January-March 2019   Volume 53 Number 1   ISSN 2277-8969

­Editor-in-Chief
Mandeep S Dhillon Journal of
Postgraduate Medicine
Education and Research

The Official Journal of

Postgraduate Institute of Medical
Education and Research, Chandigarh, India

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JPMER Journal of Postgraduate Medicine
January-March 2019 Vol. 53 No. 1 Education and Research

Editor-in-Chief INTERNATIONAL EDITORIAL ADVISORY BOARD

Mandeep S Dhillon Ajay Sandhu, California, USA
(Radiation Medicine and Applied Sciences)
Associate Editors Anupam Aggarwal, Alabama, UK (Nephrology)
Dheeraj Khurana
Kapil Sethi, Georgia, USA (Neurology)
Surinder Rana
Sarvdeep S Dhatt Patrick S Kamath, Minnesota, USA (Medicine)
Ramandeep Virk Pravin C Singal, New York, USA (Medicine)
Sanjay Suri, Ontario, Canada (Dentistry)
Assistant Editors
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Shalini Gainder
Sandeep Bansal Vikas Khanduja, Cambridge, UK (Orthopedics)
Vikas Prasad, Berlin, Germany (Nuclear Medicine)
Editorial Coordinator
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NATIONAL EDITORIAL ADVISORY BOARD
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 Editorial
The Essence of Practice of Medicine: Is it Science of Evidence Based Medicine or Art of
Clinical Medicine?
The field of medicine has seen a sea of change in the way we teach and practice medicine. The technological
advancement has transformed medicine from a clinical bedside art to a field of sophisticated equipment and
gadgets. Simultaneously, the principles of finance and management have percolated into the practice of medicine
with hospitals and physicians being considered as service providers. Increased reliance on gadgets and equipment
have decreased the humane touch and compassion, a principle that was so fundamental in treating sick patients.
We have started believing that medicine is evidence based pure science and health care is a business and this has
led on to a vital blow to the patient doctor relationship as well as art of clinical medicine.
India is also witnessing similar changes in the practice of medicine over last 2 decades and there are increased
concerns on the gradual decline of art of clinical medicine. Earlier the Indian health care was primarily driven by the
individual clinical expertise and experience of the physician. However, in-face of increased medico-legal aspects as
well as increased and wide availability of sophisticated equipment’s, the clinical practice is gradually shifting from
clinical expertise to evidence-based medicine (EBM). In 1991, EBM word was 1st time coined by Gordon H Guyatt
as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of
individual patients.1 EBM provides more dedicated, systemic and homogenous pathway for making clinical decision
for patient’s management. When EBM was envisaged, its objective was not to replace the clinical expertise-based
decision but rather to help it with objective evidence.2 However, in recent years there has been overreliance on EBM
over clinical expertise and experience leading on to concerns about the gradual death of art of clinical medicine.
From its inception, EBM has remained in controversies as many of the leading physicians considered it as a
‘cookbook medicine’ and considered it to be inferior to the clinical expertise.3 EBM mainly relies on various clinical
trials to produce data regarding particular disease and management protocol. However, many trials from which
EBM is formulated have been found to be suffering from major limitations like poor methodology and study design,
suboptimal power of study or non-representative study cohort. Moreover, on many occasions, reliability of the
data has also been questioned by world’s leading physicians. Ioannidis JP et al., reviewed 49 highly cited articles
(cited more than 1000 times) from 3 leading medical journals.4 Forty five studies claimed that the intervention was
effective and of these, 7 (16%) studies were contradicted by subsequent studies and only 11 (24%) studies remained
unchallenged. They concluded that controversies are not only common with highly cited nonrandomized studies,
but even highly cited randomized trials may be challenged and refuted over time.4 In recent years many articles have
shown contradictory and opposite results making decisions based on such evidence difficult. Moreover, influence
of various drug companies on major clinical trials has sometimes raised questions on reliability of various clinical
trials.5
Also, the medical literature has seen an exponential rise in meta-analysis or systemic review of various topics.
However, many times, the studies included in meta-analysis or systemic reviews are themselves underpowered
studies making it an unfruitful exercise. Moreover, in recent years many meta-analysis on the same topic have been
published and this leads on to confusion. One recent article has shown that annual publications between 1991 and
2014 has increased 2,728% for systematic reviews and 2,635% for meta-analyses versus only 153% for all PubMed-
indexed items.6 And, contradictory results even in meta-analysis increases the confusion on management.
Despite EBM being suffering from these important flaws, it has now become an indispensable part of current
medical practice. We as a clinician should always remember that EBM is meant for supplementing the clinical
experience and expertise, not to replace it. Critical review of an article or meta-analysis including understanding the
study designs, study population and results is of utmost important before coming to any conclusion and modulating
the clinical practice. There are three basic pillars for practicing EBM more rationally: clinical examination or expertise,
current best evidence and patient’s desire or patient’s best interest. All three pillars are indispensable for effective
clinical practice and ideally, they all should be integrated for better clinical outcome. In practicing EBM, modulating
current evidence according to the local scenario or available resources to maintain patient’s best interest is of utmost
importance especially in resource limited country like India. As the routine challenges faced in India is quite different
from challenges faced by majority of developed countries, modulating best current evidence according to local
scenario or available resources is of utmost importance to achieve best clinical outcome.
iii
Journal of Postgraduate Medicine Education and Research

To summarize, clinical expertise and evidence both are an important part of today’s medical practice.
Understanding limitation and strengths of each evidence is of utmost importance before its application. EBM should
always be backed up by sound clinical knowledge and expertise. Both clinical expertise and EBM are required for
effective patient management and they should be integrated to provide an ultimate goal of health of patient. In our
opinion, modern age physicians, along with acquisition of knowledge of medical science also need to learn and
nurture the art of clinical medicine that involves treating patients with compassion and humane touch.

REFERENCE
1. Szajewska H. Evidence-Based Medicine and Clinical Research: Both Are Needed, Neither Is Perfect. Ann Nutr Metab 2018; 72:
13–23.
2. Godlee F. Milestones on the long road to knowledge. BMJ 2007; 334 Suppl 1: s2-3.
3. Charlton BG. Restoring the balance: evidence-based medicine put in its place. J Eval Clin Pract 1997; 3: 87–98.
4. Ioannidis JPA. Contradicted and initially stronger effects in highly cited clinical research. JAMA 2005; 294: 218–228.
5. Angell M. Drug Companies & Doctors: A Story of Corruption. 2009.https://www.nybooks.com/articles/2009/01/15/drug-
companies-doctorsa-story-of-corruption/ (accessed 12 Jan2019).
6. Ioannidis JPA. The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses. Milbank
Q 2016; 94: 485–514.

Jimil Shah, Surinder Singh Rana

Department of Gastroenterology
Postgraduate Institute of Medical Education and Research (PGIMER)
Chandigarh, India-160023
Address for Correspondence:
Prof Surinder S Rana, MD, DM, FASGE
Department of Gastroenterology,
Postgraduate Institute of Medical Education and Research (PGIMER)
Chandigarh-160012
India
Email: drsurinderrana@gmail.com
Tel No: 91-172-2756555
Fax No: 91-172-2744401

iv
Journal of Postgraduate Medicine
Education and Research
January-March 2019   Volume 53 Number 1

Contents
ORIGINAL ARTICLES
• A Cross-sectional Study of Prevalence and Correlates of Tobacco Use in
Three Districts of Punjab, India........................................................................................................................... 1-6
Garima Bhatt, Sonu Goel, Suman Mor, Rakesh Gupta
• Drug-induced Acute Kidney Injury/Acute Tubulointerstitial Nephritis: A Clinico-etiological
Study from a Single Center in North-east India............................................................................................. 7-10
Manjuri Sharma, Manzoor A Parry, Pranab J Mahanta, Prodip Doley, Gayatri Pegu, Hamad Jeelani
• Effect of Extent of Hippocampal and Amygdala Resection on Seizure Outcome in
Patients with Refractory Epilepsy Secondary to Medial Temporal Sclerosis......................................... 11-16
Sachin Bindal, Navneet Singla, Parampreet Singh, Manish Modi, Kokkula Praneeth, Manju Mohanty,
Sameer Vyas, Sunil K Gupta

REVIEW ARTICLES
• Accelerating Adoption of Artificial Intelligence in Healthcare................................................................. 17-20
Amarjeet Singh, Siddharth Angrish
• Adverse Drug Reactions to Disulfiram Treatment with or without Alcohol Challenge in
the Indian Setting: Systematic Review........................................................................................................... 21-30
Jaison Joseph, Debasish Basu

CASE REPORTS
• An Extremely Unusual Case of Type A Interrupted Aortic Arch in a Young Male............................... 31-33
Uma Debi, Prem Kumar, Manphool Singhal, Manoj Rohit
• Maxillofacial Reconstruction with Patient-specific Implants.................................................................... 34-37
Vidya Rattan, Sachin Rai, Satnam S Jolly, Vijay K Meena
• Post-surgical Extraoral Commissure Stent for Correction of Microstomia in a Child with
Chemical Burns: A Clinical Report.................................................................................................................. 38-41
Nidhi Mangtani, Gunjan Pruthi, Veena Jain

BRIEF COMMENTARY ON MEDICAL EDUCATION

• Authentic Assessment in Medicine................................................................................................................. 42-44
Shalini Gupta

BIOSTATISTICS SERIES
• Statistics Corner: Measurement Scales........................................................................................................... 45-46
Kamal Kishore, Rakesh Kapoor

CLINICOPATHOLOGICAL CONFERENCE REPORT (CPC)

• Lupus Flare in Pregnancy.................................................................................................................................. 47-58
Ritambhra Nada, Manoj G Madakshira, Shefali Sharma, Tulika Gupta, Vanita Suri, Savita Kumari

v
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