The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 31: Documenting conversation

In busy consultation time, recording the conversation with the patient/attendant, is not always possible in our set up, but this is routinely done in some western countries, to avoid misunderstanding later. In some centres, the entire proceedings are video recorded and preserved, to be reviewed in the event of a dispute. The office secretary transcribes the conversation dictated by the Doctor, prints it in the file. The patient, while leaving, reads and signs it, to indicate his agreement with what transpired.

For example, the consultant had suggested the patient to undergo gastroscopy, on some suspicion of a gastric lesion. The patient was not prepared at that time and said he’d undergo the endoscopy during his next visit after a month. He never reported for review as scheduled, but after a few months, when his symptoms worsened, he went to some other Doctor, who performed endoscopy and detected cancer stomach.

If the conversation with the previous Doctor was not recorded, there is a possibility that the patient could complain that the disease would have been picked up much earlier, had the Doctor suggested endoscopy last time.

Another simple viable option is, to make a note on one corner or on the reverse of the prescription paper, any important investigations or consultations suggested to the patient, but not done. This will serve as a proof that you advised, in the event of a dispute.

“Reflexes seem normal. You kept him waiting over two hours.”

Chapter 32: Counselling

Since many diseases are self-curable, ‘medicine is an art of entertaining the patient, while nature cures him’

This is an integral component of our daily activities and requires, besides grip on the medical science based on a strong rational foundation, astute communicative skills and diplomacy. A diplomat is one, who tells you ‘go to hell’ in such a manner, that you actually look forwards for the ‘trip’.

An American Psychologist did a study to find out why public litigates against Doctors, interviewed several persons involved and concluded that the main culprit was inadequate or inappropriate communication. In Indian scenario, another factor, self-centered behavior of some Doctors such as, lack of empathy towards co-practitioners and the so-called one-up-manship (vide infra), may be added.

It’s suggested that certain antisentimental words, such as cancer, malignancy, TB, death, mortality, fatality etc, to be avoided, as much as possible, during counseling. Instead terms like bad tumor (or it may turn into something bad), bad lung infection or unfavourable outcome, may be used respectively.

To a patient, who came with advanced malignancy, beyond the scope of surgery, it’s much better to say that ‘you don’t require surgery’, than to say ‘your disease is too far advanced that surgery can’t be done’ or ‘surgery is useless’. The colloquial term ‘current treatment for radiotherapy, also to be discouraged, instead ‘x-ray treatment’ is more acceptable.

If you are planning for surgery, the pros and cons of nonsurgical options, if any, also have to be discussed. We must remember that the patients sometimes wait for days or weeks to see us, just for a few minutes and every word we say will have profound impact in his mind and influences his emotional balance.

It’s said in lighter vain that if a patient refuses surgery for his symptomatic hernia, inspite of adequate counseling, you ask him ‘go to hell’. But make sure he goes only to hell, since there may not be any ‘good’ surgeon in heaven, if he wants to get operated there.

Two questions, often asked by patients before surgery, difficult to answer:

1) will I be alright after surgery ? We should tell them, no guarantee would be given and ask them, if they could give 100% guarantee to go to Central station and return. ‘We surgeons only cut and stitch, god (nature) heals’

If so, to expect total assurance for a major surgery is unfair and we decide for surgery, since the risk/benefit ratio is in its favour.

2) Next question is if the patient should write the Will (for his properties), before surgery. This is more sensitive issue, suppose you say, ‘yes, I think it’s a good idea’, in all probability, the patient may not come for surgery. If you say, ‘no, it’s not necessary’, it may turn out to be a wrong advice, since no one can be sure of the outcome of any procedure.

I found an answer, ‘your surgery is scheduled for next Wednesday, is there a guarantee that you will be alive till then’. To dilute it, you may add ‘will I be alive till then ? Surgery is only one event, but there are many risky situations in daily life, such as going by flight, travelling by train, crossing a road etc. which we accept and carry on. Hence if there’s a need for writing a Will, do it immediately, but not necessarily for the operation’.

You have to realize some cancers, such as papillary ca thyroid in young women, lymphocyte predominent Hodgkin’s, ca prostate, seminoma testis, carry best prognosis, where as some, such as anaplastic ca thyroid, ca gallbladder, acute myeloblastic leukemia (AML), glioblastoma multiformi (GBM) of brain are so bad and considered as oncological disasters.

“Heads, you get a quadruplicate bypass. Tails, you take a baby aspirin.”

Chapter 33: Seed and soil theory

Doctor should be prepared to answer even intricate or insinuating questions raised by the patients, keeping scientific facts in the background. When a patient is diagnosed to have a rare disease, generally he’d ask ‘why me?’.

It’s a human tendency whenever one is faced with an adverse situation, but strangely no one would put that question, when something good happens, say when you win one crore rupees in a lottery or when you become the President of the country. One may call it as luck, but science may not accept it.

Remember the Chinese aphorism: ‘Luck favors the one who doesn’t believe in it’.

Most of the diseases develop as a product of genetic makeup (nature) and environmental factors (nurture). Of course, the former is not modifiable, but the later certainly is. One can choose his father-in-law but not the father. This is where ‘seed and soil’ theory comes handy.

Suppose a few friends met and had some soft drink together. Only one of them develops gastroenteritis, due to suspected food poisoning. When everyone took the same drink, why one person gets it ? Does it mean all the germs got into a single glass? No, though the seed is sowed in every one, only one fellow’s inner soil is fertile or conducive to accept it.

Medicine is a science of uncertainties and art of probabilities, since a drug which can cure someone, may kill another and many aspects of biological behavior of humans are still beyond comprehension to our present knowledge.

Chapter 34: Breaking a bad news

There may be many sensitive situations, when a Doctor has to disclose a bad news to the patient or relatives and it requires very high level of communicative skills. It may be simplified as ABCDEF:

Advance preparation

Build a suitable ambience

Communicate facts & figures

Deal with emotional reaction

Encourage free communication

Final summary of plan of action

Of course, the intellectual level of the patient/attendant also largely determines the extent of technical discussion and the type of questions expected from them. It’s very common for the close relatives of a patient with advanced malignancy, to request us to give them an idea about his life expectancy; it’s wise not to commit, since we had seen surprises and miracles. Best answer would be to say that since the genetic makeup and biological behavior of each patient is different and the response to the proposed (palliative) treatment is unpredictable, a specific time frame could not be given. However, they should be advised to ensure that the patient executes whatever documents required, with regards to transferring properties, business etc. as early as possible, while he is fit.

Chapter 35: Expressions to be avoided (preferred expressions in brackets)

Some expressions may generate negative thoughts in the patient or may have legal implications:

Cancer or malignancy

(bad tumor or growth)

(bad lung infection or Koch’s disease)

Leprosy

(chronic skin infection or Hansen’s disease)

Death or mortality

(unfavorable outcome or results may be bad)

5% mortality

(95% of them do well)

Situation is hopeless, nothing can be done

(science is so advanced, let’s see if something can be done)

Disease is too far advanced

(never too late, but you may not require surgery)

Postop incisional hernia

(ventral hernia)

Drug-induced gastritis

(stomach upset or some thing you ate, didn’t agree with your stomach)

Drug-induced renal failure

(kidney dysfunction)

Antibiotic-induced superinfection

(opportunistic infection, when the resistance is low)

Spinal (anesthesia) headache or shock

(low or unstable BP)

Postop neuralgia

(nerve irritation or pain)

Injection abscess

(abscess due to some infection)

Similarly, never guarantee a cure, especially on statistical grounds. For patient with a problem requiring surgery, which carried 90% risk, nobody was willing to operate.

One surgeon ‘confidently’ agreed to do it and assured the skeptical patient by saying ‘it’s true that 9 out 10 don’t survive, but since previous 9 patients for whom I did the same operation died, statistically you should be alright’.

Earlier days, Doctor could ask the patient putting irksome questions, ‘who is the Doctor, you or me ?’ But now an informed patient will shoot back, ‘of course, you are the Doctor, but you’re planning surgery on me, I have to know the score’.

“Apparently you contracted a virus from your computer, so we had to erase your memory. I trust you had a backup copy?”

The Consultation Room

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