Do-No-Harm

We doctors, are suspended in a strange state of limbo. Gone are the days when consultants treated patients like minions who had to accept their judgment without questions. Also are bygone the days, when concoctions from bottles of various sizes were mixed together and passed on as panaceas for all ailments.  The compounder who would dutifully carry the doctor’s bag and keep the clinic running like clockwork is also, now an extinct species.

We are now in an era where hospitals are treated like business with business models, plans, huge glassed buildings and air conditioned offices. The targets they have to meet to get such a huge gargantuan venture going, loom large in front of the doctors.

The reason we are in a limbo is probably this- that at heart we are still pompous old world people who believe in our skills and dealing with a patient who does not believe in it brings us crashing down to reality!

A lot of patients now behave as though they have come to a hospital for a business transaction. They give us money and we give them health. When the deal works well, everything is hunky dory, but when things go awry, the doctor bears the brunt of it. And how. He is beaten up, the hospital is ransacked and the staff are manhandled, before the good old police finally reach the scene.

In such a scenario, it is not strange that doctors develop a defensive attitude of not accepting our mistakes. And mistakes do happen. After all we are humans. Only, we deal with other humans!

Though treatment procedures have been standardized for years, first in the lab, then on hapless animals and then tried on humans to prevent any mishaps, we know that patients react differently to different drugs. At least 1 in 10 patients and their illness does not behave as obediently as we expect. According to a study in Australia, about 18000 deaths occur in a year due to medical errors! A lot of times the body plays tricks on us. Placing red herrings, leading us on a merry path to a destination, which is exactly at the opposite end of where we want to be. We have to start afresh then. Slightly more cautious and worried. And rarely, it does happen that we mess up bad. And it does end in the patient’s demise. A valuable but a very sad lesson.

Unfortunately, in our profession, accepting our mistake is taken as a sure fire sign of guilt. We only have the freedom to accept our mistakes when we are doing our residency, when the worst we have to face for this is the wrath of our teacher.

Therefore, when I read “Do No Harm”, by Henry Marsh, a neuro surgeon from Britain, I enjoyed it immensely.

First, because it acknowledges that we as doctors are human and need to get it into our head that failures do happen. He has portrayed himself as genuinely as possible. That, at times, he is guilty of losing his temper, sometimes his decisions have been made by how tired he was or how the weather was behaving! This admission according to me, was extraordinarily brave. l have made some purely selfish decisions, but till date ,have great difficulty in acknowledging it! It is always easier to defend myself. And hence, the greatness of this man, who has actually put it on paper.

Secondly, the book also gives us examples of the times when things do not go as expected. The moral being- catharte, accept, console, move on- but do not forget for next time!

Thirdly, that vice versa can also happen. Those whom we expect the worst to happen, go on to outlive their children and we end up being at the end of condescending glares and living room gossip. So to learn to communicate the truth, but not to give out ultimatums. Instead, to be gentle and as hopeful as possible.

Lastly, but most importantly, the book gives us insights about knowing when to stop our work and accept that nature has to take its course. As doctors we sometimes get carried away by the drama of keeping the patient alive by all means. But the consequences of such survival may be more of a burden than help. Like when the operation is a success, but the patient ends up in coma for years. The relatives are at a loss financially, emotionally and unable to take a decision about the future!

Do no harm is a book which deals with such difficult questions and circumstances which every doctor faces but is unable to voice out. It is honest, upsetting sometimes, but definitely re assuring for two reasons.

One because, it gives a sense of solace that the dilemmas shared by doctors all over, are not unique.

Two, because come what may, being honest with the patient and family, brings alive a bond akin to what was present eons ago- a sense of understanding, and a trust level which allows for acceptance even if we inadvertently harm their dear ones.

How I wish this book was a part of my medical school reading!

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A little bit of empathy- Doctor diaries.

 

Monotony brings in boredom. I believe that this happens to the best of us, in whichever profession we happen to be involved in, and so medicine is no exception. Though we start of as idealistic, bright eyed, young doctors, over the years, we get jaded due to tiredness and the sheer numbers that we treat. There is hardly any time to think. Rather, we work more by force of habit, than the passion that we started of with.

Prof. B.M. Hegde, the former Vice Chancellor of MAHE University was often known to quote, that as doctors, we need to cure rarely, care often and comfort always.  But in the mad juggle of life, responsibilities and work, we sometimes lose out on the sensitivity which we need to show the patient, rather than just treating him.

As a mental health professional, the number of times that I have had to diagnose a life threatening illness is less as compared to many other branches of medicine. Rather, most of the illnesses in my bag, fall in the category of life altering. Nothing remains the same after the diagnosis is made. Both for the patient and the family. A lot of times, this causes morbidity in ways which are unseen, but cause a lot of suffering. Decisions that fall outside realm of medicine, like long term medications to be given to patients who are not so willing to swallow them, the crashing of dreams which the parents would have built for their children, the change in roles and responsibilities when the bread winner of the family falls sick, the insecurity of a relapse, the frustrations of the family which work adversely on patient outcome and the societal shaming – all of which are invisible to us, but very much a part and parcel of the illness. And as it is invisible, it often becomes easy to brush off conveniently under the carpet.

It was on one of such days when I diagnosed schizophrenia in a seventeen year old boy. The mother  broke down and started crying copiously. After customarily consoling her, I happened to remark that there were others who had worse forms of the disease, and so should consider herself lucky. To which she replied that maybe it was so, but she was crying not only for her son, but also for breakdown of her life which was painstakingly constructed for the past so many years. She told me that she had to cry so that she could grieve the loss, the burden and her son, and only then she could accept it. She asked for permission to cry, because she could not do it in front of her son or family. Once done, she walked away quietly, only to return for the next visit with a set of questions regarding how her son and family could cope better.

This small incident made me rethink my qualities as an effective counselor. As a doctor, I had thought it important to treat the disease, but forgot about the patient and his family. I could have consoled myself saying that the lack of time was the cause of this heartlessness, but it somehow seemed unforgivable. There are many instances that I have seen, where there are doctors with no super specialty degrees or  swanky clinics, but where the Que for visiting the doctor is serpentine. What they call “Kai guna” in kannada, must be the magic of sharp observation, unhurried questioning and a profound sense of empathy used together as treatment. This combination must be more potent than all the medications and hi fi equipment put together.

From then on, I resolved to spend a little more time with my patients than just enough to spot the diagnosis. And the results have been nothing short of remarkable. Now I have extended families in my patients. The caretakers know that they have a shoulder to cry on and are hence more comfortable. Each milestone they have achieved becomes partly mine. And when the seventeen year old passed his class twelve with a first class, I got home a huge box of yummy mysurpak. There seems to be no monotony anymore.

Of death and discomfort..

My nephew is undergoing  a small surgery. My logic understands that the surgery is very small with a hundred percent success rate. We know the surgeon and that he is very reliable and we have already planned his homecoming. But there is this strange feeling the whole day. And it bothers me. There’s a  tingling inside of my tummy, alongside a few mandatory butterflies, some strain in my shoulders, a sudden missed heart beat when I am in my OPD, a squeeze in the heart and a strange shiver along my spine when I think of tomorrow. Just the fact that he is undergoing something which is unnatural, increases my level of discomfort. How much ever my logical brain tries to convince itself, my emotions refuse to obey and remain subdued. It irritates me, makes me scared and wants me to delete the whole day and wake up tomorrow morning to find that it is all a dream.

In these terms,December this year, has been a month of such discomforts. Eventful, scary and sad. In the span of one month, I heard of about ten accidents back to back and lost quite a few near and dear ones in the process. Those who survived, are right now still in bad shape. A surgery scheduled in the midst of all this. And just when the dust seemed to have settled, the news of the senseless terrorist attacks in Peshawar!It sort of shook me and dragged the rug from right under my feet!

Here I am, trying to plan my future, our children’s education,my son’s birthday party and what to read this weekend when boom! You are no longer living! It sure is a scary thought. I know I am being morbid, which I should not be, as it is close to Christmas, and new year is just round the corner,blah, blah — but this whole week, thoughts of death and sickness have enveloped me. It was weird writing about this. I had never imagined in the wildest of my dreams that I would one day write about death and the like, but the more I thought, the more there seemed to be things which were queer about how we face death and sickness.

The first thought was: what exactly is it that makes you feel bad when someone suffers or dies?

Well, when you open the newspapers early in the morning, it is quite likely that you hear about at least four to five deaths. Murders, suicides, accidents, sometimes old age and ill health; the reasons are many, but a lot of them attain in death probably what they did not achieve in their lifetime- a mention! But have you ever wondered why it is that we feel bad only for a few people, and not for the rest? The answer, it seems, is a word called empathy. Empathy literally means putting ourselves in someone else’s shoes. I recently read an article in “The Week” about empathy which said that we end up feeling some sort of emotion only towards people who are similar to us in race, ethnicity, religion,education or situation! I was denying this fiercely in my mind, when I realized that I was actually doing what the article said! When I read, hear or see something bad happening to Indians, women, children, mothers, doctors etc.. I end up feeling a little more sadness and a state of understanding, than I do for everything and everyone else. I tried telling myself that I had felt really sad about Philip Hughes death, and so I am empathetic towards all! But when I rationalized, the sadness was more for his parents because they had lost a child and that loss was irreplaceable(this I can understand, because I am a mother!). I felt sad about the Malaysian Airlines tragedy a few months ago, but that was more distanced compassion and sympathy than an acute sense of grief! So you see, the article seemed to be right after all. Maybe to preserve our sanity and a sense of calm, our mind processes only what is similar to our lives and leaves the rest to a mild apathy! Try it on yourself. It is strange, but true.

The second is the aptness of reaction.

Quite a lot of times, professionally and personally, I have been in a slightly uncomfortable position of dealing with the aftermath of death. The consoling of the survivors. Sometimes, I have to go with the oft repeated ‘ It was for the best. He was suffering so badly. At least now he rests in peace’ to ‘ This was so unexpected. I can understand how you must be feeling’ and finally, when I feel most inadequate, just ‘I am so sorry’. But what ever it is that I say, I feel a sense of inadequacy, that I have somehow failed to do my job as a consoler well. I immediately end up thinking of the next few days – how dependent the survivor was on the deceased or vice versa, how their home will seem empty from now on, how photographs or familiar places will bring forth a barrage of memories and emotions –so on until I make myself miserable, and the discomfort becomes mine!

The worst was when I read about the terrorist attacks in Peshawar. I have never blanked out so badly. I really did not know how to react. Any of the dialogues I’m so used to made any sense in that situation. I crossed out emotions in my mind. Anger- no use; shame- I don’t know; sadness-woefully inadequate; fear- but for how long and where?. Basically, empathy failed me. But this horrible discomfort stayed. I could not be myself for the next three days. Then, time slowly eased me back into normalcy. Day by day, the weight on my shoulders and the tightness in my chest when I woke up in the morning eased. I started laughing more normally and became calmer about my children going to school. I used to feel that by consoling the relatives, I was helping them ease their suffering a little bit. But I realized that grieving often is a very lonely process. Kind words help, but do not lessen the grief. As time passes, and life goes on, we learn to live with it and start taking it for granted. That is when it stops hurting, but yet, it does not go away! So, a tight hug and holding on to a bad feeling inside of me,is probably the best way to react! It makes me feel that I am partly bearing the burden of their grief. It is not necessarily an overt, over the top reaction, but one that makes me feel that I have actually done my best.

I have finally made peace with the butterflies in my stomach and my nephew’s surgery. I accept the  discomfort and will hopefully understand it better.