Through the masked face, express empathy
For many people Covid-19 and the lock-down have completely changed their lives. For some of us, privileged lot, not much as changed. My 7-day work week has not changed. I am not locked down inside my home and go out to the hospital every day. For some of us, the not so ‘socially active’ lot, not meeting people, not hanging out, not going out for lunches and dinners etc. also do not matter much. But when I look at my work closely, I have realized that so much has changed. The change has been so sudden, but the ambient uncertainty and anxiety of the pandemic has made it imperceptible.
Yesterday, I saw the video of an innovative ‘no contact’ Covid-19 screening clinic. It is a model of screening patients with suspected Covid-19 while minimizing the contact between the patient and the doctor. The video goes like this. The patient’s token number is called out in the public announcement system. A well dressed, confident young man walks into the OP as soon as the name is called. This man must be a staff of the hospital playing the role of the patient for the sake of shooting the video. There are two transparent rectangular booths facing each other. In one of the booths is seated a doctor clad in full personal protective equipment. The public announcement system instructs the young man to walk into the other booth and sit in front of the doctor. The doctor and the patient are facing each other, in separate booths. The doctor then switches on the microphone in front of her. I am assuming it is a ‘her’. She calls out the name of the patient, “Mr. Ganesh” and says, “Please pick up the yellow coloured gadget on the table to your right and wear it on your finger”. The young man picks it up and wears it. She says, “Show me the gadget now”. When he points his ‘gadget wearing finger’ towards her, she reads out the values displayed on it and scribbles it down on her writing pad. She then says, “pick up the other black coloured gadget on the table. Put it on your chest”. The young man does that. She takes out her mobile phone, switches on an application and wears her headphones. She can now hear the lung sounds of the patient through the Bluetooth in her mobile phone. Then she puts her hand through the double gloves that are protruding out from her side of the booth into the patient’s side of the booth, instructs the young man that she is going to take a swab from his nose and performs the procedure. She then says, “Mr. Ganesh, now you may leave the room” and the young man leaves. Immediately after than she switches on a button which sprays disinfectant all over the room in which Mr. Ganesh was seated. The public announcement system calls the next token number. I was really fascinated by the innovative use of technology to minimize contact between the doctor and the patient. But the scene did not look like a doctor-patient consultation to me. The warm greeting, the general enquiries about his well-being, the meticulous process of taking a detailed history, the all-important touch and ritual of physical examination and finally the detailed process of explanation of treatment and follow-up were all conspicuously absent. I wondered if this is the way medicine is going to be from now. I hope not.
Over the past month, that I have been working in the triage department of my hospital which does the work of receiving all patients who walk into the hospital, identifying those with Covid-19 symptoms, directing them to the Covid-19 OP, directing patients with acute illnesses to the emergency department ,treating a few patients right at the point of triage itself, and sending back patients who have come for non-essential services, I have seen the change in the way we practice medicine so clearly. One episode left a very deep impact on me professionally as well as emotionally.
A young woman, in her mid-twenties walked towards the triage area holding the hand of a little boy, about 4 years old. She was wearing the shawl of her dress as a mask covering the lower half of her face. Her eyes and forehead revealed a deep sense of worry. The little boy was holding on to his mother’s hand like he was clutching at a lifeline. There was a blue coloured striped handkerchief tied around the boy’s lower face as a mask. As soon as she came and stood in front of me, the mother uttered, “Doctor, the child has fever for 4 days.” The reason for the panic in her eyes were clear. She must be scared that this could be Covid-19.
The triage area is just outside the hospital, under a tree. We are three to four doctors standing there at any point of time. We all wear masks that cover half our faces. There is no way I can use a warm smile, a look of concern, to calm the mother. I asked her, “Does the child have cough, or cold?”
“No doctor. There is no cough or cold. But he is having a high fever. I am giving him paracetamol syrup, but the fever is just not going away”. Even through the face mask, I could clearly sense the anxiety and fear that was embedded in her voice.
“Don’t worry. There is a separate OP for seeing patients with fever. Please take the child to OP no. 10” I said and pointed the way to the mother. She thanked me and walked slowly holding the boy’s hand.
After this, patients started coming in steadily and we got immersed in our work. About an hour later, I desperately wanted a drink of water, as the summer heat in the open area had reached a peak. So, I walked out of the triage area to have water. I saw the young woman with the little boy standing in the open, just outside the fever OP. I walked towards her and enquired, “What happened? Have you seen the doctor?”
As though my question was her cue, she started crying. “The doctor in the fever OP has asked us to go away. She refused to treat my child. I came walking all the way from Porur (clearly more than 10 Kms), as there are no vehicles or buses plying on the roads. I don’t know where else to go now and what else to do”
I said, “There must be some mistake. Come with me, I will take you to the OP.” and led the two of them into the OP no. 10. There were two doctors, both my colleagues from another department, seated in the OP. They were both wearing surgical masks and a plastic gown. There were no patients in the OP. Both were sitting and talking something to one another. I made the lady and her son sit on the patient’s stool and started explaining to the medical officers, “Ma’am, I am the medical officer from the triage area. I sent this child to you about an hour ago.”
One of the two medical officers, the senior one said, “Sorry, we cannot see the child. We are not paediatricians. Ask the paediatrician to come and see the child”.
In order to prevent the mixing up of patients with possible Covid-19 with the non-Covid patients in the hospital, the hospital had drawn out a policy to have a separate fever OP. The fever OP would be run by medical officers from various departments. In order to minimize the number of medical officers who will be seeing patients in the fever OP, all patients who had fever had to be seen, irrespective of whether they are adults or children or pregnant women in the same fever OP by the same medical officer. If the medical officer had doubts and questions regarding management of the patient, they could call the specialists on the phone and consult them.
The senior medical officer went on, “During this pandemic period, I am made to sit in this fever OP exposing myself to infection, while the paediatricians are relaxing in their department. This is not acceptable. Ask them to come here. I will not see this child”.
I was completely aghast by her attitude. I pulled up a chair and started seeing the child myself. The child’s history and physical examination revealed a possibility of a urinary infection. I called the paediatrician over the phone, discussed the details of the child with her and gave the treatment. The clinical encounter was complete within 10 minutes. When I finished and got up to leave, the senior medical officer in the fever OP looked at me and said, “I could have done that too. But that is not the point. The point is that paediatricians also must be held responsible. They must also come and work in this environment. Why should I alone be exposed?”
I knew any reply I gave her would not be understood and would only build up an argument. I wanted to tell her that there was no excuse for sending away an anxious mother and a sick child without even seeing them, but I did not. I wanted to tell her that even during emergency pandemic times, the anxiety, worry and concern of a mother about her child’s sickness is the same, if not more, but I did not. I wanted to tell her that medical professionalism apart, what she did to that child and mother was bordering on inhuman, but I did not. As I walked back to my triage area, I directed the young woman and the little boy to the pharmacy to get their medicines. The woman thanked me and walked away.
This episode showed me how much the practice of medicine has changed in just 2 months. I do not know whether this doctor would have treated the child and the mother in the same way even before Covid-19. Maybe she would have, maybe not. But one thing that this pandemic has done is to make self-preservation supersede compassion. A couple of months ago, we were not averse to treating patients with tuberculosis. We were ok with dressing infected, maggot infested, fowl smelling diabetic foot ulcers. We routinely diagnosed and treated measles chickenpox, malaria, dengue and every fathomable illness. But suddenly, things have changed to the extent that we are insensitive to the anxiety of the mother of a sick child. It is particularly important for all of us clinicians to know that the pandemic has not changed the way people experience sickness, pain or discomfort. If anything, it has only worsened it by adding layers of uncertainty and fear. Our role as clinicians cannot change at this point. We are even more required now to be the pillars of support for our patients. Through our masked faces, we must find a way to express genuine concern and empathy. Through our glove clad hands, we must find a way to touch and comfort. Through our meticulous attention to details, we must show our patients that we are always there to care.