Monday, October 3, 2016

#6

Doctors: Redefined

I always imagine this kind of picture when someone mentions the word doctor: doctors always look so cool to me, especially when they are working in their white coats, a stethoscope lingering on each neck. Since I was 17 (which also was the first time I considered medicine), I held this specific belief of what a doctor should be. Obviously at that time I did not have much exposure of what it meant to be a doctor. In fact, my thoughts on doctors were purely based on what the media fed me, from those unrealistic television series that never, not for even one second, portray what it’s really like to be one.

Little did I know, as I embark in this journey of literally becoming one, I was forced to reevaluate my definition of being a doctor. After almost 2 years in training, reality hits me hard in the face after having a lot more exposure of what it’s like to be a doctor. Tutorial after tutorial, I am reminded time and time again on how huge a responsibility doctors should shoulder on themselves. As a doctor, we do a lot of things. We are taught to obtain a thorough history, do physical examinations, leading to countless investigations to rule out differentials until finally we come to a definitive diagnosis. It is probably not difficult to gauge how much time and effort spent to come up with a diagnosis. This year, it has come to my attention that as a doctor, we have to care the human side of a patient too. I have seen the high level of importance of carrying out both duties of ‘cure and care’ as I learnt more about biopsychosocial model, mind-body connection and whole person care throughout the year.
           
Having gone through a few encounters with patients in tutorials these 2 years, we have never failed to ask one or two questions on their experience with the health system as well as getting advices for us, future health practitioners. I saw a similar trend on their answers, which are well summarized from a paper I found:
1.      Competence
2.      Concerned
3.      Communication
What patients want in general are a physician who is competent, concerned about them as individuals, listen to them, be honest to them and take time to explain things on their level.2 From these 3 characteristics, 2 of them have no real connections to science of diseases but rather just about feelings, emotions and many other humanly factors in treating patients.

During my community visit in late May this year, I met with Ms L S, age 45, who has Cushing’s disease secondary to pituitary tumour. She has had a surgery in attempt to remove the tumour, however the surgery had not been successful to remove all the tumour cells. The tumour has caused her fatigue, muscle wasting, necrosis of the hip, blurry vision, decreased concentration, central obesity and diabetes insipidus.

Ms L S case was a really interesting one as compared to my other classmates’ cases. At this point, we had not heard anything about Cushing’s disease at all since we had not learnt it just yet.  So everyone seemed to be very interested during the presentation. I had to admit, it was very intriguing to know all about the disease and treatment, however I must say Ms L S’s whole experience with the health system was actually far more remarkable and thought-provoking to me at times.

It was an undeniably horrendous process that Ms L S had to go through to have herself diagnosed with Cushing’s disease. She is a very well educated patient. She knows what is going on with her body and all the treatments that she is on now and also if there is any optional treatment for her. Unfortunately, most of the time she was not being listened to by the medical staffs and that was really frustrating her. It took her years to get diagnosed just because her GP did not listen to her when she said she needed to do this and that tests based on her own research from the Internet.  However what really stuck in my mind after an hour or so session with her was when she said she still had the symptoms after the surgery but the doctor dismissed her very quickly by saying:

 “You had the surgery, you should be cured by now.”

 The doctor said this not once, not twice but he said it for 9 times. Imagine listening to this for 9 times and you still did not feel any better at all. How frustrated can you be?

Unfortunately, the worst thing happened. 3 months later during the follow up session, they found the remaining tumour left in the hypophyseal region. As if it was not bad enough for her, she developed diabetes insipidus post-surgery due to some damage to the posterior pituitary gland and has to take desmopressin for the rest of her life as the consequence. I still could not completely forget how she finished with a very deeply hurt sentence (during the follow up session):

“You know what, if only you’d listened to me before.” 

Note the lots of despair and heavy frustration in just one sentence.

It did not occur to me the importance of whole person care until I had this conversation with Ms L S because why would I care if the patient is coping or not?
Or have enough money to buy good food?
Or having crises just before they come to the clinic?
 There are not my problems.
Honestly I cannot be any crueler than that and it is so depressing to think that I have to care about it. However, regardless, I do really have to care about it because every single thing that happens in their lives is impacting their health and wellbeing. There are significant evidence on having stressful events in life could bring about health problems.3 Anxiety could worsen a heart attack. Panicking exacerbates asthma, just to name a few. We are taught to give reassurance to patients to manage this and not so much on other things because the mind and the body are really connected that when we alter one part of it, the other part just follow through. It is all making sense why I should care about the human side of a patient.

The concept of whole person care is actually significant in patient management. From the HIC booklet, ‘Whole Person Care’ is combined attention to both the disease and the person of illness or in other words, to both goals of ‘cure’ and ‘care’5 and to be a whole person practitioner is defined as one who is competent to manage disease and respects the individual in the context of his or her illness experience1 It means that on one hand, a doctor should try to identify and manage the disease also acknowledging patients’ illness experience and suffering on the other. In reference with Ms L S case mentioned above, certainly she was not respected as a patient and as a person by the medical practitioners.

I was lucky that we are exposed to the ‘care’ side of medicine very early in our training. However, I do not think I ever care about it as much as I care about other things. In fact, I failed my HIC component during ELM2, I thought I could do it at the back of my mind, I was wrong.  Apparently, I still need to learn how to be empathy and know how to deal with strong feelings. I believe that the medical school has done their best in trying to nurture essential values in us and it is not like we have not learnt it enough, but there are always more pathology, anatomy, bugs, drugs and whatnots that are deemed more ‘important’ than just thinking about how to deal with emotions. I bet it is not just me, but somewhere along the journey, I inherently losing some humanities in me to make sure I am able to do the ‘cure’ side of medicine.  It is such a shame that I had to choose between the two, when both of ‘cure’ and ‘care’ are equally important in patient management.

I presented Ms L S’s case earlier to illustrate how ruthless it could be if doctors ignore the human side of a patient. I was and still am appalled with what I heard from her, that I never thought that it has a really big impact on her. Nevertheless I learnt a lot from her and her experience. I hope it would be a good reminder for me to not do the same thing in the future.

No doubt, I feel quite overwhelmed sometimes with the burden from high amount of expectations that are sought from doctors by the society. Apart from being pressured to know everything, mistakes are seen to never be acceptable for a medical practitioner.  More often than not, I found myself doubting my own ability on carrying out our main job as well as fitting in into these expectations. Doctors are humans too, in every sense of the word. And humans are not perfect, hence we are subject to fallibility.4 I should take courage in admitting mistakes, and acknowledging my own limit as a human, and that it is definitely okay not to know everything. It is undeniably difficult to conceit defeat to our own imperfections due to the nature of being a doctor – that everything has to be perfect, and one small mistake could be potentially fatal.


Even so, I should work hard and give my best to be a good one, an all-rounded doctor, now that I have a new definition of what a doctor should be. 

References:
1.      Davis, R. (n.d.). Whole Person Care: A New Paradigm for the 21 st Century. Journal of Palliative Medicine, 623-625.
2.      Martin, S. (n.d.). What is a good doctor? Patient perspective. American Journal of Obstetrics and Gynecology, 752-754.
3.      Scheneider, Riffle, T. (2012). Stress and Illness. In Encyclopedia of Human Behavior (Second Edition) (pp. 536-539). Elsevier.
4.      Templer, P. (Director) (2015, August 12). Adverse Outcomes and Patient Safety. Lecture conducted from , Dunedin.
5.      Wilson, H., & Cunningham, W. (n.d.). Being a doctor: Understanding medical practice.

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:)

there's always a little truth behind every "JUST KIDDING ", a little knowledge behind every " I DON'T KNOW ", a little emotion behind every " I DON'T CARE ", and a little pain behind every " IT'S OKAY "