Thank you, Doctor

This reflection will be brief and little different. I had two great experiences this week with the human side of the medical profession. Of course every shift we do a lot of reassurance than actual medical actions. But these two are particularly interesting.

Earlier this week, I met this 70 years old woman for a follow up of a chest CT scan ordered for a suspicious mass on the xray by an emergency doc the night before. Her main complains were fatigue and dizziness in the morning for a few months. Her family doctor could not diagnose her. She is a caregiver for her husband with a terminal cancer. My mission was to tell her: your CT scan is normal, how do you feel this morning? Before I said anything, I would describe her as a beautiful woman but with a very sad look on her face, like I was going to tell her, I finally found what is the reason your fatigue, you are dying too. I said the opposite. Suddenly, I saw her magical smile and she told me this: I know you are much younger than me, and we do not know each other, but I could really use a big hug! And I hold her in my arms like she was my dear grandmother, she said thank you, I respond THANK YOU, and she left.

I met the other patient in a geriatric outpatient clinic. This was upon the request of a closed friend of the geriatrician. Her father was diagnosed with dementia, his family doctor was overwhelmed, polymedication, and there were a matter of new investigation? I review the chart, saw the patient with his family, tested him cognitively, and then, met again with the geriatrician this time. Here is the situation. Five years ago, he was diagnosed with dementia, most likely Alzheimer, does not have a vascular history, few medications (every medication is indicated and does not worsened the dementia), his MOCA was 4/30, and even if he is not there (the lights are on, but nobody is there), he seems happy though more anxious than he used to be. He lives with her dear other half who is in good health and very committed to his care. What else as a doctor could we do? He is too far gone to try any dementia medication, the diagnosis is pretty clear, investigation is not very relevant. Anyhow, the final meeting with the patient, his family, the geriatrician and me lasted an hour and a half. What could we possibly tell the family? In fact, a LOT. We talked about his prognosis (he will continue to decline to a point that he will not be able to do anything by himself), we talked about her caregiver’s health (she has to have more help in the house, some breaks to do things that she loves, other things, she needs to plan her long term care particularly with the long waiting list in her region, she should meet other caregivers to exchange tips, thoughts or just to talk about it with persons that can actually understand her, etc). We talked about his medication, keep going with the same thing, we are not going to change anything, let us know if you notice any other problem. We talked about his driver license, power of attorney, and finances. We talked about falls prevention although he is a pretty robust guy. We talked about exercise. We answered any questions they had. At the end, the family was so pleased by this meeting (even if we did not do anything medically). I can not recall how many “thank you” they said to us. They left satisfied.

Sometimes, being a doctor is more than knowing everything in the books. It implies to be a human being with compassion and a sense of listening. When I graduated from medical school, the Université of Sherbrooke gave us a book of Sir William Osler. I remember to have actually read it. I do not have it with me but his main battle as a medical teacher was to get students out of there books and amphitheater and teach them at the bedside of patient. He was absolutely right, and these two cases are a proof of that.

As an emergency doctor, we have little time with patients. Spending one hour and a half with a patient, he has to be very unstable!! But very small things can improve patients satisfaction and trust in us. First, a strong hand shakes at the beginning and the end. They appreciate it a lot. It is like we engage ourself to them “I am with you in this”. Another trick I discovered with time (I know I am still young!) is at the first visit, giving them a time frame and engage them in our plan.

Here is a concrete example:

“I understand you are having abdominal pain right at the spot for appendicitis that I am worried about. If you are ok with this, we will do some blood work, do an ultrasound but in the mean time do not eat or drink anything in case you have to go to the operating room which is the treatment of appendicitis. I will come back as soon as I get the results for both tests in about 2-3 hours. Is that a good plan for you?”

With that, they feel like they have their say in this and they know that they will be there for a long time so they will be patient and not surprised.

Finally (I know they are tons of other things that we can do, but those are my favorites!), patients come to the ER not for appendicitis or fracture. They come because of a symptom: mostly pain. Make sure that you give them something for the pain at your first visit. This way, when you do not find anything to explain their pain, they have less pain and they still feel satisfied. I always start with “I have very good news for you” your test is negative. This way, the “I didn’t find anything visit” starts positively.

Oh, and I have another special favourite thing to do: shared decision-making. I will make a reflection all about it someday. There are a lot of evidences around this.

In conclusion, everyone can be a good doctor. The hardest part is to be a GREAT doctor! This is not written in books. I hope I will be this great doctor someday!

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