PATIENT: “Sat sree akal Ji” (form of wishing in Punjabi)
“Doctor Sahib, Apna reporte ayaa hai” (Doctor, my reports have come)
DOCTOR:“Babaji, thuade Ghale me cancer hai” ( Uncle , you have a cancer in your throat)
PATIENT:”Achha Ji”(Local term for Yes sir, but it comes so spontaneously that what it actually means is that I heard something but I didn’t get any thing)
“Waise teek hai na” (after all that is normal, right)
It is interesting to watch how people receive bad news. During the last two years I have had the opportunity to see patients with bad prognosis day in and day out. Thanks to being in a prime institute of my country, India, I have developed an expertise in spelling out the death certificates to the patients. There was a time when I used to avoid such situations on purpose as I had considered myself emotionally inefficient to deal with such cases. But it was when I had to do my thesis on oral cancer that I developed this touch in spelling out misery.
People react to their disease in different ways. Everyone has their own unique way of defending pain. Some cry, some get angry at themselves (and at the doctor), some deny it all, some defy it,some withdraw into themselves, and some get ready for the fight. This depends on many factors such as whether the patient is a male or female and on his or her educational, economic, religious and social backdrop Therefore as a resident doctor it is very important to assess the mental and emotional capacity of the patient before you spell it out. The trick is to say the truth without provoking the patient, to be tough but without hurting him , emotionally bonded to the patient but within the limit that you never become his or her sympathizer.
A patient once came to my late OPD in the late hours with a CT scan report. As I had already packed up my instruments and was ready to leave I was a bit reluctant to entertain him. But he told me that he had not brought the patient and just needed opinion regarding the CT finding. I saw a huge tumor involving most of his nose, sinuses and nasopharynx. Seeing the amount of destruction it caused to the bones around I could say that it was highly malignant. I told him that his patient had a malignant tumor which was rapidly progressing and destroying his body and most probably was not amenable to treatment with curative intend. He sat there and heard the whole sermon of doom. Then he replies,” I hope everything is all right then”. I sat wondering which part I or he had missed . I told him that we could not cure the patient who asked me whether everything was alright. I told him that it was not the case and that his patient was dying. I asked him to bring the patient and we would explain the rest.
It is extremely difficult to explain the prognosis to women. However informed and educated they may be , they have this inborn character of cracking up in such situations. An old man with carcinoma of larynx in an advanced stage had been coming to my OPD. Each time I sent him for biopsy he got lost and came to my OPD next time without the results. So this time I insisted on him to bring someone from home. But to my dismay, a young lady in twenties had accompanied him. I preferred to explain the prognosis to the old man rather than to the lady. But she told me that she was a distant relative and was a nurse working in a peripheral hospital which comforted me. At least she must have seen patients like this. I sent the patient outside and started explaining the bad prognosis of her uncle’s disease to her. She told me she was expecting this for sometime seeing the smoking habit of her uncle. I told her that the biopsy was just to prove the diagnosis; even though we were 99% sure it was cancer. She was calm and composed. She said she would later break the news to the relative and left. I was sorry for the patient but was happy for my accomplishment of breaking the news to a women and not making her cry for the first time. After 5 minutes she rushed into my room her eyes red and raining with tears. She told me she could not face her uncle being informed that he was going to die. She began to cry loudly and other patients tried to notice. I asked her to calm down and be stronger. Things like this could happen to any tom, dick and harry . I have a fixed protocol of lines to calm patients down. It took me around ten minutes to console her and she left wiping off her tears. I felt a little relieved but still waiting for that woman who can receive the bad news.
We have our own ways not to frighten the patients because majority of patients coming to us are scared either of the disease they have or of the surgery we perform. So one wrong word would make them run and hide at their homes. It is very easy to convince the patients that they are ill . After all that is what they expect when they come to us. On the other hand, it is very easy to make a patient disagree with surgery. Just explain the procedure in layman’s terms and he will never allow you to cut him open. Most of our patients are neurotic which simply means that they are obsessed with disease. The moment you tell them they are normal, they either switch the doctor or keep increasing their complaints and visits. So we try to formulate terms and conditions which would satisfy them. Globus hystericus is the most fascinating among them all. Seen most commonly in women, this condition just means that the patient has a feeling of a lump in her throat but there is nothing wrong. If you tell her she is normal, she would just come again and again. If you tell her the fancy name, she will be happy irrespective of whether you treat her or not. Such patients are very happy with relative gimmicks like diet management, exercise, steam inhalation etc though none of these is a definite treatment. Not all tumors are dangerous or deadly , so it is very important that we don’t frighten the patients and make them count his days. So we have got wordings which would explain to him the disease perfectly. These words are just locally evolved and have the same meaning, but the idea it gives to the patient is different. Like for instance, a ‘Gant’ is a swelling which is benign, a ‘rasoli’ is supposed to be a similar swelling which is more dangerous and everybody understands when we call a swelling a cancer. A ‘sojish’ is a small ulcer or oedema , a ‘chala’ is a similar ulcer but more dangerous and next stage is a cancer. Since the boundaries between these terms are pretty vague, one must use them very carefully or else the patient may get misinformed.
The only time I don’t like my patients is when they become careless and don’t follow my instructions. A patient had cancer in his larynx which was treated by radiotherapy. He had come for follow up after 6 months and had not shown any evidence of disease. I examined the patient and there was still no evidence of the disease. I removed my facemask to tell him the good news but noticed the foul smell of tobacco smoke. I asked him whether he started smoking again. He reluctantly told me that he has been smoking for the last 2 months. I got so furious that I shouted at the patient so violently that even my co-resident, who was an occasional smoker got frightened seeing my hatred to smokers . How could he start something which caused his disease at the first time? He has not understood the gravity of his disease and the extent of damage it could do to him and his family. I was under the false impression that we had conquered the disease while the patient himself was conspiring against me. I threw his card away and told him to get lost. He sat there and stared at me. I told him not to see me again until he quit smoking. I knew this was against doctor patient conduct, but my care for the patient had overwhelmed my conscience. The other patients started explaining to him the importance of quitting smoking and that I was behaving like this because I cared for him. May be the patient would never come to me again, but at least I made my point clear to him.
As a doctor we are often accused of being emotionally blunt. Especially surgeons are considered rogue and emotionally attached to patients. Some say that how can we bond with our patients and later cut them with a scalpel. But the truth is surgeons unknowingly get attached to their patients even if they don’t want to. But we often try to hide this by behaving indifferently because most of the diseases we deal with have bad prognosis and urgent decision making and action is of paramount importance. So being emotionally attached to our patients would really interfere with such a decision making. This reminded me of a joke which floated in the facebook. Physicians and Surgeons go for duck hunting. When the ducks fly over them the physician, the Internist points his gun, but does not shoot. "This bird certainly looks like a female mallard, but I must rule out geese , and swans. A juvenile Mesopotamian sea duck would look exactly the same!" the duck flies away. The surgeon comes,” look it flies,BOOM, then turns to the pathologist and asks , what was that?.
By the eldest son
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