Why did society appoint the title of 'Doctor' to medical practitioners? Some years ago I came across a book describing the meaning of the word 'Doctor' as 'Teacher', where patients were educated by practitioners about illness, how the medical world has come to understand illness and the possible remedies available.
In the olden days, the relationship between doctor and patient was paternal. The doctor would simply instruct the patient how best to approach their illness and essentially make their management decisions. In today's era, where such a large of volume of information is available at the click of a mouse or tap on a touch screen, patients have become the central decision making body, along with their family and friends. If patients do not have the insight or autonomy to make informed decisions, a public body may be appointed to make decisions on their behalf. No doubt there are hundreds of pages of ethical discussions surrounding the concept of informed consent and decision-making on behalf of patients, and I would be beside myself if I thought for a moment I understood the depths of those discussions.
However, what I have noticed is the lack of education that patients receive from their doctors. And to sit in a lecture and be taught that "psychoeducation is a fundamental component of a patient's therapy" as a senior medical student alarmed me. Students can get lost in all the dimensions of disease, their epidemiologies, risk factors, aetiological theories and the various management algorithms that are available in the large arsenal of pharmacotherapy and surgery.
So then how are we to help our patients if we do not educate them? It is very interesting to interact with people from such a vast array of experiences, education and careers. To educate them about their illness is a privilege in itself. But patients continue to complain about the lack of education they receive, the counselling they long for and ultimately the respect they deserve.
Ironically, doctors get frustrated with patients who walk into the clinics with 10 pages printed from Google saying that "Cranberry juice can effectively relieve symptoms of incontinence" and are inflamed when they are asked "but why doesn't this work?"
This brings me to something that happened at work last Sunday. It was quiet in the morning and little did I know the afternoon was going to be chaotic, but on I went with my morning with some tea and procrastination. The phone rang and on the other end was a patient who wanted to re-schedule their appointment. The study was for a CT Abdomen & Pelvis, which more often than not requires contrast (ie dye to highlight either the gut, or the blood vessels). The receptionist who scheduled her initial appointment told her about the oral fluids that would highlight her bowels, but did not mention the injection for the blood vessels. So when I explained that aspect of the study, Abigail was rightfully shocked. She calmed down after I answered some of her questions. At this point in the conversation, I was a radiographer and she knew nothing about my medical education.
She decided to ask me "so why do I need this study?"
Has your doctor explained why you're having this done?
"Well, I just moved up here and my friends recommended this GP who's apparently very thorough and I told her about my grandfather dying at 93 from bowel cancer and she decided to order a blood test. She called it a Ca 19.9, which was slightly elevated and then she did it again and it was even more elevated! She asked one of the other GPs and they recommended a colonoscopy but she thought we'd start with a CT scan."
I understand.
"But why is she ordering a CT scan? What's that going to show?"
"Okay. If this is elevated, does that mean that I have bowel cancer?"
Not necessarily.
"But it's elevated. Why did my doctor order more tests?"
She may very well be thorough and wants to be aggressive to look for things because of your family's history of bowel cancer.
"So that means if there is bowel cancer, the CT scan will pick it up?"
It may well pick it up, but there is also a reasonable chance that it might not.
"So what happens if the scan is normal?"
Well, it may be that she continues looking for the cause of your abnormal blood test.
"You mean a colonoscopy?"
Maybe. I'm not sure.
"So if I don't have bowel cancer, why is this blood test abnormal?"
That's a good question. It could be that the blood test is slightly elevated, but have you ever had this blood test before?
"No."
Well how do you know it wasn't elevated 10 years ago?
"I don't."
Exactly. A pathology laboratory determines a normal range by getting thousands and thousands of results, applying all sorts of fancy statistics to them and look at what the most common numbers are in people that do not have illness. So it could be that you are the lucky one that has a slightly abnormal test but that's normal for you but outside the norm in the majority of people. Does that make sense?
"Yes. But it could also mean I'm the unlucky one walking around with bowel cancer at the age of 40."
Maybe. But I'm sure the doctor asked you some questions about your bowel habits?
"Not really."
Okay. You do realise I have over-stepped my professional boundary about twenty minutes ago?
"I'm aware. But please help me... I'll keep the information to myself."
Have you experienced any change in your bowel habits?
“No, they are regular.”
Okay. Have you lost weight recently?
“Yes I have. I exercise regularly but 3 months ago I broke up with my partner and have recently taken up smoking. I also haven’t been eating the same since. I’ve lost about 6 kilos since we broke up.”
I understand. It could very well be that this weight loss could be due to the impact of the break up on your life. It could also be due to a sinister cause. Perhaps this is the reason why your doctor is ordering the CT scan.
“But I didn’t tell my doctor about the weight loss.”
Why not?
“She told me she had to go. I only spoke to her for about five minutes. But the first time I saw her it was for half an hour. She just had some personal things to do.”
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| "It won't be long" |
This conversation went on for almost an hour, but by the end of it, Abigail was quite happy that her concerns were addressed. I was happy to talk to her given that work was very quiet that morning. I was also saddened by the fact this poor lady had been in such psychological distress about her abnormal blood test and the underlying reason for this was her doctor’s lack of commitment. The GP obviously had other [personal] commitments, which to some extent is understandable. If it is encroaching on your ability to see your patients and even worse, if it is denying you the ability to develop a therapeutic relationship, then I don’t see the point in having professional commitments.
The role of doctor as advocate is sadly one being continually eroded, despite all the evidence and exonerations to use their amazing potential as placebo, or to cause change through brief interventions- they ignore and shy away from the role. Sometimes thought there is serendipity at work- and that was at play when Abigial was lucky enought to meet you. One very relieved patient went home that day - job well done
ReplyDeleteIt's sad that doctors are meant to be the primary providers of health care, and yet they are so busy that they simply do not have the time to explain even the most basic of concepts to their patients before they scoot them out the door.
ReplyDeleteIt's a fundamental flaw in the system.
Across various rotations, I've seen a number of consultations where doctors attempt to explain things to their patients, but it's often too hurried and occasional medical jargon slips in, and then before you know it, the doctor is gone in a whirlwind of 'I have somewhere else to be' and the patient is left with a confused look on their face. And as the medical student I see all this and know exactly what the doctor meant to say, should have said, and yet I don't feel it's my place to step in and explain it (in case I got it wrong or in case it gets back to the doctor and they feel that I've undermined their authority and overstepped my boundary), and if I stop and do so then the team will already be 3 flights down the stairs and have forgotten about me.