Mediscene

Getting it right: Healthy rapport between doc and patient

By Dr. Ruvini Abeygunaratne Karunaratne, Pic by Gemunu Wellage

We meet with disgruntled attitudes and general distaste when discussing issues of medical care and caregivers all over the world. Patients can often recall a bad situation they or their family members have experienced due to the lack of appropriate communication between the doctor and patient.

This is not a problem faced only by patients in Sri Lanka and is seen by the increasing numbers of litigation cases against doctors.

Having experienced the health system in the UK, Sri Lanka and the United States, I believe most of the problems can be avoided by clear communication between the two parties and by understanding the responsibilities each has to the other.

Medicine is a vocation, and most enter it to help people. I had grown up surrounded by doctors and nurses and wanted to be part of the institution, which made people better. Maybe not all have the same ideals, but for the most part this is the reason why we want to become doctors. The whole process of qualifying takes at least seven years of hard slog. This is just to pass out as a young doctor. It takes many more years, depending on the field, to finally emerge as a Consultant. Some give up on the way and some take other paths to fit in with their lifestyles, but all in all for you to come out at the other end, you have to have dedication, determination and a love for the job, in most instances.

‘Establishing a good communication link with your doctor is essential.’

When we first qualify as doctors, we recite the Hippocratic Oath -- the responsibilities of the doctor for the ethical practice of medicine. One of his sayings has achieved universal recognition: "Life is short, and the art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate." This personifies the responsibilities of the doctor. As doctors we are in a privileged position and our aim should be to take the patient through a vulnerable period of their life providing good medical care. The foundation of medical care rests on the statement that "we should cause no harm".

The medical system in Sri Lanka is excellent though the clinical knowledge and the dedication of the doctors in the country for most part goes unrecognized. In a system that is stretched to the limit, with a high volume of patients, the state health service in Sri Lanka works wonders. This may not be apparent from a patient perspective -- all that is seen are queues of people waiting for an appointment with a specialist! But doctors are human beings too and have to provide for their families, which cannot be done on a meagre government salary. As long as greed doesn't come into this equation and patient care isn't compromised, this should work.

One drawback of the system is the self-referral system. Patients go to see a specialist without an appropriate referral by a family doctor, because someone has told them that the doctor is good. Not only do the patients arrive for the wrong consultation with the wrong specialist, but they also leave dissatisfied as the doctor couldn't answer all their questions. This maybe because it isn't his or her speciality!

The idea of a referral is not understood in most cases. When a doctor refers a patient to another doctor for an opinion, this is done by a referral letter (or sometimes a phone call). This document or letter will contain information regarding the presentation of the symptoms, history, investigations and the reason for the referral. This is very important and enables the specialist to make a prompt diagnosis.

A good doctor isn't someone who has the most number of patients standing for hours waiting to be seen, who sees a patient in two minutes and writes a list of medication. A good doctor is someone who takes the time to listen, examine, investigate appropriately and come to the right diagnosis. A good patient is someone, who doesn't go from one doctor to another without giving time for the medication to take effect, who listens and doesn't take matters of medical care into his/her own hands. There is no point asking a brain surgeon about a rash on the face, this has to be seen by a dermatologist. Although both have qualified as doctors their expertise is different. We have lost trust between the parties and we must make changes now to rectify the situation before things go desperately wrong.

I can also see why patients mistrust doctors. When patients are admitted, especially into the private sector hospitals, it is very often the case that they are worried about the bill at the end of their treatment. This may even affect the patient's recovery. Some investigations are essential, and again by explaining why they are being carried out, the patient can be reassured.

Communication is vital. Patients should be able to ask questions without being intimidated.

Responsibilities and duties of the doctor

  • Good clinical care
  • To carry out a thorough assessment of the patient's condition, based on the history and physical examination
  • To organize appropriate investigations
  • To provide appropriate treatment
  • To refer the patient to another specialist when appropriate
  • To have good communication with the patient and family, explaining what could be wrong, and provide reassurance
  • To keep accurate medical records
  • To prescribe drugs (explaining their side-effects) and provide treatment that will serve the patient's needs
  • The doctor must keep up-to-date with knowledge and skills. The medical practice should be evidence based as much as possible, but also take into account the physician's experience.
  • A doctor should contribute to the education and training of other doctors
  • A doctor should provide information regarding treatment options and condition
  • Maintain trust and professional relationships
  • Must listen to the patient
  • Respect the patient's privacy and dignity
  • Give the patient information that he/she seeks regarding diagnosis, treatment and prognosis, and explain in terms that the patient understands.
  • Caution should be exercised when disclosing information that is distressing to the patient.
  • Respect the patient's right to decline treatment after all options have been discussed.
  • Confidentiality should always be respected. A patient's condition or treatment should only be disclosed to other medical colleagues if it is for the appropriate treatment of the patient or if there is a risk by the condition to others
  • What of the patients? You want to get better quickly, but this doesn't happen always. Your body will take time to heal with appropriate treatment, depending on other factors such as the condition being treated, other health problems, age, sex and predisposing factors. Be patient. Remember that doctors are also human beings and can get the diagnosis wrong sometimes.

Responsibilities of the patient

  • Give the doctor a full and thorough history of the illness, not withholding any information even if it may be embarrassing
  • Listen to the doctor
  • Give the treatment time to work
  • Don't go from one doctor to another just because your neighbour told you a certain doctor was good. Get an appropriate referral from a doctor.
  • Do not discuss your medical problems with every doctor you meet; they may not have the knowledge to answer your questions and may not know all the details to make a full assessment.
  • Learn about your condition -- there are good medical sites on the Internet providing information, but remember unless they are recognized sites they may provide you with the wrong information. Check the validity with a doctor
  • Provide the doctor with details regarding all the medications that you take, as some may cross react.
  • Inform the doctor if you are using alternative treatments such as ayurveda.
  • Talk to your doctor and ask questions – establishing a good communication link with your doctor is essential. This doesn't mean ringing them up at midnight to let them know that your bowels aren't functioning well. Have some consideration for the doctor's personal life.
  • Remember the treatment that you receive for the same condition as another patient may be different. This doesn't mean it is wrong. Each treatment may be individualized to treat that particular patient.
  • Trust your doctor; if you don't and would like a second opinion explain this to the doctor. Don't go to another doctor on the sly, as this would disrupt your relationship with the first doctor.
  • We are all human, and we will become ill at some stage of our lives. It is not the patient’s fault that h/she is ill and neither is it the doctor’s. The trust and understanding between the doctor and the patient should be such that the patient receives the best care possible, even if it is palliative care.
  • The relationship between the doctor and patient should be such that it gets the patient and his or her family through this troubling period with the least amount of worry and despair. This requires a good working relationship. Let's make it work.
 
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