A Lesson from Ebola: Revisiting the Art of Medicine

It was during morning rounds on the oncology service when my beeper buzzed with the announcement of a noon special conference on Ebola virus. Several weeks ago, this text message would have seemed somewhat irrelevant to an oncology trainee like me. But recently, even some of my patients had been asking me questions about the disease, so I thought it would be worthwhile to understand the subject beyond what I had read in the news or on social media. 

Our team headed towards the auditorium for what turned out to be an impressive turnout. I recognized faces from almost every subspecialty of medicine and surgery and a mix of attending physicians, fellows, residents, nurses, and medical students. One thing became clear, Ebola had certainly captivated the minds of the American public—and the medical community was no exception. 

Know Your Enemy

The discussion started with the quotation that sums up our current predicament perfectly:

“If you know the enemy and know yourself, you need not fear the result of a hundred battles.” - Sun Tzu’s Art of War

One by one, representatives from the  departments of infectious disease, hospital infection control, and emergency medicine presented an overview of the Ebola disease process, including signs and symptoms and the timeline of infection. They also presented a plan for the worst-case scenario: how to manage an infected patient in the hospital. This included screening protocols, isolation measures, and prompt notification of the appropriate authorities. 

The audience, comprised mainly of healthcare workers, soon peppered the presenters with questions and comments. 

• Will we falsely suspect potential cases now that the flu season is near and, if so, do we have enough isolation rooms?

• How long does the confirmatory testing take?

• Who will be directly involved in caring for the patient?

• What if a potential case is seen in the outpatient clinic first and not in the emergency room?

• Has this disease changed the way we practice medicine and approach our patients, or is this just going to be a temporary phase?

Reflections

The discussion that day ended with more questions than answers. Later, I reflected on the proceedings of the lecture and on one loaded question: Will Ebola change the way we practice medicine? 

For myself, the talk on Ebola virus was more of a reminder to stick to the fundamental basics of practicing medicine than anything else. The speakers emphazised the importance of obtaining a travel history, looking for signs of infection, and always using precautionary measures.

Wasn’t that what I had been doing earlier today? While completing my rounds, I would take my patient’s history, conduct a physical examination, wash my hands before and after all patient encounters, and use personal protective equipment where needed. 

So what was new? Other than Ebola itself. 

Practicing Good Medicine

It is not surprising that despite all the advancement in our medical knowledge and diagnostic technology, the art of medicine remains unchanged. Even in today’s day and age, confirmatory testing to rule in or rule out a possible case of Ebola virus will take 1 to 2 days at least, depending on availability of logistics. Our clinical acumen, the foundation of which is based on obtaining a thorough history from the patient and doing a detailed physical examination at the bedside, continues to be our foremost and most effective tool. 

A very interesting comparison comes to mind. The CDC created a checklist for patients being evaluated for an Ebola virus infection. Steps include assessing the patient for fever, determining if the patient has symptoms (eg, headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage), and obtaining the patient’s travel history or a history of contact with an Ebola patient 21 days before illness onset. 

A very similar “checklist” about evaluating a sick patient was taught by the ancient Greek physician Hippocrates around 400 BC. 

According to Hippocrates,¹ “One should pay attention to the first day the patient felt weak; one should inquire why and when it began. These are the key points to keep in mind. After these questions have been cautiously considered, one should ask the patient how his head feels, or if he has any pain or if he feels heavy... In regard to the chest, one should ask the patient if he has pain there and if he has a slight cough, with pain in the abdomen when he coughs.” 

It is remarkable how the practice of history taking has persisted and thrived across the millennia. Complex medical cases have repeatedly been solved based on simple questioning and observation. A noteworthy example is the Broad Street cholera outbreak in London in 1854. The English physician John Snow interviewed local residents, and eventually connected the dots to narrow down the outbreak source to a water pump. Disabling the pump ended the outbreak. 

However, several weeks ago, a patient in Dallas was asked the right questions but the information obtained was not communicated to or reviewed by the physician. This oversight led to the discharge of an actively infected Ebola patient back into the community. 

As we know, all an outbreak needs is a single source—the consequences of this lapse could have been devastating. 

The story of medicine is that of trial and error. Its outcome is experience and that is always a success, even if the experience is not a good one. The elusive Ebola virus is a new chapter in this story. 

Only time will tell whether or not it will impact the way we approach our patients and practice medicine in the future. For now, it has certainly taught us to revisit and reinforce what we already practice every day.

Asad Javed, MD, is a fellow in the department of hematology and medical oncology at Thomas Jefferson University Hospital in Philadelphia, PA.

Reference:

1. Hippocrates. Regimen in Acute Disease. In: Littre's Translation of Hippocrates. Appendix No. 9; 436-440.