|ART OF MEDICINE
|Year : 2020 | Volume
| Issue : 3 | Page : 101-103
The way to a patient's heart: Simple recommendations for a resident doctor
Saurav Khatiwada, Hiya Boro
Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||22-Mar-2020|
|Date of Acceptance||23-Mar-2020|
|Date of Web Publication||20-Jan-2021|
Dr. Hiya Boro
Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Khatiwada S, Boro H. The way to a patient's heart: Simple recommendations for a resident doctor. Thyroid Res Pract 2020;17:101-3
A lot has been said and done on doctor–patient relationship since the Hippocratic era. By the time one graduates from medical school, one is more or less abreast of the do's and don'ts with a patient.,, During residency, trainees follow some of these principles while they also tend to design some of their own to make survival easy among the heavy workload and the singularity of their medical environment. We are all formally taught in medical school to fully communicate with patients. One of the most common customizations to this principle in residency is of limiting communication and maximizing work while dealing with multiple patients. No one advises a resident doctor for the same formally, but it tends to happen spontaneously due to the sheer pressure in a high workload center. Unfortunately, over the course of years, these brief authoritative or harsh verbal dealings with patients and their caretakers become maladaptive habits. If not managed on time, this leads to degrading competence on a doctor's part coupled with an environment of misunderstanding, distrust, and ultimately an unsatisfied patient. It is, therefore, necessary to keep introspecting and analyzing our approaches in residency. Subtle modifications to these approaches with awareness can go a long way in shaping one's career as a loved clinician for patients and as an astute practitioner on one's part. Here are some of our suggestions to satisfying one's patients while still maintaining efficiency at work.
| Respect the Patient's Viewpoint|| |
Often while seated in a specialty OPD, when a new patient walks in, the resident is keen on getting to a diagnosis as soon as possible, that is, with minimum time and words spent and disposing him or her off with prescription, obviously for the ample number of patients waiting outside impatiently. Here, the resident has his or her perspective clear, that is, quick diagnosis and management, just as the books tell (or as “up-to-date” suggests in a difficult scenario). Yet what he/she fails to understand is that a doctor's agenda may not match with that of the patient. Patient's interest is not merely the management of the medical diagnosis a doctor makes (or has already been made). It is more importantly the solution to his or her perception of the disease and its mental and physical pain. Understanding the patient's viewpoint and solving the issues are equally important. This is because once a resident acknowledges patient's frame of mind, one can gain his/her trust and respect. With this trust, the patient follows the resident's advices more diligently in future. This is thus a win-win scenario with both doctor's and patient's interests fulfilled.
Example 1: A female patient comes to an Endocrinology resident with report of subclinical hypothyroidism (not mandating treatment) which she had undergone for generalized body ache. The resident sees her report and dismisses the concern that subclinical hypothyroidism is responsible for the same. The resident then gently asks her to leave, advising her to visit a physician. The patient then walks back disheartened, without finding any solution to her maladies and also restrains the information that she has actually been sent by a physician to an Endocrinologist. Had one gone into the depth of her symptoms, one might have uncovered anemia, moderate-to-severe depression, domestic violence, sleep apnea, chronic fatigue syndrome and so on, as the possible explanation for her symptoms and would have directed her more effectively. At the end, one could have explained about the futility of treating her sub-clinical hypothyroidism or might have initiated a trial of thyroxine based on etiology. However, the fixation on a doctor's agenda (to treat or not to treat the subclinical hypothyroidism) costs one the opportunity to solve the patient's plight.
Example 2: A patient with poorly controlled diabetes mellitus (DM) with erectile dysfunction (ED) walks into a crowded OPD. The resident discovers over the course of history-taking that the patient has a casual attitude to glycemic control. One's knee jerk response would be to point out the patient's shortcomings with glycemic control and emphasize on diet, lifestyle and anti-hyperglycemic agents (AHAs) first. Then, when the patient finally asks timidly about the ED, this time with a bit more gravity, the resident prescribes him a medicine or suggests him methods to overcome the issue. In this situation, the patient has to fight for his interests against the doctor's. Back home, he might just end up using the medicine prescribed for ED, maintaining his negligence toward AHA, diet and lifestyle modifications. A different approach for effective results would be to pick up his concern about ED first, perform appropriate focused history and physical examination (which hardly adds much time to one's consultation) with/without further investigation, and finally prescribe him the required medicine. Once this is attended to and the patient tunes with the resident for more words of wisdom, one can then easily push one's perspective on glycemic control with good emphasis. One is more likely to get a better glycemic control with this approach.
| When Patients Tell Doctors Their Problems, See Through Their Eyes|| |
It is an art to be able to read between the lines when a patient communicates with a doctor. One has to practice it and be a keen observer, especially when one is not able to solve the patient's multitude problems. Manyatimes, our patients have behavioral problems whose solutions are straight forward to us, at least on superficial observation, but are hard to mend. For example, a patient with Graves' disease may not come with timely visits and thus may have uncontrolled disease each time one sees him/her. It takes respectful and keen listening as well as an active enquiry into the patient's psyche, his/her personal, financial and occupational circumstances or even family beliefs to finally catch hold of the root of the problem. He/she will open up to a doctor only when the latter treats him/her without being judgmental throughout the conversation and also, without any ridicule. This will help the resident facilitate the patient for a timely visit. Similar story can be anticipated from a patient with DM not complaint to a healthy diet practice and hence coming with poor control in each visit despite explicit dietary advices. In summary, a doctor has to be on the patient's side even for the lamest of their problems to be able to help them out.
| While On Rounds, Always Use Respectful Words for the Patient|| |
In South Asian teaching hospitals, we often present rounds to consultants referring to patients sitting on the bed as a third person. The problem is often in the derogatory translation of “he/she” in Hindi/Urdu/Nepali (“Yeh”/“isne”/“esle”) instead of respectful tone with “Inhone” (Hindi/Urdu) or “wahale”(Nepali). In addition, the complete details of history which the patient has confided to the resident need not be spoken right in front of him/her in rounds but can be discussed earlier or later. These two sensitive issues need to be addressed by residents to make lives comfortable for the already grief-stricken patients.
| Communicating On Communication|| |
It is always advisable to be available to patients and their care-givers for communication but that's easier said than done. Residents usually have very busy schedule right from the morning till night and being available for communication may not be practical. Unless the patient is critical, a few choices that resident doctors can make are:
- One has to adjudicate fixed time(s) of the day for communication and inform patients pre-hand about it
- In case, a patient wants to discuss his/her problems with a resident while he/she is off-duty or already leaving, one could be diplomatic to answer them: “I would love to tell you about this in detail with assemblage of all reports and information and some discussion/analysis of pros and cons of various possible treatment modalities/review of previous cases, it would be best to meet tomorrow at so and so hour. Would that be okay?” Or a gentle request with “May I talk to you on this afresh tomorrow if it's okay with you as I have had a hectic day and am exhausted tonight?” A resident should respect patient's concerns and be gentle with one's words and expression and sometimes, even give them choices. People feel honored when given choices. For example, “Would you like to hear an incomplete detail tonight as I do not have much information now or a full detail tomorrow morning when I will have assembled full information for you?” A resident will get the best possible farewell for the evening with these words.
| The Art of Creating Agendas (Being Diplomatic To Guide Patient's Irrational Expectations)|| |
Often a resident is dealt with circumstances when patients come asking for consultations at untimely hours, asking for expediting tests or results which are beyond one's control. A common way out of this circumstance is to first empathize with their problem, and then tell them why it is not possible at that hour. A third step would be to diplomatically encourage them to follow one's agenda by showing the perks of doing it one's way for the patient. For example, telling the patient that one would be able to see him/her the next day afresh. The key is not being defensive or overtly offensive but “creating an agenda” by leading them to the brighter side of the 'best' way out.
| Treat Patients With Honor|| |
Greeting patients and caregivers in OPD/IPD with “Namaste'/'Adab” and a smile, being friendly and interested, nonjudgmental for their mistakes yet thorough with one's management makes one a loved and effective clinician. A doctor is not merely a prescriber or a preacher of medical literature but also a life coach.
| Harness the Wisdom of Psychology, Social and Administrative Management|| |
Last, but not the least, not all solutions come from medical books. One's patient may just be in need a crude knowledge of cognitive behavioral therapy in dealing with his life problems. He/she may just be in need of solution to an administrative hurdle related to procuring medicines or related to occupational hazard requiring one to deal with public health authorities. Therefore, a resident has to be open to these communications outside the doctor-patient talks to manage one's patients better.
In conclusion, a resident doctor's life in a South Asian medical school is of utmost struggle and hardships, among the swarming number of patients and overburdening academics. In such circumstances, he/she often tends to lose patience and become rude and judgmental toward a patient. In the long run, this may lead to the development of an atmosphere of discontent, misunderstanding, and distrust. Therefore, it is important to understand that irrespective of the circumstances, for a resident to be an astute clinician, the foremost measure is to win patient's trust and this is possible only when one is empathetic and nonjudgmental toward a patient and understands and respects his/her frame of mind. Use of words and directions diplomatically can help avoid confrontation and bring satisfaction to patients in this frustratingly busy atmosphere.
| References|| |
Parsa-Parsi RW. The revised declaration of Geneva: A modern-day physician's pledge. JAMA 2017;318:1971-2.
World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4.