” …Sherlock Holmes The thrill of deductive analysis in clinical problem solving and unraveling the deep mystery of a diagnosis, beats most pleasures of life. Professor Ashru Banerjee's passionate and poignant piece [1] on clinicopathological conferences (CPCs) in academic institutes, struck a melodious chord in our hearts. The dying art of an unbiased analysis of evidence in clinical practice, amidst a din of sophisticated investigations, is a worrying phenomenon. Hence, we aimed to evaluate,
Evolution of clinicopathological conferences Medical science has drawn problem-solving lessons from many deductive sciences such as the practice of law.[2],[3] While most scientific lessons in medicine are learned from pattern recognition in large case series, legal sciences assign significant importance to singular landmark cases and judgments. The origin of CPCs lies in the inspiration derived by Walter B. Cannon [Figure 1], a renowned Harvard physiologist when he shared a room with his friend, a law student.[2],[4] These views were also expressed by Cannon in the Boston Medical and Scientific Journal, the present day New England Journal of Medicine. In Cannon's own words “the current 4 hours of continuous lecturing on various diseases from 2 to 6 o'clock, 5 days a week is a dreary and benumbing process” andthe “study of case histories have been shown to arouse great enthusiasm and excitement among students.”
Richard Cabot [Figure 2], a famed internist, in his book on the history of Massachusetts General Hospital in 1939reminisced about his practice of private quiz sessions of interesting cases since 1895. In 1910, he initiated CPCs, emphasizing on case studies and confirmation of a diagnosis by autopsy.[2],[5] Since 1924, CPCs have been published regularly in the New England Journal of Medicine as Case Records of the Massachusetts General Hospital. Thus, the origin of CPCs lies in the concept of encouraging case-based learning wherein factual knowledge finds practical application. However surprisingly, the Oslerian school of medical teaching did not confer much relevance to CPCs.[3]
Anatomy of a Clinicopathological Conference Pertinence, solvability, and discussability are the key elements that sustain an exciting CPC.[6] Most clinical medicine works on a problem-based learning approach. The scenario posed by the sick patient makes us to recognize familiar patterns (such as a motor cortex structural lesion or a hemicord syndrome). Further, we construct a differential diagnosis based on this familiar pattern, our experience, and knowledge. The key elements in a traditionally styled CPC include,[4],[5],[6]
Contemporary status of clinicopathological conferences We undertook an informal survey amongneurosurgery, neurology, and neuroanaesthesiaresidents regarding the relevance of CPCs in their postgraduate training. Among 30 residents surveyed, 2 had never attended a CPC and 16 were trained earlier in institutes that had no regular CPC program. Very few institutes were noted to have a regular CPC culture that brought together several departments for a lively discussion. Heudebert and McKinney,[2] in a review of CPC practices in 278 institutions having internal medicine training programmes in the US, noted that 80% of the institutes surveyed had CPCs as a regular practice. The number of CPCs scheduled varied substantially across institutions from 2 per year to almost 2 per week. Often, academic meets and conferences also include exciting CPCs to add flavor to their academic content. The Neurological Society of India (NSI) and the Indian Academy of Neurology (IAN) have started the convention of having a CPC as part of their Annual Conference proceedings to revive this dying science. Local societies such as the Bangalore Neurological Society (BNS) have been religiously continuing the tradition of a CPC every December on the first Saturday spearheaded by the Department of Neuropathology, NIMHANS, which continues to be attended with great enthusiasm by neurologists, neurosurgeons, and neuroradiologists, as well as other allied neuroscientists. We recollect an intriguing and illuminating routine academic CPC/Clinical grand round at AIIMS, Delhi, several years ago that emphasized the need for a holistic and out-of-the-box thinking for each clinical scenario. The case involved a young lady presenting to the general surgery casualty with features of subacute intestinal obstruction. A detailed evaluation by the general surgery resident did not miss an additional subtle lower limb weakness, which prompted a neurology consultation. Further evaluation and symptom progression confirmed a diagnosis of Guillain–Barré syndrome causing subacute intestinal obstruction due to autonomic neuropathy. Prompt treatment with plasmapheresis brought about a good improvement of the symptoms. This CPC discussion stressed the need for a thorough multisystem examination and thinking out of the familiar terrain of one's own specialty. Traditional medical school teaching relies heavily on didactic lectures and factual information. CPCs offer an opportunity to translate this into logical reasoning inculcating a step-by-step problem-solving approach in every clinical situation. However sadly, CPCs appear as a regular fixture in very few medical institutes and sometimes appear as a namesake academic chore being practised for tradition's sake. What ails clinicopathological conferences?: Critique and correction Making a correct diagnosis is the essential first step in treatment and prognostication. Misdiagnosis is responsible for approximately 10% of adverse events in hospitals.[7] The diagnosis is often routine and humdrum, and occasionally, exquisite and fascinating. Rarity thrills and draws crowds, while commonness hardly excites. Skeptics of the problem-solving approach feel that too much emphasis in CPCs is laid on “the diagnosis.” The patient who is the centre of the discussion is often forgotten in the pursuit to reach a rare diagnosis. Occam's razor,[7] “No more assumptions should be made than necessary” is often ignored in the heat of CPCs discussions to attract audiences. In the quest for rarity, commonality takes a backseat. An alternate viewpoint supporting the long list of differential diagnoses is the Hickam's dictum, “Patients may have as many diseases as they damn well please.” However, all diagnostic deductions rest heavily on coherent reasoning as is echoed by Crabtree's bludgeon, “No set of mutually inconsistent observations can exist for which some human intellect cannot conceive a coherent explanation, however complicated.”[7] The actual treatment of the disease, long-term follow-up, and natural course of the illness is most often forgotten in the rush to name the ailment. Suffering need not always have a name or classification. Mitigation of symptoms till a diagnosis is “affixed,” is equally crucial. Too much emphasis in CPCs may be laid on investigations rather than a detailed history or clinical signs elicitation. Hence, CPCs must touch upon their own shortcomings and add a passing note on the natural course of the illness, alternate treatment, and what could have been done differently. A non-judgemental yet illuminating “patient-centered” discussion rather than a “diagnosis-cantered” approach, is the need of the hour. A shift of focus to therapy and care, rather than clinching the diagnosis would be ideal. What the future beholds and beckons? Each medical specialist often views an illness through the window of his or her own specialty. Thus, upper abdominal pain could appear to be an acute coronary event to a cardiologist, reflux esophagitis to the gastroenterologist, acute hepatitis to the internist, cholecystitis to the general surgeon, endometriosis to the gynaecologist, pyelonephritis to the urologist, dorsolumbar radiculopathy to a neurosurgeon, etc., The era of superspecialization in medicine has paved the way for loss of a holistic approach to patient care. Thus, CPCs which make us think beyond the comfort zone of our own specialities,[5],[6] would continue to have a special place in bringing together stalwarts of diverse expertise to discuss and debate the evidence. However, CPCs need to be reinvented in tune with the changing times to sharpen diagnostic skills, shape therapeutic practice, and enhance clinical wisdom. Virtuopsies or virtual autopsies, wherein postmortem imaging avoids the need for the traditional open procedures, may be a new tool in CPC discussions in future. CPCs continue to thrill the medical intellect and attract audiences, but perhaps its present day relevance and position is waning. Every patient, rare diagnosis or common, cured, or uncured, holds a vital lesson in clinical medicine that must be preserved for posterity. This lesson may have a ray of hope for many others, the world over. Thus, we echo Professor Ashru Banerji's plea to revive this fading educational tool, or rather, the dying art of playing Sherlock Holmes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2]
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