Few days back, me and my friend (currently doing residency at US), were discussing the differences in medical practice between Nepal and USA. I have shared a situation which I had faced recently. An old lady in her 70s came with her daughter and other relatives visited our OPD with complaints of deep yellow eyes and skin and pain in her belly. The blood and USG report showed obstructive jaundice and a gallbladder mass, most likely Carcinoma of Gall bladder. I asked my friend about the way in which she would have told this bad news to the patient or their family. She replied that she would firstly take the patient in a private room, ask what the patient thinks she has, then tell her the diagnosis, discuss about the management options with her and her family, give her time, tell her the truth but also give her the hope that she would always be by the side of the patient, etc. Or you can say ‘just as we read in any Medical ethics book’.
Breaking a bad news is never an easy job. Most of us who do this are never taught or trained for this job. We see around us, listen and watch our seniors doing this and copy them. For myself I couldn’t go according to the ethics. I couldn’t say “it looks like you have a cancer”. I couldn’t utter the word ‘cancer’. But I told her that “it looks like a bad disease and you need to go to a higher center for further check up” and as she got out of the OPD, I told to her daughter, “it looks like cancer.”
Why did I do this?
To know this you have to place yourself in my situation first. Imagine the real scenario of the working condition, settings, patient education, understanding level and many more in our hospitals. Your duty isn’t finished just by telling the harsh truth in their face.
First imagine the OPD scene of our government hospitals in rural villages – understaffed but overflowed with patients. We don’t have a patient room for consultation and doctors don’t go to those private rooms to see their patients. We have a common OPD room where 2-3 doctors sit and see their patients. Patients wait for their turn outside the room, sometimes inside also, for their turn. So most of the time privacy is the last thing we can think of. Good thing about it is that many times we all can have a good laugh on a single joke, counsel them in single if they have same problem. But the bad thing is we and our patients have least privacy if we want any. Discussions about sexual life, personal issues, life decisions and psychological issues become very uncomfortable for both the patients and the doctors.
Another is the doctor-patient relationship. It is one of the most important things in medical field; everything in medicine starts with this and revolves around this. But are we giving enough value to this sacred relationship in our setting? If you have visited government hospitals, you may know this. Patients are never seen by a single doctor. In one visit, one doctor sees him and in next, there will be another doctor. Doctors hardly know their patients by name and same is with the patients too. What we really lack is the continuity of the care by a single or team of doctors. Patients also keep on changing doctors without informing their doctors.
This patient was also initially seen by my colleague the day before. But when the patient came to show her report she was on 24 hours duty and off from OPD. If she had wanted the same doctor to see then she had to wait another day which means they had to spend more of their meager fund for hotel just to show the investigations and get the referral.
Next thing is the amount of time we can give to this patient. Not only the doctors but all the staffs like nurses, paramedics, lab technicians, etc. are really outnumbered with the volume of patient flow. We can hardly give 5 mins to our patients to tell their story, examine them, and explain about the disease, investigations, management. The pressure from the crowd of patients waiting outside the OPD compel us. So in the above case, if I had told her it looks like ‘cancer’, I couldn’t have stopped just with that, I had to give her time to explain her about it cause many have fear with the word ‘cancer’, I had to listen to her fear, I had to give her hope. You may tell that “that’s what the doctors should do, what you didn’t do”. I also feel the same. I always have a question in my mind “Is it better to give a compromised care to all patients who come to you or to give the best care to a limited number of patients and send away all others?”
Can anybody answer me please? Does managing a patient mean only giving away some pills, or syrup for the disease?
Now let’s think in this case what if the family members had requested not to tell the patient if anything really bad comes out in diagnosis? Here in Nepal doctors mostly follow these kinds of requests from family or they discuss with family whether to disclose the diagnosis with patient of not. According to ethics the doctor is responsible to the patient mainly and he/she discusses the things with the patient directly and plan about the management. But that usually doesn’t happen here in case of senior citizens, females because most of them are dependent to their family members economically, physically and psychologically too. It’s totally different from the countries where people live independently and usually have medical insurance to bear their medical costs. Usually a ‘Jaanne Sunne’ (educated, male and who knows better in family) member comes with the patient who discusses the issues with the doctor. He takes the decision about the patient. And doctors also find it easy and quick to communicate with that ‘Jaanne Sunne’ visitor rather than spending time with their real patient.
Medical ethics says “Do not lie to your patient”. But that doesn’t mean you should tell the harsh truth at any cost. And it also doesn’t tell that “Tell the truth and your duty is over.” It expects to assess the situation of the patient, of the surroundings, tell the truth and then help your patient to cope with the life threatening condition, help them to move ahead with it.
It sounds like I am defending my wrong deed. May be I am. I am not saying that I am doing my best but we have limitations. I and the whole of our medical system need a lot of improvement.
I have shared my experience here to let you know our situation. There are many hospitals working in similar situation, many doctors working on same condition around the world. Please share what you would do in the situation like this so that it would be helpful to improve us.
Thank you, in advance.
Dr. Samir Lama
MD General Practice Resident final year
TU Teaching Hospital, Maharajgunj
(Now Mid-Western Regional Hospital Surkhet)