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"... The dogmas of the quiet past, are inadequate to the stormy present.... As our case
is new, so we must think anew, and act anew...
ABRAHAM LINCOLN
2 ND ANNUAL MESSAGE TO CONGRESS. DEC. 01/1862
Introduction
At the end of a semiology class, one of the students asked why we should learn the semiological maneuvers of abdominal exploration if we have ultrasound, magnetic resonance imaging, computed tomography, etc. available today.
The arguments raised by the speaker indicated that her skill and sagacity arose from the fact that she had already learned that medical semiology has limitations, of course, but that in order to establish them it must first be studied. In other words, she had stud ied semiology and had learned what it teaches, that is, to reflect. To reflect technically, which is what a medical semiologist does, ultimately.
Semiology and medical semiology
In general terms, semiology is defined as the science of identifying social signs, symbols and language1-3. This is why military semiology (hymns, fanfares, command voices, etc.), community semiology (language and mimicry), and so many others exist, including medical semiology, which identifies both clinical and paraclinical signs of disease. A clinical sign is the way in which a disease is perceived by the patient and how he/she expresses it.
The great forgotten ones?
Pathophysiology, the science of why? and how?, involves studying disease processes and leads basic clinical research to understand the intrinsic mechanisms of disease. Unfortunately, and as occurs with medical semiology, they both lack an appropriate niche as courses in some educational institutions, and are expected to be taught throughout the entire career, but with no indication of how to do so. Some medical schools in Colombia have already eliminated them from their curricula and everything seems to indicate that there is no plan to integrate them into these programs in the reasonable future. The result is a constant requirement for students to be pathophysiologically and semiologically competent, using hasty and not very rigorous remedial workshops which are periodically proposed when a professor requires them.
Today these learning packages are presented using mannequins that have a heart rate of 80/min, breathe 18 times per minute and have an oral temperature of 37°C. Famous British cardiologists assert that, by learning auscultation, with expert tutor supervision, clinicians could propose reasonable hypotheses regarding heart diseases. But this learn ing requires a process similar to that of learning to play a musical instrument; that is, something like two to three years 4.
Pathophysiology, laboratory medicine, studies the abnormal function of organs and systems and the mechanisms to adapt to these changes, as there are those who claim that the mechanisms that keep us healthy are the same as the pathophysiological mechanisms that make us sick. It is a matter of an imbalance between the response and the context 5. Pathophysiology begins with a knowledge of cellular genetic alterations to explain the functional abnormalities that cause organ, apparatus and system alterations. To achieve this, it differentiates between causal phenomena, their link to pathological phenomena and the potential for early diagnoses using techniques with a high predictive value 6.
The mutation of a gene or invasion by a microorgan ism trigger a disease that causes molecular, cellular and systemic responses that are signs of the disease. Therefore, knowing the physiology and its signs helps in understand ing the disorder, its diagnosis and its treatment.
As Sir William Osler stated, a doctor who practices with no knowledge of pathophysiology and semiology is making stabs in the dark, sometimes hitting the disease and sometimes the patient, but not really knowing which he hit.
Teaching semiological practice is easily confused with the interesting and valuable pathophysiological discourse, which is so attractive to both professors and students. Consequently, and without ignoring the importance of either, the acquisition of semiological skills and attitudes takes second place, to the point where semiological skills are not often considered. The obvious result is the typical bewilderment of students and then novice physicians when they have to percuss a lung or examine an x-ray and sud denly discover that they do not know how to do it nor why they should. But as mentioned previously, the eloquence of the pathophysiological rhetoric today easily outstrips the tenacity and persistence of those who want to be properly trained in the simple but rigorous semiological discipline which created the clinical method, but lacks the spectacular apparel of other important disciplines of medical thought.
The semiology professor's mission
Since medical semiology is the student's first contact with the patient, the following teaching objectives must be highlighted:
To educate students in the knowledge, attitudes and skills that will enable them to consider the patient as a harmed human being, perfecting their intellectual and moral faculties for this task. Various resources are available to accomplish this, such as:
a) Developing empathy; that is, the cognitive ability to understand the extent of the suffering due to the dis ease. b) Learning to recognize that there really are no illnesses, but rather ill people. c) Observing medical ethics to preserve the axioms of autonomy, beneficence and non-maleficence, as well as justice in the use of healthcare resources. d) Helping the student recognize that, as W. Osler said, "the education upon which he is engaged is not a college course, not a medical course, but a life course," and therefore it is necessary to ac cept up front that physicians are perpetual students. e) Learning to use the benefits of the history and physical exam. f) Learning to use medical reasoning to obtain the maximum yield from the information obtained. g) Learning that the uncertainty of medical practice can be balanced using set techniques. h) Recognizing that the medical history is the best available resource for medical practice.
The medical semiologist trains students to reflect, critique and participate in learning the skills, abilities and dexterities that will allow them to problem solve through the appropriate use of the available tools for correct di agnostic and therapeutic decision making in any branch of medicine.
To achieve these results, he/she must have true autono my, freedom of action, job and academic recognition and, above all, time 4. These conditions are notably absent in Colombia due to several factors like a) Lack of academic recognition, since medical semiology is not recognized as a specialty; and b) The fact that semiology professors, as will be seen later, are perhaps the only ones who enter teaching by appointment rather than merit.
Some facts in current medical practice
The controversy between scholarship vs. skill
The physician's mission is, first of all, to console and relieve. This is followed by curing the disease. The lat ter has increasingly displaced the first two. Even so, the cold statistics have shown results that are at odds with the enormous financial and administrative efforts designed for this purpose.
A recent WHO report 8 has brought the following to the forefront: a) Seven of the main causes of death are noncommunicable diseases; b) Heart disease continues to be the main cause of death worldwide (9 million deaths in 2019); c) The next most frequent causes are lung disease, diabetes, cancer and dementias; d) Life expectancy reached an average of 76 years in 2019 compared with 67 years in 2000; e) Disability has increased; f) The diseases that cause the most years of healthy life lost are heart disease, stroke, cancers and chronic obstructive pulmonary disease, which, along with trauma, caused a combined loss of more than 100 million years of healthy life; and g) The urgency of drastically improving primary health care as one of the most useful approaches for effectively combating noncom-municable diseases.
The practice of medical semiology
The medical semiologist's task is torn between orphan hood (who defends it?) and discredit, and therefore it is an almost embarrassing activity that is labeled as facile and academic "filler" by some teaching colleagues.
Medical semiologists are seen as monuments of the past, as a tradition that sometimes elicits mocking and sarcasm, something that does not seem to have a place in the grand show of medicine portrayed in soap operas and mass-appeal movies.
This situation is starting to be seen in the curricula of some schools of medicine which, as has been mentioned, have chosen to include semiology in the so-called "hori zontal programs." In other words, it disappears as a subject to be taught and is expected to be studied throughout the whole career. This is similar to what occurs with ethics which, according to Law 23 passed in 1981, should be included as a mandatory subject, which is stated but not followed 9.
Healthcare administrators and medical semiology
The avalanche of so-called medical technology has produced many changes in healthcare organizations, but the most remarkable has assuredly been the progressive disappearance of the physician as the head of the healthcare team, giving way to the healthcare administrator filling this role.
Most healthcare administrators, whether academics or not, are very expert professionals in their work but, with notable exceptions, lack experience in direct patient contact. That is, they do not perform direct medical care with patients, but this results in the paradoxical fact that they are the ones who advocate how medicine should be practiced and taught.
This new approach to medical practice translates into several facts. The first is that the responsibility for learn ing almost always falls on the professors. If the student does not pass to the next year, the professor is labeled as the one "responsible," and the student is the injured party. Second, people try to introduce the idea that learning to be a doctor is easy. Attractive proposals are designed that try to minimize the need for student effort, but they do not men tion that more than a dozen years of strenuous training are required to achieve reflexive proficiency. Third, if teaching is considered to be a business act, it is almost mandatory to assume that the student is the client and, therefore, it is accepted that, as occurs with business relations, "the customer is always right" (because student dropout must be avoided at all costs...etc., etc.).
The idea that both medical practice and learning are business acts has repercussions in all areas, but especially in what relates to the professors' treatment (or mistreat ment?), since their ranking and progress, both academically and professionally, have almost completely disappeared. This translates into them being considered merely as employees without any consideration for their rank. The recognition needed to progress academically has disap peared, and therefore the terms "instructor," "professor," etc. are not found on the employee list, having simply been replaced with the term "teacher." Professors make the same small wage as newly arrived employees who do not need to certify the knowledge that was previously held to be essential.
Research in medical semiology
Without getting into an analysis of the very modest re sults of medical research in Colombia, medical semiology research could be described as practically null, as it has been limited to a few topical reviews.
The current practice of medicine
Its essential elements still lie in an appropriate medical history. Its tools are those used by medical semiology; in other words, a history, physical exam, clinical reasoning and decision making to help establish hypotheses that may be proven. All of this is based on an appropriate doctor-patient relationship in which medical language plays an increasingly important role.
History taking
Actually, the student's argument was almost true, be cause for many years semiology, with all its term confu sions, was dedicated to teaching students the techniques of inspection, palpation, etc., devoting much of the limited time to deciphering the mysteries of physical examination like detecting pulsus bisferians or performing Damoiseau maneuvers to identify "the parabolic chest curve from the spinal column to the lateral wall which identifies the shape of the upper limit of pleural effusions, convex for exudates and concave for transudates..."10, as well as the famous Perthes and Trendelenburg tests and others with such low sensitivity, specificity and predictive value for identifying (?) the adequacy of venous circulation that are still part of the appalled students' exams.
I recall, and have recounted several times, what we experienced as internal medicine residents at Hospital San Juan de Dios in Bogotá, when one of the nuns who helped in nursing at that time told us, aghast, that a patient was suggesting to her that he leave his assigned cubicle, using uncouth head and neck movements.
Our professor, Dr. Uribe Uribe, proceeded to conduct the respective exam, speaking to the patient in his usual friendly way. After about 15 minutes, he addressed us mentioning that, among other things…"…on physical exam we found a patient with a positive de Musset sign, pulsatile uvula, bounding pulse, divergent hypertension, the apex in the seventh left intercostal space beyond the ipsilateral midclavicular line, a palpable domed thrill and a decrescendo 4/6 protodiastolic murmur on the aortic area.. ..As you can see, this is aortic regurgitation"!!!
What amazed us most was not so much the statement of the hypothesis but rather the restraint and assurance of the semiological act, performed without hesitation and with certainty in each of Dr. Uribe's movements.
It is very likely that this professor was unaware of the use fulness of Doppler echocardiography or magnetic resonance imaging to prove the hypotheses proposed in the physical exam, and that his knowledge of the pathophysiology of the disease was limited to what was found in the textbooks of that time. But the most striking thing was his rare ability to understand the message provided by the patient; in other words, what is known as taking a medical history.
A medical history is extremely valuable for producing reasonable diagnostic hypotheses (close to 80-85%), but despite this, it is only assigned a secondary role in curricula.
A. Medical language among physicians
It appears that with the current technological subordination (technophilia) with all its successes and aberrations, medi cal language is experiencing such a disturbing devotion to abbreviations ("abbreviatophilia") and acronyms ("acronymophilia") that the latest editions of medical texts include a growing number of pages devoted to a list of "abbreviations," "initials" and "acronyms." If this happens in textbooks, it is even more prevalent in "scientific articles" that compete with the books in a game to try to eliminate the proper enjoyment of reading with an excessive typographic "fundamentalism" that is clearly unnecessary. On the other hand, it is not unusual to find texts like the following in some medical charts: "PT, ADMT, WITH CHD, EF <40", in all caps and using abbre viations, initials and acronyms, because medical charts today disregard grammatical norms, thus contradicting the editorial rule that establishes that the text should be clear, pleasing and understandable. All of which means that the medical chart loses one of its most important characteristics, which is that of accessibility, understood to mean that any member of the healthcare team is able to fully comprehend it.
As will be shown further on, it appears that doctors today pay little attention to the six qualities of language when speaking to their patients, but it is worthwhile to recall them: Language should be:
Warm, Scientific, Clear, Consistent, Concise, and Brief.
B. The physical exam
There are many reasons for performing a good physical exam 11-14.
a) Effectiveness and efficiency if it is based on a well-taken medical history; b) The ability to detect important signs early, for example: systemic hypertension, diabetic foot, etc.; c) Proper guidance for an intelligent use of medical technology; and d) Physical contact with the patient, which creates an atmosphere of trust between the doctor and the patient with an evident therapeutic effect. (Table 1)
Table 1 Some very useful physical exam maneuvers.
| ITEM | Usefulness 100/100 |
|---|---|
| Taking the pulse | 95 |
| Weight - height - BMI* | 95 |
| Blood pressure | 95 |
| Temperature | 95 |
| Pulse oximetry | 95 |
| Rectal exam | 90 |
| Pelvic exam | 90 |
| *BMI: body mass index |
It is worth repeating that, overall, in 80% of the cases, correct diagnostic hypotheses are proposed through the medical history. The physical exam increases the likelihood of reaching the correct diagnosis by 10%. The physical exam generally has limited accuracy and, often, low interobserver reproducibility. Its findings are more sensitive than specific, and therefore its rational use and interpretation are impor tant to avoid tests that are often alarming and costly for the patients. For this, it is important for the physician to acquire skills in using complementary diagnostic measures: imaging, endoscopy and laboratory tests, among others.
C. The new patients
The following are some of the characteristics of the new patients or consumers.
a) They have the best understanding of their experi ence with the disease and, therefore, express it in the way they consider most appropriate; b) They are autonomous in their decisions and therefore can accept or reject the medical orders; c) They can and must indicate their ac ceptance through informed consent; d) They can sue the physician in a court of law; e) They are the main actors and protagonists in caring for their own health; f) They have unlimited access to medical information which, with unfortunate frequency, tends toward pseudoscience; g) They are exposed to pluripathology; and h) They adopt the attitudes of consumers, critics and, almost always, judges of the medical procedures.
D. Physicians as translators
As we well know, diseases do not read medical text books, and therefore the development of the former lacks the structure of the latter. Thus, the disease follows its course in such a way that most times the disorder perceived by the patient is the initial element which the person ex periencing this disorder expresses as he/she sees fit and according to his/her perceptual abilities. One of the phy sicians' functions is to translate the patients' verbal and nonverbal expressions (for which they generally use their own language) into medical language. This is when physi cians play their role as translators. But everyone knows that translations have serious risks, as the "perfect translation" has not yet been described, one which represents exactly what has been expressed in a different language and under different circumstances.
Furthermore, it is advisable to remember again that patients have little phonetic baggage, and therefore their expression may be influenced by the severity of the disease, their capacity for stoicism and, sometimes, by the potential for secondary gain 15. This has shown that patients today are different from those in earlier times and, in turn, that today's physicians are also different.
E. The new physicians
The following chart is anonymous and was published on the internet (Table 2).
Table 2 Definitions before and now.
| Before | Now |
|---|---|
| I was a physician | I am a healthcare services provider |
| I used to practice medicine | I function within a managed care system |
| I had patients | I have a list of consumers |
| I diagnosed | I have to request approval |
| I treated patients | I have to request authorization |
| I was successful among people | I lack everything, even paper |
| I listened to my patients | I have to justify myself to administrative authorities |
| I was a physician | I am not sure what I am |
F. Clinical reasoning
Clinical reasoning is also a basic component of clinical competence, but since it is not defined in the curricula (be cause it is very hard to define 16), it is classified as "the art of medicine," without including this topic's concepts, and therefore disappears from university teaching programs.
The currently identified models that explain clinical reasoning can be divided into two types: analytical and nonanalytical. One of these, the hypothetico-deductive analytical model, includes the following stages: a) Careful observation; b) Information gathering; c) Physical explo ration; d) Generating diagnostic hypotheses, e) Correlat ing the data obtained with the proposed hypothesis(es), and f) Confirming or refuting the hypothesis(es) through testing. All of this is carried out during the semiological act, to wit: a) Systematized observation; b) Obtaining information, that is, medical history taking; c) Physical examination; d) Generating hypotheses through medical reasoning; and e) Confirming the hypotheses.
On the other hand, the nonanalytical model is based on the clinicians' experience, determining the diagnosis through a "rapid pattern recognition" process which de pends on previous experience. This way of reasoning is automatic and quick, which exposes it to a greater risk of error. However, it must be acknowledged that these two ways of thinking are not mutually exclusive. Medical se miology allows for a reasoned use of both methods.
The new, the old, and the recent
The proposal of the newly acquired diagnostic tech niques poses several questions for today's medical semiol ogy. First, it is noteworthy that the use of pulse monitors, thermometers, blood pressure monitors, stethoscopes, etc., has become emblematic of instrumental medical semiology, but that over time, those who teach it have neglected learning about imaging and clinical laboratory tests which are, as has been stated many times, undeniably valuable for detecting the signs of disease (Table 3).
Table 3 Premodern and current physicians.
| Premodern or classic | Current |
|---|---|
| Analyzes test results with those who perform them | Firmly believes in the reported conclusions |
| Appears very rarely on television | Gives many interviews on television and broadcast media |
| Based on experience | Based on evidence |
| Gives priority to continuous self-learning | Gives attention to international congresses |
| Trusts in his experience | Carries out the recommended protocols |
| Sees the patient as a harmed human being | Sees the patient as a service consumer |
| Considers the patient-physician-family triad to be important | Gives importance to the insurer-consumer-physician triad |
| Considers his personal appearance to be important | Does not consider it important |
| Considers that each patient is unrepeatable | Considers that all consumers are the same |
| Considers that each patient is unique | Considers that all consumers are the same |
| Considers that the course of diseases depends on many circumstances like age, finances, the environment, etc. | Gives more credence to the theory that the course of disease is static and linear |
| Believes that he should always console | Believes more in efficiency |
| Believes that diseases are rarely cured | Believes that all diseases are or will be curable |
| Practices in his own office | Practices in someone else's office |
| Chooses the treatment recommended by experience | Demands treatment validated by academia |
| Is a perpetual student | Studies on the latest smartphone |
| Is a physician 24 hours a day | Is a physician during the contracted schedule |
| Is very careful when prescribing medications | Considers that all diseases are cured with several medications |
| Based on the detection of clinical signs | Based on tests and protocols |
| Maintains a healthy skepticism regarding the technological avalanche | Enthusiastically accepts technological advances |
| Investigates the relationship between clinical signs and diseases | Investigates the statistical relationship |
| Independent | Teamwork |
| Ingenous and skeptical | Skeptical but enthusiastic |
| Questions the patient | Refers for technological tests |
| Appeals to his distinctions | Based on competence |
| Likes seeing patients | Likes to wait on consumers |
| Likes caring for patients | Likes to study the disease |
| A constant reader | Reads reports, protocols and care guidelines Lee informes, protocolos y guías de atención |
| Reads a lot Lee mucho | Uses his cell phone a lot |
| Expresses interest in prioritizing experience | Expresses interest in evidence-based medicine |
| Does not practice treatment intensification | Is interested in therapeutic success |
| Paternalistic | Respects autonomy |
| Little interest in costs | Makes a cost-benefit analysis |
| Greets the patient | Delegates to the secretary |
| Always carries out a physical exam | Considers the physical exam to be unreliable |
| Conducts the medical visit personally | Delegates to his residents |
| Based on clinical reasoning | Based on protocols and management guidelines |
| Orders very selected laboratory tests | Considers that the more tests a patient has, the better care he receives |
| Uses the scientific method and humanism to develop diagnostic hypotheses and treatment | Uses the evidence to develop the diagnosis and treatment |
| Uses both subjective and objetive information to develop hypotheses | Considers that only measurable things are valid |
| Is the head of the healthcare team | Abdicates the role of healthcare team head |
| Consoles and accompanies terminally-ill patients | Sometimes refers consumer to the Palliative Care Unit |
The instrumentation frenzy led to the appearance of many devices, including Santorio's thermoscope (1538), followed centuries later by Daniel Gabriel Fahrenheit's mercury thermometer (1724), which was replaced around 2000 by infrared thermometers measuring heat flow and the digital thermometers used so often during the COVID-19 pandemic, as they do not require skin contact.
The Hippocratic schools emitted the theory that, along with temperature, diseases are related to the arterial pulse rate. John Floyer's "physician's pulse watch" appeared around 1710, which led to multiple modifications crystal lized in the proposals by Kare, Mailer and others which, in 1935, produced digital pulse monitors and, subsequently, the current pulse oximeters which simultaneously measure heart rate and the percentage of arterial oxygen satura tion, respiratory rate, electrocardiographic tracing, blood sugar, etc.
The idea of the stethoscope came from Laennec in 1819 17, whose work is considered today to be one of the pil lars of pulmonary and cardiac auscultation. Auscultation began to be used in obstetrics (Pinard) and gastroenterology, producing Cammann's binaural stethoscopes (1851), and a century later, Rappaport and Sprague's work led to the Hewlett-Packard model in 1940 and then Littman's model at Harvard around 1960.
Likewise, in 1896, Riva-Rocci produced one of the first commercial mercury blood pressure monitors, of un matched precision, followed by Vásquez-Landa-Korotbaf's model in 1900. Subsequently, the first digital blood pressure monitors appeared around 2012, which measure blood pres sure using light signals, thus facilitating its measurement, since auscultation is not required.
Furthermore, mathematicians and physiologists led by Koliber, Muellen and Manhead recorded the heart's electrical activity for the first time in 1872, which allowed Augustus Walter to obtain the first electrocardiogram trac ing in 1887. This then helped Wilhelm Einthoven in his work leading to the Nobel Prize in Medicine for describing the usefulness of the string galvanometer for this purpose.
The development of the mathematization of informa tion provided more results. Beginning in the 19th century, university hospitals and quarantine periods were created. Vision improved with the advent of glasses, as did dentition with dental plates. The Cesarean section technique began to be taught, and then a growing stream of discoveries emerged such as vaccination, antibiotics and antivirals, the discovery of the human genome, the development of laboratory tests, the new means of infection and immunity phenomena, stem cell research, anesthesia and new surgical techniques, vitamins and nutrition supplements, along with the rapid improvement of imaging tests like computed axial tomography, Doppler, scintigraphy, magnetic resonance imaging, etc., which, together with the new genetics, have contributed countless aids for diagnosing and treating many diseases.
This is one of the many facts that our intelligent detractor presented. Why do medical semiologists like paraclinical tests so little? Why, she asked, if very effec tive instruments can be used (thermometers, stethoscopes, ophthalmoscopes, electrocardiographs, etc.) with a high degree of efficiency, why are students not trained in the basic aspects of radiology, as well as the criteria for or dering them? This, together with learning the criteria for performing the more than 4,000 currently available labora tory tests, to be able to order the right test at the right time for the right reason 18.
Medical-surgical specialties in Colombia
In 2020, Ascofame [the Colombian Association of Medi cal Faculties] published recommendations for the future of medical education in Colombia (19), from which the following information is extracted:
There are 63 undergraduate programs in medicine and 529 medical-surgical specialty programs in Colombia (Table 4).
Conceptual aspects regarding the medical-surgical specialties. The definition of medical-surgical specialties contained in Article 2.5.3 of Decree 1330 issued in 2019 is adopted: "These are programs that allow physicians to delve further into a specific field of knowledge in medicine to acquire the knowledge and develop ad vanced attitudes, abilities and skills to care for patients in different stages of their life cycle, with diseases of the different organ systems that require specialized care. Theoretical and practical teaching-learning processes are required for this level of training. The practical aspects include completing the practice time in the clinical rotations and participating in a sufficient number of cases to ensure achievement of the learning outcomes sought by the program. The students should have the required accompaniment and monitoring." [Translated from the original Spanish.] As was already mentioned, and without naming it, the goals of medical semiology are set out here.
Table 4 Medical-surgical specialties with the most programs in Colombia.
| Title | Programs |
|---|---|
| Internal medicine specialty | 29 |
| Pediatric specialty | 28 |
| Obstetrics and gynecology specialty | 26 |
| Anesthesiology specialty | 20 |
| General surgery specialty | 20 |
| Ophthalmology specialty | 18 |
| Psychiatric specialty | 18 |
| Critical medicine and intensive care specialty | 16 |
| Radiology specialty | 15 |
| Orthopedics and trauma specialty | 13 |
| Urology specialty | 13 |
| Dermatology specialty | 12 |
| Cardiovascular surgery specialty | 11 |
| Neurology specialty | 11 |
| Reconstructive and cosmetic plastic surgery specialty | 10 |
| Neonatology specialty | 10 |
The first conclusion reached from the texts above is that neither pathophysiology nor medical semiology have been considered to be specialties and, therefore, those who practice them lack their corresponding privileges and duties.
Is medical semiology a medical specialty?
In 2022, the Colombian Ministries of Education and Health once again produced a "Consensus for the Stan dardization of Medical Specialty Names..."20,21. This document indicates that there are 68 specialties in Colombia, but it points out that, in 2012, "there were 138 different names for specialized medical training in clinical and surgical areas. " [Translated from the original Spanish.] They also note that Decree 1075 issued in 2015 repeats that the medical-surgical specialties are "programs that allow physicians to delve further into a specific field of knowledge in medicine to acquire the knowledge and develop advanced attitudes, abilities and skills to care for patients in different stages of their life cycle, with diseases of the different organ systems that require specialized care. Theoretical and practical teaching-learning processes are required for this level of training." In other words, what medical semiology is intended to do.
The extensive literature on the creation and structuring of specialties in Colombia reveals the genuine interest of Ascofame and the government entities to provide the mechanisms to enrich the information on the topic. It also shows that neither pathophysiology nor medical semiology have been considered as candidates for a specialty despite fully meeting the standards mentioned initially by Ascofame, according to the definition of specialty 22.
Medical semiology in Colombia
Medical semiology is probably the only academic ac tivity that is exercised by appointment due to the curious custom of some healthcare administrators who consider it to be a "foster home" for their protégés until they achieve a better professional position. No prior training or evalua tions are required. Once appointed, they are admitted to the Semiology Units to teach as instructors or, worse still, as "professors" but, after a few months, they migrate toward their long-awaited specialty and leave a vacancy which is rapidly covered by another protégé with the same charac teristics. This explains why there is such a high rotation of teaching staff every semester.
Medical semiologists are no exception to the straitened compensation that characterizes university teaching and lack the incentives to foster their development. This may be one of the reasons why research is notably absent and the contributions to knowledge are limited to a few publi cations of almost always debatable quality.
Furthermore, since they do not have the category of "specialists," medical semiologists do not have the privileges of specialties, which healthcare administrators take advantage of to maintain the precarious conditions mentioned previously. It should be clarified here that these authorities believe that the medical semiologist's job is to "teach class." They believe that teaching class is an activ ity measured by the hour, and therefore assert that a class lasts one hour, and that this hour's price is similar to that of other healthcare workers.
This way of thinking disregards the fact that "teaching class" is only a very small part of the educator's true mis sion, which consists precisely of that: educating. There are digital resources available today for communicating sci entific information that surpass the educators' intellectual capacity and are used by them as complements and not as the goal of their work.
The diagnostic instinct
The medical act is a moral act, recognized as such by the government through the declaration of medical autonomy, with all its privileges and obligations. Consequently, physi cians should make a constant effort to fulfill this contract and thus obtain the respect of the community.
One of the strategies used to achieve this goal is for physicians to be convinced that they need to become per petual students, acquiring the necessary skills to diagnose appropriately. This is where medical semiology finds one of its clearest objectives, as identifying the signs of disease provides physicians with the information which, when subjected to synthesis and analysis, allows the most relevant diagnostic hypotheses to be proposed. Learning to obtain the information, synthesize it and analyze it scientifically (in other words, reflect on it technically), constitutes one of the goals of medical semiology.
If we accept one of the many definitions of "instinct" as the ability to carry out unlearned actions well, we could affirm that the instinct of wonder is present in all living be ings, including humans. It consists of performing repulsion and attraction maneuvers in the face of strange facts, things that are not part of what is common or routine.
Medicine appears to have emerged as a response to the wonder of those who experienced different, anomalous and unexplainable sensations. It is similar to what happens to a medical student when she sees that her patient, the real one, the one she has in front of her, tells her that he's "short of breath" instead of saying that he has "dyspnea." The patient continues to express his symptom in the way and with the phonetic and verbal resources he has available because, as has already been stated, diseases do not read medical textbooks. Therefore, the patient's version leaves the surprised student with many gaps that are transformed into wonder, a concerning sensation that forces her to find out more about the patient's complaint. In her search, the student notices things like the fact that the symptom never appears alone, but that through a proper technique, she can transform the instinct into a standard procedure. Thus, she begins to recognize the existence of medical semiology. This minimizes the errors already mentioned by Beckman (1984) 16) (23, Makary (2027) 24, and Cooper (2021) 25, which are ultimately summed up as the expression of errors made in patient care.
Medical semiology teaches students the importance of maintaining the capacity to wonder when faced with something strange; that there is a way of detecting and understanding since, based on pathophysiology and medi cal semiology, the patient's situation can be understood in a way that is similar to what they have read in the medical textbooks. This process begins with history taking, physical exploration, medical reasoning, the development of a diag nostic hypothesis, and confirmation with complementary resources. In other words (and it must be repeated), using the scientific method 26.
As Kassirer says, the diagnostic process is an example of unstructured problem solving 27, a constantly repeat-able process consisting of several stages: a) Gathering data (the symptom never appears alone); b) Deducing all you can from the information obtained (activation of the pertinent hypotheses). It must be added that any technically obtained data is able to activate a hypothesis. Therefore, many hypotheses may arise; c) Challenging or reaffirming the hypotheses obtained; d) Establish ing which hypotheses have withstood the challenge; e) Proposing a list of hypotheses in descending order of importance; f) Proving the hypotheses; and g) Proposing the diagnosis as a work plan.
Medical semiology is the scientific discipline that teaches the way in which the previously outlined steps should be followed. When done in this way, the likelihood of being correct increases significantly, with an unquestion able benefit for the patient and a notable reduction in cost, because it also teaches how to use the medical technology that is so effective but so costly. To say it another way, medical semiology teaches students the process of learn ing to think like a physician and to identify, with at least relative ease, the sick individual.
Pathophysiology and medical semiology play a primary role since they are the proof that the medical act can be a scientific act governed by the scientific method but based on an indispensable humanism. The combination of the scientific act and humanism will result in a medical act in accord with the academic demands, that is compassionate from an ethical perspective, effective from an academic perspective, and efficient from a financial perspective 28.
In conclusion, we can say that there are very valid argu ments for both pathophysiology and medical semiology to be accredited as medical-surgical specialties in Colombia.
