Provisional History

     A patient was admitted with pain and swelling in the left inguinal area. The casualty officer doubted it to be an irreducible hernia and got an ultrasound examination of the swelling. Ultrasonologist felt it to be an inguinal abscess, but did not want to rule out a grave possibility of irreducible hernia. He was taken to the Operation room for exploration of the swelling. On exploration it was found to be an abscess with abscess surrounded by indurated and inflamed tissue in the subcutaneous plane. Every thing was superficial to the External Oblique fascia.

      After the surgery the house surgeon asked the operating surgeon, “Sir, I have written the history for obstructed hernia, shall I change it to the history for inguinal abscess?”

PS: History: patient had an insect bite at the area of inguinal canal 3 days back. He developed severe pain and swelling following the bite. He never had any swelling in the inguinal area previously.

The important lesson

         Communication is the center pillar of a successful surgical practice. Long years in medical school and hospital practice make surgeons accustomed to the blood and pus. It is easy to explain the possible complications of a disease to a medical student. But only a surgeon can understand the chance of collateral damages associated with a surgery in a difficult situation.

        Some days ago my professor was called in to gynecology operating room. They had opened a patient for a large ovarian cyst. The patient had history of four abdominal surgeries. The gynecologist made a rent in the rectum while separating the adhesions in the pelvis. There was bowel contents were released to the peritoneal cavity. Considering the nature of injury and comorbidities, my professor advised a covering colostomy after repairing the rent. Now the difficult part was to get things explained to the relatives. They will never understand how difficult it is, to operate in an abdomen with adhesions; they will never realize how easy it is, to get bowel injury while separating adhesions, even with utmost care. But my professor handled the situation very smartly. He met the relatives and explained them, that the tumor was adhered to the rectum. The options left were to leave the part of tumor or remove the tumor completely with a part of rectum, for which a covering colostomy is required. The relatives were happy to agree to do the colostomy.

         This incident is a story about my professor in medical school. He did a thyroid surgery; unfortunately the recurrent laryngeal nerve got damaged on one side. He could identify it on the table itself. He went to the relatives and explained about the patient condition. He said “I was in a difficult situation during the surgery, I had to choose between the life and voice of the patient. I asked God. He told me, life is more important than voice. So I had to do it that way. So patient may have some change in the voice, but thank Him for giving back the life.”

Revelations

         I started working as a teacher in the department of surgery at a private medical institution in my home state. A month has passed and I understood two things, relevant to situations, which I never encountered previously. First thing is related to my views about teaching in medical profession. Second thing is about hospitality and patient communication in a private setup.

          Regarding teaching as a profession, this short period has opened my eyes wide. The difficult part of teaching is not transferring the ideas, but maintaining discipline and motivating. Sometime before, I had written, that education is about making people capable of thinking at a higher level.  I developed this clarity about my profession only after some years after entering college. It is very difficult to make a young man or woman open up their mind. They remain unfocussed even after repeated advices. Taking classes for the undergraduates is very easy. I know what I am teaching. I have the experience of treating patients. I know how to conduct a good session on any topic related to my practice. But guiding the students to think out of the box, or motivating the house surgeons to go to the bottom of a treatment plan, is a herculean task. Teaching is easy, but educating is not easy. That is the feature, which keep some teachers apart from the rest. It also requires being strict with the rules. Students and house surgeons are in the constant process of thinking how to avoid responsibilities and how to disappear from the duties. The capability to motivate the students, the capability to make the students think of their own; It’s like starting a campfire from damp wood. Until it gets going by its own, one has to struggle a lot. I now realize why teaching is considered as one of the greatest professions in the human civilization.

           Second revelation was about the hospitality, while practicing in a private setup, where the patients pay for the treatment by themselves. Except for a short period as a casualty medical officer, I had always worked in government run hospitals. I had developed a reasonably good communication skill and I considered myself good at explaining about diagnosis and treatment plans to the patients and relatives. I remember most of the patients were happy with my communication. But there used to be some patients, mostly patient relatives who are unsatisfied with the logistics or discontent with the functioning pattern of the hospital facilities or staff. In such situations, I used to defend the hospital and staff pointing out how good we cared for the patient regarding the disease management. But in a private hospital a whole new realm is added to a doctor’s practice- hospitality. Now sometimes, I have to keep my pride away and talk like a customer relations manager in a showroom. I have to make them feel like; the staff in a hotel or some kind of tourist center treats them. We are not supposed to fight with them. We are not supposed to make them correct. Only thing we can do is to make them happy, make them feel they are served right and decide what they want. Now I am working on it.

Seven steps in OP Room, that makes your patient comfortable

     So many things are taught in medical school about communication, examination and disclosing information to the patient. Here I would like to share some points, which I learned during my residency.

 1.     Give privacy to your patient: Close the room when the patient walks in. Ask your non-medical staff/ assistant to wait outside while talking and examining the patient. This will also help to prevent the tendency of patient to talk in a low voice and as a result, come closer to the doctor’s face during conversation. Always try to keep a safe distance from the patient while talking.

2.     Request the patient and attender to sit: I have always watched that the patient and attender feel comfortable and happy when I ask them to sit before starting conversation. Most of the patients will sit even if you do not ask them to. But offering a seat helps to make them open up. People have told me, how good they feel, when the doctor offers the seat.

3.     Elucidate the history with some leading questions: We have been always taught to avoid leading questions while taking history. But in practice, there will not be sufficient time to hear the elaborate stories of our patient. It is unrealistic to expect information in the form of  ‘presenting complaint x duration’ format from the patient. Most of the patients will be anxious and do not know where to start. Often they start with the least bothering symptom and half the time, they are in a hurry to show the ultra sonogram or CT scan report even before starting the conversation.

4.     Washing hands and wearing gloves: Hand hygiene is very important, not only for preventing infections, but also as a part of good manners. Ensure you wash or use an alcoholic antiseptic solution before and after touching a patient. Wear examination gloves whenever required. Examining the patient without such prerequisites is disrespecting the patient. Washing hands and using antiseptic lotions help to build confidence in the patient about your safe practices. After all, no one wants to put himself or herself before knife under a careless surgeon.

5.     Never turn your back until the patient gets down from the examination table: Our professor taught this dictum. It may seem silly, but if you are not in the habit of doing it, you will see your patient falling from the examination table now and then. The examination tables are made narrow and tall for the comfort of examining doctor.

6.     Explain the disease to the patient and treatment options: This does not need further elaboration because it is a thing, which we cannot miss. There are many ways to do it and the polite, lucid explanation is always the best.

7.     Refer the patient to appropriate specialist: Try to refer the patient to a person who has the knowledge and skill to manage their condition, if you are not the person to do it. Rather than just referring, you can tell them the easiest way to reach that specialist. I believe that, fifty percent of the disease gets resolved as soon as the patient reaches the right person to treat it.

       I haven’t described anything new. But making a conscious note of these things help to improve the patient interaction over a period of time.