Tuesday, May 27, 2008

Truth versus Lie

After the bitter experience with the gentleman with liver cancer, I am trying to be more truthful to my patients who are on terminal Care.
A 65-year-old Widow,the mother of a son and daughter, came to me with painful swellings on her neck. She had been investigated in another hospital and was given a prescription of medicines to be taken for one month. She was brought to me by her brother because she was not happy with the treatment she got from that hospital. Her brother is an old patient of mine and have tons of faith in me.
I went through the investigation reports. Everything possible have been done including CT Scan and a biopsy. The final diagnosis is there printed clearly. The swelling was the spread of a worst kind of Cancer and no treatment options were available. She had barely few months to live. I was hesitant to look up to her face. So, again and again I shuffled the pages of the file and finally had to look up at her expectant face.
Should I give her false hope? Or should I blurt out the cruel truth? Or say some truth but hide the rest?
I choose the first option. I told her that she will be alright soon and gave her a prescription for medicines to be taken for 2-weeks and asked her to come again after that.
But my mind was in a turmoil. I know what I did was wrong. I wanted to tell her brother the truth first. So after a minute, I asked my assistant to call back her brother for a clarification. Then I told the truth to him. He was devastated and started crying. I just sat there with an empathetic look. Then I asked him how she will take it if I tell her the truth. He said he don't know. Then I explained why it will be better if I tell her the truth, at least a half truth. I told him that she can have her last wishes fulfilled and have a peaceful death. He agreed and asked me to tell her as much as I wish.
Then I asked her to be brought in. I told her that the swellings in the neck are cancerous and they are inoperable, but medicines may help. So, I asked her to take those medicines and come back to me after 2 weeks. She took it much better than her brother. Then came the dreaded question. How much time I have, to live?
I evaded the question. Did not give a direct reply. Said nobody can say that. If medicines worked, she may live long (I know that was a lie). Then she said she would like to continue to do her part time job as a cleaning assistant so that she can support herself financially. I told her that she can work as long as she feel up to it. If she find her work very tiring, she should stop.Then she cried for some time and left promising to come after 2 weeks.
I feel that 'the truth' even though it created a temporary mental trauma, will certainly help her to face death.

Monday, May 26, 2008

Can a doctor lie?

You may always think of a doctor as the most truthful person.But in many occasions Doctors are forced to lie.
I still remember the face of an elderly Gentleman who was suffering from terminal Liver Cancer.The family did not want to disclose the truth to the patient.Each time he come for a consultation his face search my face questioningly.Several times he had asked me about the gravity of his illness and always I had given him false hopes.Fortunately I was not at his bedside when he died.Few months later his Son came to me for something.I asked him about his father's last days.He said it was terrible.His Dad while dying was blaming his son for not giving proper care.He also blamed me for not finding out the correct diagnosis.
I have heard that in Western Countries they believe in disclosing everything to the patient.In a way that is good.The patient will know the truth and will be able to fulfill his last wishes and die peacefully.In India the Society and the family always tries to hide the truth from the patient.They believe that the patient may not be able to face the truth and may suffer from severe mental trauma hearing the bad news. But I feel disclosing the truth is better.What do you think?

Friday, May 23, 2008

Crisis averted?

Doctors working in Government run Hospitals in my native State Kerala has called off their proposed strike yesterday. The working conditions of Doctors in Government sector is so poor that only a hand full of new pass outs from Medical Colleges join it.The demands of Doctors agreed to by the Government may help in persuading those who work in that sector not to leave it.But will it help to attract new recruits?Chances are low as there are much greener pastures waiting them elsewhere. This raises a doubt.Is the current Government really interested in Public Health?

Thursday, May 22, 2008

Life and Death

Recently the doc on duty in the Hospital I work did a heroic resuscitation of life.An 85 yr old lady bedridden with chronic lung disease and Crippling arthritis suffered a massive heart attack and went in to a Cardio respiratory failure.He along with the nursing team revived the lady with all the equipments and medicines available.The lady survived for another five days only.Those 5 days made a huge hole on the pocket of the family.With no medical insurance they had to suffer a big financial burden.
With most patients here paying from their own pocket such heroic measures of resuscitation often do more harm to the family than good.But who is to decide to what extend resuscitation should go on?

Sunday, May 18, 2008

Medicine and Astrology

The other day I was attending a Medical Conference.A reputed Cardiologist from nearby City was lecturing about recent advances in Cholesterol Management to an attentive group of Doctors.He was quoting left and right from umpteen clinical trials showing his vast knowledge in evidence based medicine.The lecture was well appreciated.

After the lecture it was dinner time and casual conversation was going on.The speaker was telling a real life incident of his relative suddenly collapsing and dying few days after a successful Coronary angioplasty and stenting.He finally commented that it may be better for the patients and even for doctors if the services of an Astrologer is made available at all Cardiology Departments.
Doctors and Scientists in many other fields tend to forget logic and a Scientific attitude when it comes to near and dear ones.Am I right?

Saturday, May 17, 2008

Anti Diabetic tablets in Pregnancy

Until now, pregnant women with diabetes related to Pregnancy[Gestational Diabetes]had limited treatment option. Excessively high blood-sugar levels during pregnancy were controlled primarily by modifying a patient's diet or, if that failed, using insulin to treat the condition.
Now, there are two other drugs women who have this condition should consider. Glibenclamide[also called Glyburide], an oral medication has been a viable treatment option for pregnant women since 2000, and metformin, another oral drug is an option newly deemed safe and effective in a study published on May 8 in the New England Journal of Medicine. In addition, dietary changes remain important, since they can reduce the risk of having a large baby and a more difficult delivery. The addition of metformin to the list of options for pregnant women is important, since pills are helpful for women who are wary of giving themselves shots of insulin.
Importantly, the new study found that metformin treatment was not associated with increased risks to the baby, compared with insulin. Women in the study also said they preferred metformin over insulin. Both drugs are already used as treatments for type 2 diabetes in adults, but prior to this week's study it wasn't known whether metformin was effective in gestational diabetes—or whether it might cause problems for the fetus.

Thursday, May 15, 2008

Did I think too much about mind?

When you correctly identify a patient as having psychological cause for his/her illness there is a trap in which you can fall into.It happened to me once.
A 60 year old lady was constantly coming to me with symptoms like tummy pain,tendency to pass motion immediately after taking food,bloating sensation etc.My clinical examination and investigations including endoscopy were negative.I labelled her as a case of functional bowel disease due to psychological reasons.My treatment with that diagnosis was successful and she was happy.She came to me less frequently and later stopped all medicines.After 2 years she came to me again with almost similar complaints.I treated her in the same way as before.The response to treatment was not that good but I continued to reassure her .Only after 2 months did i realise that there is something wrong.An endoscopy showed a stomach cancer.Surgical removal was done and chemotherapy started.Unfortunately she succumbed to the disease.
Did I think too much about her mind instead of her body? May be yes.

Wednesday, May 14, 2008

Mind and Body again

An injured mind can down our body defense mechanisms. And this in turn can even cause mortality.A close relatives or friend's death can produce so much trauma to the mind that it can trigger an illness which can take the life out of the body.So often you might have heard that the spouse getting sick and dying immediately after the partner's death.
Recently an 80 plus man, a widower and a patient of mine for many years , who fought and won against many illnesses succumbed to trivial infection immediately after his last son moved out of his house thus making him feel lonely.
The emotional support you get from your loved ones is as important as any medicine or an expert doctor's care.

Saturday, May 10, 2008

Mind and Body

An 18 year old boy is coming to me frequently with complaints of severe headache.I had a provisional diagnosis of Migraine.Standard treatment regimens were not working.His visits continued.Then one day he came with his mother.I asked her mother whether she can think about any reason for his headache.She said it started after his father's sudden death.Then I understood that that his symptoms were psychosomatic and may need psychological counselling rather than medicines
In a primary care Physician's practise such patients are very common may be as much 30 percent of Out patient practise.On a busy day one often forget or don't have time to assess the mind of the patient and the cause of the illness may remain undetected