The most important asymmetry between a doctor and patient is the asymmetry of knowledge.
The doctor generally knows much more about what is going on in the patient’s body, what needs to be done about the same, and what is the likely outcome, than what most patients will ever know. Such asymmetry of knowledge is rather inevitable, given the vast and complex nature of modern medical science.
However, given this context, the doctor has a duty to share a small portion of his or her vast pool of knowledge with the patient—at the very least by carefully answering the questions and doubts of the patient and caregivers; and by allowing the patient and caregivers the autonomy of choosing among appropriate treatment options, wherever applicable.
Hence when we choose a doctor, one of the most important considerations we may keep in mind besides technical skills, is the doctor’s willingness to talk, explain and offer reasonable options.
Dialogue makes a difference
One case from Dr Arun Gadre’s experience is quite illustrative of the importance of these attributes in a doctor.
A 90-year-old man was admitted at midnight into a reputed nursing home, with heart failure and severe breathlessness. The relatives were anxious, since even though they knew that age was catching up with grandpa, his present suffering was unbearable.
The physician came and prescribed something; he was not ready to entertain any questions. His blunt response was: “What can we do for a person at the age of 90 with such severe heart failure?” When the patient’s son tried to inquire about how to lessen the old man’s suffering, the rude answer came, “Do not argue with me, I have no time to answer silly questions.”
Grandpa was shifted to another hospital, because his grandson was a surgeon, who reached home from another city in a timely manner, and intervened in the management.
Now another physician was consulted, who patiently answered all the questions and elaborated upon the nearly hopeless long-term prognosis for the elderly man, but agreed to perform a small procedure to remove the liquid that had collected around his lungs, and thus to relieve him of his severe suffering due to breathlessness.
The simple process of dialogue between the patient’s caregivers and the doctor made a huge difference.
The message is simple—whenever there is a choice between two doctors with similar years of experience and qualifications, opt for the doctor who is willing to talk with you and explain things.
The practice of medicine is not just about good technical skills, to a great extent it is also about good communication. The very word ‘doctor’ is derived from the Latin word for ‘teacher’. Unfortunately, lured by the desire for making more money, and by taking on more and more patients but talking less and less with them, some doctors seem to have forgotten the original meaning of their designation ‘Dr’, which almost becomes their second name.
Many of the disputes in hospitals, and much of the dissatisfaction among patients related to healthcare today, stem from inadequate communication by providers, and patients not being given sufficient information.
In brief, whenever we are in the role of a patient or caregiver, we should try to choose providers who are willing and able to communicate—every patient deserves to be talked to decently, and given an explanation about their illness and the treatment that they are undergoing.
It has been said that if you can make a person sufficiently fearful, you can get him to do almost anything. And there is perhaps nothing that induces as much fear as the apprehension of physical suffering or loss of life.
In this context, when a patient approaches a doctor, there is a valid expectation that while the severity of the problem should not be underplayed, the patient should not be driven into panic and rushed into taking a major decision like undergoing an operation (except of course in the case of genuine emergencies).
Unfortunately, nowadays instances of such “panic-inducing medical advice” are becoming rather common. We have not infrequently come across situations where immediately after an angiography, the cardiologist has told the patient that “angioplasty must be done immediately, within a few hours”—and the patient has been rushed into undergoing an invasive procedure, even though the option of waiting and taking a balanced decision might have proved to be more appropriate.
The following experience illustrates this kind of problem quite well.
Dr Arun Gadre has a friend whose daughter is an athlete, who loves to exercise. One day her knee got unlocked and she fell down suddenly while just standing! Concerned about the fall, my friend took her to an orthopaedic surgeon, and the MRI confirmed that she had torn her knee ligaments while exercising.
The surgeon advised laparoscopic surgery of the knee joint. When asked about the consequences if the surgery was avoided, he plainly threatened that her knee joint would get ruined, she would get severe arthritis, and in the end she would have to undergo total knee replacement.
My friend was panicky. With help from me, he accessed another orthopaedic surgeon for a second opinion. The second specialist calmly explained that surgery is only the last resort in such cases. Even after knee surgery, the girl would have to keep on doing certain knee exercises for life. And if she does these exercises without undergoing surgery, she might never get her knee unlocked again, and hence might never require surgery.
He explained that any surgery carries small but definite risks. His calm way of putting forth both alternatives was a contrast to the urgent threatening by the first surgeon.
Would we not like to opt for a doctor who does not create excessive fear or panic, but allows us to take properly informed decisions?
“I don’t know”
A fact which not all doctors might like to publicly admit is that in a significant number of cases, in the beginning, the doctor himself or herself may be unsure of the exact diagnosis. In these situations, the doctor is acting on probabilities rather than certainties. The doctor may rule out various possibilities only in the course of investigations and treatment.
So when the patient or relative anxiously asks “Doctor, what is the illness?”, in a certain proportion of cases, the fact may be that even the doctor does not exactly know.
This is inevitable given the unimaginable complexities of the human body, and the limits of medical knowledge. In such situations, the doctor may not be able to give a one-word answer, but instead of getting irritated at the patient (and at his own lack of certainty) the doctor needs to explain, at least in brief, the main probabilities and broad line of treatment.
And regarding some questions, he or she might even have to muster the courage to utter the magic phrase which all doctors are conditioned to never speak—”I do not know”.
It has been truly said that a wise man will admit what he does not know, while a fool cannot acknowledge his ignorance.
Excerpted with permission from Dissenting Diagnosis, Random House India. We welcome your comments at firstname.lastname@example.org.