Relating to Patients, by Lee Yi Yong (M3 2004/2005)

            What makes being a doctor different from a normal 9 to 5 job?  Besides the long working hours, long years of study, being a doctor is special because you get to meet many different people everyday.  They come from all walks of life, speak different languages and range from little babies to grandpas and grandmas.  I’m not here to belabour the point about bedside manners or a doctor-patient relationship.  People more qualified than me will tell you about that. What I’d like to share with you is how to enjoy meeting patients—whether you’re someone who’s extroverted or introverted.

            To me, it’s essentially a balance between friendship and professionalism.  These two qualities sound like they are opposites, but this is not true.  They aren’t mutually exclusive and I’ve found that the best way is really to balance the two rather than to choose one or the other.  

            If you regard patients as potential friends, you’ll definitely look forward to meeting them.  In the same way, they will enjoy meeting you—which also means that they won’t regard you as a pest; they will talk to you and teach you about their illness.  But what do I really mean?  Behave towards patients as you would treat a friend.  For example, when you first meet a friend, you smile and introduce yourself—your name and your identity, because some patients will mistake you for a doctor.  Next, most people start off a conversation with a new friend by asking, “How are you today?”  Don’t just introduce yourself and straightaway ask if you can examine the patient.  It’s almost like going up to a stranger and asking if you can strip them.  It doesn’t take long to just find out how the patient is feeling, and by doing that, they realize that you are concerned about them, and you don’t regard them as specimens in a lab.  It helps to find out the patient’s name beforehand from the patient list at the nurse’s station, and it really helps to address them by name.  If you have a problem remembering names like me, you’ll find that it is very easy to slip into the habit of thinking of patients by their diagnoses or by their bed number.  When you make the effort to remember their name, it’s easier to see them as a person with family and a life outside the hospital, rather than the temporary habitat of a disease entity you’re interested in.  When asking questions to take their history, try to speak in a conversational manner, as if you are asking a friend about something that troubles him or her.  For those of you who have taken vivas or oral exams before, you know what it feels like to be interrogated.  So don’t just read off a list of questions.  Talk with the patient.  They will be more relaxed and tell you more.  Perhaps you’re thinking this is not possible in the limited time for a test, but even in that situation, you can try explaining to the patient that this is a test, so you’ll have to ask direct questions.  However, you can keep your tone friendly. You’ll enjoy clerking patients more, they will enjoy being clerked more, and you will definitely learn lots more—not just about medicine but also about life.

            Next comes physical examination.  You won’t start stripping a friend in public, right?  In the same way, ask the patient for permission before even touching him or her.  Draw the curtains before asking the patient to undress.  All these gestures help the patient to trust you, so that even if you cause them some discomfort later, they are more tolerant of you.  Sometimes they may be in pain or breathless if they lie down flat, so always ask how they are feeling.  Something that made an impact on me when I first entered the wards was when I saw a doctor warm his hands by rubbing them before touching the patient and apologize for his cold hands.  I remember that because my hands are always cold too.  So I’ve also tried to do that—I warm my hands and my stethoscope before I place it on the patient.  This also helps the patient to trust you because you don’t shock them with something cold suddenly.  You are actually graded on your physical examination technique during tests, and it is said that once the patient says, “Ouch!” your grades drop drastically.   One more point to remember is to pull up the railings of the bed after you complete your examination.  Some elderly patients can fall out of bed.  Being considerate to the patient is important because they will be more tolerant of you, and allow you a longer time to learn more.  Some of them even teach you how to do physical examination because they have been examined by the doctor so many times!  But earn that tolerance by remembering that they are people, not just bodies or specimens.

            One problem you may encounter is when a patient has a sign that is a “must-see, must-know”, for example, during your CSFC, you will probably go around looking for patients with hepatomegaly.  Word will pass around and the patient will have more than 10 medical students visiting him or her asking to press on his or her abdomen.  You have to decide for yourself whether you want to be the 11^th person to ask to press on his or her abdomen.  After all, the patient has been hospitalized for treatment, not to be an exhibition specimen.  He definitely needs rest.  One way is to just say hi and ask how he or she is feeling, and ask if you can come back the next day.  Many of them actually want to help you, but 10 students pressing on them is really their threshold of endurance.  So come back another day.  Another way is to take turns.  Within your CG, some of you can practise clerking, some do physical examination, and reverse the roles for the next patient.  Ultimately, remember to cherish every chance you are given to examine a patient—it’s probably more effective to examine a few patients thoroughly than many patients in a slipshod way.  Don’t be afraid to admit you can’t feel anything so that your tutor can guide you.  It’s better to learn it well early on when the tutors have lower expectations of you. 

            Another conflict you may face is what if the patient is asleep or has visitors when you want to clerk him or her?  There is no blanket answer to this, but a good principle I have found is to consider the patient’s needs first.  If the patient is asleep, I generally don’t wake him or her up, but I talk to another patient, and come back to him or her later.  Consider it this way too: the patient will actually be less likely to want to talk to you if you wake him or her up, so I don’t see much point in annoying him or her anyway.  If there are visitors present, I will assess the situation.  Sometimes their visitors are there just for company, so I still go ahead and ask permission to talk to and examine the patient.  In fact, if the visitor is the spouse or a child, you can also take a history from the visitor.  Sometimes they are quite willing to talk to you.  However, if the patient is clearly occupied with his visitors, it also makes sense to come back another time, since he or she will probably refuse to talk to you if you interrupt his conversation with his or her friends.

            A friend who studies in a medical school overseas once asked me if it was true that NUS medical students harass the patients in the hospitals.  I think each of us has to answer that question for ourselves.  Some patients will certainly feel that way, and in fact they will tell you that.  Some of us have been shouted at by family members who feel that we cannot help them at all.  You may feel that way yourself, and thus hesitate to approach patients to clerk them or examine them.  I think the truth is that there is a role for medical students to play in the wards as well.  A tutor once told me that we can add value to every single patient we come into contact with.  We may not be able to prescribe medicine or pay for their medical bills.  What are some things we can do then?  We can just smile at them, tell them some jokes or listen to them for a while.  We can explain their illness more thoroughly, or explain what medicines they have been prescribed.  We can give them advice to stop smoking or cultivate a healthier lifestyle.  These are things that take time—and that is a luxury that sometimes the staff may not have, but we do.  But one important point to note here is that you should only explain what you are certain about.  If you don’t know what the medicine is for, please be honest and tell the patient you will find out for him or her.  Don’t try to second-guess or contradict what the doctors have told the patient.  Check it out with the doctor or nurses first if you are in doubt.  One other important point is to take note of whether the patient knows the diagnosis or not.  Sometimes, especially for elderly patients, the family chooses not to reveal the diagnosis to the patient.  So be careful when you’re taking the history.  If the patient looks very ill, but tells you that he or she only has indigestion and will be discharged soon, be on your alert.  One of my classmates got into trouble when he or she told the patient the diagnosis when the family chose not to.  Ultimately it’s the family’s choice.  You may think: this is the patient’s right, but the family knows the patient better, and how he or she may take the news.  If you’re unsure, seek help from a nurse or doctor. 

            When I’m really discouraged, I try to recall all the events that inspired me such as the first time a patient thanked me.  I met this diabetic patient during a very busy surgery night call.  She needed an IV plug to be set, but her veins were very fine and many of them collapsed when the HO tried to insert the plug.    The HO was reputed for her plug-setting skills, but even she had trouble getting it in.  The patient was nearly in tears because you have to test whether a plug is set correctly by flushing it with some saline, and that is very painful if the vein is bust.  She had endured a few failed attempts by the time the HO I was following arrived to help.  My friend and I held her other hand and started talking to her and asking her all about her kids, what she likes to cook for them, how they’re doing in school, and every other topic we could think of to talk about, till the HO succeeded in setting a plug.  The next day, that patient passed a message to us through another of our CG-mates to thank us for distracting her while the HO was setting the plug.  We weren’t the ones who set the plug that night, but I think my friend and I made a difference to that patient.

However, friendship must be balanced with professionalism.  This is something some of us learnt the hard way.  One of my friends gave her number to a young ♀ patient who was depressed and suicidal.  This patient messaged her after discharge and threatened suicide.  My friend panicked and tried to get her home number from the ward staff to check if she was alright.  Eventually she discovered that the patient was in fact out enjoying herself.  We should regard suicidal intent seriously but the lesson to be learnt here is that we must learn to draw the line between work and our personal lives. 

This is especially emphasized for guys—you need a ♀ chaperone when you examine a ♀ patient, even if she is pretty old.  So be nice to your ♀ CG mates!  J During our psychomed posting, our prof told us about these two ♂ medical students who actually dated an attractive ♀ patient who had borderline personality disorder.  He didn’t really tell us what eventually happened but I don’t think there were any happily ever afters.  This also applies to ♀ students.  Two of my ♀ classmates were talking to 2 ♂ patients at IMH last month during my psychomed posting.  They were in an interview room, which is locked automatically from the outside.  During the interview, the patients became a little unruly, but one of my ♀ classmates, who’s probably half the size of the patients sternly said, “Don’t think that you can bully us just because we are nice to you, ok?”.  The interview was completed without anything unpleasant happening.  Later my friend told me she was actually quite afraid, but she kept her cool and maintained control of the situation.

One other situation you may encounter is when you meet patients outside the hospital.  It’s ok to say hi, but be careful about asking the patient about his or her illness.  If they’re with their girlfriend or boyfriend and you start asking how his gluteal abscess is healing, it can be a pretty embarrassing situation.  Unless the patient talks about his or her illness first, it may be wise to just speak like a friend even if you’re concerned about his or her health.

To round things up, let me give you just one principle to sum all this up.  Prof Tambyah taught me this one year ago and it’s really helped me.  He said that we will be kinder and gentler if we remember that the patient is someone whom God loves.  As a Christian, that made a difference to me, because I love God, and if God loves that patient, I’ll treat him or her in a special way.  In the same way, perhaps you have experienced being with a loved one in the hospital.  If you can recall that the patient before you is someone who is loved by his or her family and friends, it may help you to be kinder and gentler.