Monday, March 23, 2009

Am I reassuring too much?

A patient always like to hear reassuring words from their Doctor.
A doctor is also happy to see the smile of relief on patient's face.
I reassure my patients a lot.But some times I ask myself
Am I reassuring too much?

The other day in my practise it was a day of reassurance.

First patient was a 29 year old woman,in the last few weeks of Pregnancy.She was diagnosed to have Gestational Diabetes.She is working in one of our Metros and was under the care of a specialised Gestational Diabetic Clinic there. Now she has come home for delivery and wanted me to look after her Diabetes.

She was on Insulin, 3 injections per day and was monitoring her blood sugar every day 2 to 3 times at home with her glucometer. She was given a long list of dos and dont's and a detailed diet chart.She was following everything perfectly.

After reading her reports I looked in her face.She seemed to be distressed. I asked her what was troubling her. She said her blood sugar is fluctuating very much and is afraid her baby will be harmed. She also said instead of gaining, she was loosing little bit of weight and is worried about.

The blood sugars were fluctuating but with in a narrow range and was well acceptable. When ever a small rise in blood sugar happens she is much worried that she reduces food intake. Some of the diet restrictions told to her from her speciality clinic was extreme and had not much scientific basis. Her mother is also confused about what food her daughter should be given. All the home grown wisdom of what to give and what not to give for a pregnant daughter was set aside and they were religiously following the diet chart.

I smiled at her and said " You are worrying too much. Your blood sugars are excellent and I am sure you will have a healthy baby and a normal delivery. Yes, you should regularly check your sugars but eat more liberally. Tell me what you really like to eat and I will tell you what quantity and how often you can eat your favourite dish."
That reassurance visibly made her happy. By next visit she started gaining weight and more importantly was at ease. I hope she will deliver normally a healthy child.

Next patient was a retired Government Clerk. He came to me few weeks ago with features of Cirrhosis Liver,probably due to alcoholism. He was send to a Gastroenterologist for detailed evaluation and was found to have severe Liver disease. He has come back with the reports.
"Is it really bad doctor?"
"Your Liver is affected by your drinking".
"I stopped the day I first came to you. Will the Liver function improve?"
"If you do not drink again you will definitely improve, don't worry", I said looking in to his eyes.
That was really not the truth.The reports showed he have irreversible liver damage and his liver function may deteriorate over several months to years. But his symptoms will temporarily improve with medicines. That's why I could confidently reassure him.
My answer I am sure made him feel better.

Third patient was a 64 year old Rheumatoid Arthritis patient. Her knee joints were so much destroyed that she needs Total knee replacement for both knees. Her family was not very well off . I had discussed it with her son and the family was not very keen to find the money for the surgery.
"Will I be able to walk properly and climb steps doctor?" She usually ask me.
" Let us see. You are showing some improvement.So if you continue the treatment......let us see."
In my mind I was sure she will not be able to walk properly. I had hinted to her once about surgery which she refused immediately citing old age. Also the family may not be able to afford it. So she will most probably go on like that using a walking stick, moving very slowly,swaying her body to either side till her death.
But each time she leaves my room, she is satisfied with my reassurance.

Am I reassuring too much?
Some times I do, hiding the gravity of the illness so that the patient is not too much upset. Some time I reassure prematurely before arriving at the diagnosis to avoid unnecessary mental tension.
Making the patient fully aware of the situation may help in avoiding future surprises.It may also help in compliance with therapy. So should I change my method?

I am confident I did do the correct thing in all three instances.
As the great TB physician Dr Edward Trudeau said
"To cure sometimes, to relieve often, to comfort always,"
should be the motto of each Physician.


CALpumper said...

I don't think your assurances were out of line in any way.
The best thing you can do is explain the situation and always offer encouragement and hope.
In life, you just never know sometimes. And mental anguish, worrying all the time about your health, can make the whole situation worse, quickly.

And Dr. Trudeau is so right....that last part is Very important. You are doing fine.

Seema said...

I guess giving comfort is different than giving reassurance. A reassurance is probably based on each individual case facts and needs a judgment call as you would be mixing your professional expertise and humanitarian sentiments. But getting a patient into a non-skeptical zone is very challenging and that is what giving comfort would be. For instance your liver disease patient probably would get his hopes high even though his conditions improve only temporarily and when deterioration starts he might shatter. But as CALpumper says mental distress can worsen the situation so it is really a catch 22 situation.

deepz said...

I dont think that ur way of approach went wrong in any a patient,i do expect from my doctor some words of helps to make me feel that i will be alright very soon...if doctors behave very rudly ,thn people wont feel to go to him...

Charakan said...

calpumper,thank you.Yes as a doc I should atleast try to comfort

Charakan said...

Seema as u said both are different.But reassuring is always comforting.So I tend to do it a lot even if there is not much scientific basis. Many Pts had told me that they come to me to feel better.May be they tell that to other docs too,I do not know.
As you said in the case of Liver disease patient late deterioration may be unexpected and painful.Again I will try to give comfort...

Charakan said...

deepz, thank you for the understanding. More than being rude many docs especially in West tends to over emphasise on all the possible complications and side effects. Fear of lititgation may be one of the reason. But such an emphasis will not be reassuring.
I am the opposite, sometimes sweep under the carpet all expected complications.Wont reveal unless asked for.Both extremes are not good.