How the health industry is lagging:

The demands of modern lives and the response of health care

Living in the industrial age or what we call the modern era has changed a lot in the life of sapiens. There is general agreement, things have changed for the better. Food, health, transportation, and the economy have seen improvement. But there is a question here to answer. Do all the aspects mentioned above have seen equal improvement or some of it is lagging?

Let’s consider the food industry. Its growth has drastically improved. Its delivery and storage got better. Perhaps about unequal distribution among humans, but the absolute quantity and quality of food have changed. The transportation industry has seen phenomenal success. From aviation, to bullet trains and future Hyperloop systems, all promise and deliver efficient transport across any part of the land in a short time.

The evolution of medicine has seen several turning points in its path, each promising a better future. The aspect which changed the most is treatment. Diseases have been known to humankind for ages, but treatment saw a drastic improvement in the last century. Both surgical and medical treatments have seen several improvements in quality and quantity. Often there are multiple equally effective treatment options for the same disease, creating a problem of selection for both physician and well-informed patients. Diagnostics has similarly seen significant improvements as well. Now we can image several pathological processes to the tiniest of resolution and can predict its nature.

The aspect of medicine which has not changed is the way physicians assess patients on the first presentation. History and examination are the cornerstone of medical practice and essentially the art of medicine, which lies in the hand and mind of physicians. During medical training, we emphasize the importance of this repeatedly, and medical literature always mentions knowledge of these aspects before describing any disease process. Over the last century, as medical knowledge has expanded, very little has changed in the way we take history and do a clinical examination.

Physicians cannot diagnose any clinical problem without having a relevant history and examination. Despite its central importance, one drawback of it is unreliability and uncertainty. History taking is deeply operator and narrator dependent. We can improve the skills of physicians, but how can we improve the narrating skills of patients. Several medical symptoms are complex. For patients, it’s difficult to express their problem in a way that aids the medical diagnosis of their condition. Also, what patients feel is important might not be important to physicians and the process of diagnosis. The result is often a missed crucial diagnosis because patients may not convey the problem and the physician may not decode it.

Apart from patient and physician limitations, several diseases are symptoms less at the onset when they are most likely to be treated successfully. Almost all cancers fit such clinical conditions. All cancers once symptomatic are already advanced, and chances of successful treatment have reduced several times.

One such clinical aspect is performing and interpreting a digital rectal examination, in which the physician inserts a gloved finger in the patient's rectum to diagnose some relevant pathologies. Prostate Cancer is one such pathology. The diagnostic workup of prostate cancer is complex and filled with uncertainties. Central to start the process of diagnosis is a serum test called PSA and physical findings on the Digital rectal examination.

Once again the findings of DRE are unreliable, operator dependent, and might be completely absent even in the presence of significant cancer. Studies report a low sensitivity of 51% and low specificity of 59% for screening in primary health care. Apart from low diagnostic ability, the examination is very uncomfortable to perform and get performed, undermining the privacy of the patient. Other issues are reproducibility and dependence on the experience of the physician.

Apart from the low diagnostic yield, there are other issues related to the procedure. A 2009 study concluded that 97.6% of students agreed that they were taught DRE during medical training, but only 3.9% felt reasonably confident in differentiating BPH from Prostate cancer. Only 8% of students said that senior doctors confirmed their findings. Studies documenting the perspective of patients regarding this examination are lacking and limited to physician’s opinions only. If patients are well informed about issues related to DRE, most might refuse to undergo the examination.

Guidelines issued by the Australian cancer council do not recommend performing DRE as part of the diagnosis of Prostate cancer. However, European and American urology guidelines recommend the examination in combination with PSA testing to improve their combined diagnostic yield.

In the absence of other reliable diagnostic methods, DRE remains important despite issues related to it. Realizing this will help us innovate alternative methods to improve our armamentarium. One essential component of modern life is to have certainty. It is our duty as medical professionals to provide this essential need for certainty by innovating better methods of assessment of our patients.