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.

The ‘Learning Curve’ and the ‘Gut Feeling’

I just completed my postgraduate exam in surgery. Thank God, I passed and I am happy that I could perform well in the exam. But the exhaustive preparation that has been going on for the last two months revealed me some realities of academic life.

 I have been in the field of medicine for last ten years. For a surgery exam, one has to be well versed with all the related topics starting from anatomy. Anatomy was my favorite subject during the first year of medicine and I had learned in pretty well. I used to look up the etymologies and tried to learn a little more elaborately than just mugging up. After five years, I had to revise anatomy in detail for my pre postgraduate entrance examination. Now again, I had to do a detailed revision before exam. But the thing I realized was that, even after repeated revisions, when I tried to recollect, it was difficult. It was not that, I don’t remember things; rather things were getting messed up in the head. There was an explosion of several things or feeling of mining out something from depth.

Second thing, there was no more surprise questions. During the undergraduate time, it was common to see new terms or diseases, in the exam question paper, that haven’t heard off. Later we had to search through the textbooks to find them. But now, it is rare to come across a new term. But this does not mean that I know what that term means. I know I have read about it, but I find it difficult to recollect about it.

While reading a book, I have started to appreciate things that are mentioned in subtle way, but have a greater meaning. For example, while describing a surgery, the author may have mentioned things like where to cut, what direction to cut, where to hold etc., which did not make much of sense in early years of medicine learning. More depth of knowledge is felt while reading the same lines that I read some years ago.

I wonder, what was the purpose of all those hard-core physics and higher mathematics, which I learned in the pre medicine classes. I was fond of solving those problems and used to feel authoritative on those things at that time. During that time, I thought I would never forget those theorems and formulas, because those were so thorough and I could do calculations at flick of my thumb. But now, I even find it difficult to calculate BMI, without a calculator.

My aim is not to point the inadequacies of the education system, but to look, deep to my own brain activities. Has it reached its memory limit? Why cannot I recollect things, when I need, at least those which I spend time to memorize? I had a feeling some years earlier that everybody had the same capacity to memorize and learn. But now I recognize, everybody have different capabilities, the reason why some find it difficult to learn things the traditional way. I can say this, because working in a premier institute of the nation has given me the opportunity to meet people, some of whom are extraordinarily brilliant. I have considered myself an average intelligent person and I know, when I work for a thing and when I don’t work for a thing. I have seen how these people simply drift through situations, which I have to struggle to.

I am not at the brim of a nervous break down or anything of that sort, but definitely now I can imagine how things can go wrong if someone tries too hard on themselves. Said this, taking an exam is about strategy and one don’t have to be a super computer to pass any normal competitive exam. The basic thing for good exam preparation is to know one’s own limitations and plan accordingly. Also brilliancy and intelligence are not above compassion and common sense, qualities that are really required for a successful happy life.

It is true that one have to read multiple massive books on their way to become a specialist or super specialist in medicine. But it is not necessary to remember all that stuff all the time. It is not humanly possible. During the early periods of practice, it will take a little time to recollect the important things that has to be taken care off, while treating a patient. As time passes by, all those steps come as a reflux, rather than reasoning out the logic behind it, and the time required to attain that capability is called the ‘learning curve’. This is the reason why the ‘gut feeling’ of the professor is always better.

The wonder drugs

          Recently there was a flood in my country and lot of related things were flooding the social media. One thing I noticed was the list of essential medicines. Three of my favourite medicines were in the top of the list. There are lots of things that need appreciation in the field of pharmacology. But I love these three drugs because of the magic they do. I am sure everyone reading this will have used these medicines more than once.

Acetaminophen (Paracetamol)

This is number one drug. Can you believe this drug has been discovered a century ago? However it required repeated testing and clarifications regarding toxicity before it became available for public use in the second half of last century. Fever, body ache, malaise, head ache, you name it, it is the first thing to be swallowed. I hated the bitter taste when I was a kid.

Till recently I believed that animals could take all the drugs, which are safe for humans. But it is not so. Each animal different metabolism and drugs can turn out to be toxic to them. Paracetamol is toxic to cats and they are used as toxin for snake control program in Guam!

ORS (Oral Rehydration Solution)

The concept of ORS therapy has been developed within the last 40 years. It is a simple solution for a dreaded problem. An attack of diarrhea can make one all empty. ORS really helps to fill up the missing volume and make feel better. It is from my and my patients experience that, it is definitely one of the best solutions.

Nasal Decongestant spray/drops (Oxymetazoline, Xylometazoline)

This is a day saving drug. All of us know how tiring it is to work with a stuffed nose. This is the magic drug, which clears the nose within seconds. I have been a fan of this drug. This medicine has saved my day, more importantly my sleep, than any other one.

Given that, there is no wonder why these medicines top the list of essential medicines. All of them are over the counter medicines and I think every one should have it in their home, unless they haven’t got it already.

I respect those wizards who make these magic potions. Medical science would not have done much to alleviate the sufferings of human being with out the contribution of chemists and pharmacists who dedicate themselves for the development of new medicines.