Let's humanize medicine

Let’s humanize medicine

Vijay Gopichandran

I did two deeds today, both of which I am ashamed of. Writing about them is the only way for me to get tuned to the reality that all doctors and teachers are humans and all of us are error-prone. While there is no room for error in medicine and there should be zero tolerance, such a high level of accuracy can only be expected from the system as a whole and not from individuals practicing medicine.

An elderly man walked into my clinic today. He had a very slow and unsteady gait. He was holding a big branch of a tree as a support as he walked into my room. He said that his main complaint is severe pain in his left hip, thigh, knee, and feet. He was unable to bear the weight of his body on the left leg. So, he needed the big stick as additional support for walking. He said he usually comes to our clinic and has been seeing other doctors. He has been prescribed several medicines and pain-killer injections. All these medicines help temporarily but his pain and disability come back within a few days. He seemed to have resigned to his life of pain and difficulty in walking and came just seeking some temporary pain relief from me.

I asked him to lie down on the examination couch. The moment he did, I found that his left lower limb was in an abnormal position. His hip was semi-flexed, knees were semi-flexed, and his ankles were rotated outwards. I asked him if he can keep his left leg straight. He replied that the position in which he was lying was the most comfortable. If he tried to straighten his left leg, it led to severe pain. Memories of orthopedic surgery lessons flooded back into my thoughts and I recognized that this attitude of the resting lower limb almost always indicated a fracture of the neck of the femur. I checked his left hip and found that the femur and the hip bone were moving abnormally, indicating that there was a fracture. As I touched and checked his hip, the old man winced in pain. Attempts to straighten his left leg also elicited a similar painful response. It was very clear that this man had an old fracture of the left hip, which has not been treated appropriately.

As I started writing a referral letter for this man to send him to a tertiary care center for orthopedic specialty treatment, I was flipping through the case sheet. Three different colleagues of mine had seen this patient. Two of them had even examined the left leg and detected some abnormalities. But they had not put the pieces of the puzzle together to arrive at a diagnosis. It was at this point that I did a big blunder of which I am ashamed. I gave a small “lecture” to the students in the clinic about the importance of physical examination and how one should never do the “mistake” of missing a clinical finding. I exaggerated a mistake, used it as a teaching opportunity, making the doctors who missed the diagnosis appear as fallen angels of medicine. While I emphasized the importance of clinical methods and clinical reasoning, I think I placed emphasis on the mistake and doctors who make mistakes, rather than the importance of the clinical examination.

A second event happened today, which is once again not something I am very proud of. A young medical student who was in the clinic with me today made a very interesting observation about a patient and jumped, rather hastily into a diagnosis. Rather than encouraging him for his agility in thinking and guiding him towards sound clinical reasoning, I made it a point to prove him wrong. A 39-year-old woman came to the clinic clutching her chest and crying in pain. I was finishing up with another patient and so I asked this young medical student and his classmate to check the vital parameters of the patient and make a quick initial assessment. The student came back to me and said that the lady probably has an acute myocardial infarction (heart attack). He said, “Sir, her blood pressure is high, heart rate is high, the pain is diffuse all over the chest, it is severe, she is crying in pain, the pain is associated with severe sweating. The pain came immediately after food. So I think it must be a myocardial infarction”. I told him he is not correct. I took the history again in detail, punched holes into his history, and told him that it is more likely to be esophagitis (inflammation of the food pipe). I told him that non-diabetic women in the reproductive age group are protected by estrogen from developing heart attacks. Then to prove my point, I asked him to take an ECG anyways and show it to me. When the student, brought the ECG, I made it a point to show him that the ECG was normal. The student was not wrong in thinking of a heart attack in a patient with acute chest discomfort. In fact, in a highly gendered medical world, which teaches that any woman presenting to the clinic with chest pain and crying has a “psycho-somatic” problem unless proved otherwise, I should have encouraged the student that he had an open mind. I should have walked him through history, physical examination, ECG findings, and my clinical reasoning. It should have been a process of learning together, rather than ‘proving a point’ or exercising intellectual superiority.

To me, both these instances are indicators of the dehumanizing nature of medical practice. Doctors are deified to such an extent, that they are seen as ‘mistake-free’ people. A medical student in training is insulted, humiliated and slighted at every small mistake because it is taught that there is no tolerance to mistakes in medicine. Such an intolerance to mistakes of individual doctors both within the fraternity and from the society has led to huge problems. Doctors do not like to accept their mistakes. It is almost impossible to see a doctor who apologizes to a colleague or to a patient. Seldom does a doctor seek help for a problem that she is unable to solve. This systemic intolerance to mistakes has led to a breed of professionals who are afraid of their own mistakes and super-critical of the mistakes of others. So, what should the health system do? Is developing tolerance and leniency towards mistakes the solution? It is obviously not, because there really cannot be any tolerance to mistakes in the medical profession. However, such a zero tolerance to mistakes cannot be expected from the humans who practice the profession. The zero tolerance for mistakes must be systemic. I have a super-smart nurse in my clinic who doubles up as a pharmacist dispensing drugs to the patients. Once I had written Metformin instead of Metronidazole in a prescription. She picked it up and came and corrected me. I am so grateful to her for correcting me and averting a major disaster. The health system should set up such checks and balances at multiple levels to prevent mistakes. A system cannot operate expecting humans to be error-free. The system should be prepared for mistakes and avoid them through systemic interventions. The use of checklists has been described as a highly effective method of reducing mistakes in surgery and in childbirth. Atul Gawande talks about the importance of checklists in this Ted talk. Rather than dehumanizing doctors and making them demigods who are not capable of mistakes, we need to see doctors as humans. We need to teach young medical students in training to be more accepting of their mistakes. We need to teach them that mistakes are not ok, but they are not avoidable. Therefore, accepting mistakes and working in teams to minimize mistakes is important. Taking criticism positively and working towards minimizing errors is the correct attitude in medicine.

To me, this blog is my first step towards humanizing myself both as a doctor and as a teacher of medicine. I am trying to step down from the tall pedestals of both these roles, and grounding myself as the mistake-making – eager – to – correct – himself person. I think this is the first step towards a minimal error, high-efficiency medical practice.