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But doctor, what are the possibilities?

Biases, decision-making and patient care. Why doctors can’t tell you all the information or unbiased opinions. Ask your doctor for more information.

Each ailment has its own palet of therapeutic options. Often doctors discuss the most medically and culturally accepted option, the one that most patients would choose. However, you might not be like most patients. With time pressure, sometimes not all options are explained well enough and as a consequence patients could make suboptimal choices.

Everyone has their own way of thinking, so information and choices should be tailored per patient. You might think that doctors shouldn’t tailor information, but the reality is that with time pressure not every option can be explained in detail; why should the doctor waste time on explaining irrelevant therapeutic options? Bad choices can be caused by multitude of factors: time pressure, biases and assumptions from the doctor, but also biases and assumptions from the patient.

Interestingly, culture also plays a large role. For example, in some countries, life prolongation is often preferred over quality of life. Louis Theroux made a thought-provoking documentary called “Life on the Edge” (Louis Theroux’s LA Stories episode season 1, episode 2). He illuminated how, for better or worse, the American culture of “fighting till the bitter end” has permeated clinical practice. He showed several situations in which doctors have pushed the life-extending option to the patient. In one case the patient chose to have another cycle of chemotherapy, making him extremely weak in his last days on earth. In the end, the patient died without any life extension benefit. I’m definitely not criticizing American culture nor American doctors, these types of situations can happen in any country and depends on a multitude of factors. One study investigated end-of-life practices in European intensive care units (ICUs). Remarkably, the withdrawal of life-sustaining treatment differed across the doctor’s religion, for example Protestant Christian physicians withdrew life-sustaining treatment in 44% of cases as opposed to 16% of Jewish physicians [1]. Another study surveyed 535 doctors from Sweden, Germany and Russia surrounding end-of-life treatment decisions [2]. They found that Swedish physicians chose fewer life-prolonging interventions as compared with the Russian and the German doctors. The authors concluded:

“The lack of compliance with patient wishes among a substantial number of doctors points to the necessity of emphasising ethical aspects both in medical education and clinical practice. The inconsistency in the treatment decisions of doctors from different countries calls for social consensus in this matter.”

Unfortunately, it’s going to be almost impossible to create a “social consensus”, simply because beliefs and ethics varies across different religions, countries and continents. Instead of waiting for this social consensus to happen, I’d want to give you the power to make fully informed decisions. Rather than accepting the doctor’s advice head-on, you may want to consider asking about the pro’s and con’s of each relevant therapeutic option. In short, you may want to ask the doctor: “But doctor, what are the possibilities?”

References

1.         Sprung, C.L., et al., End-of-life practices in European intensive care units: the Ethicus Study. JAMA, 2003. 290(6): p. 790-7.

2.         Richter, J., M. Eisemann, and E. Zgonnikova, Doctors’ authoritarianism in end-of-life treatment decisions. A comparison between Russia, Sweden and Germany. J Med Ethics, 2001. 27(3): p. 186-91.

Photo by Javier Allegue Barros on Unsplash

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Substack

I set up a substack newsletter. I’m really excited to write more about how “HOW TO (NOT) BE A BETTER PATIENT”. This will be a biweekly newsletter. Check it out here if you like this topic.

My blog at www.manivenkatesan.com will be about more wide-ranging topics, kind of like a personal diary. Get in touch with me if you have special requests about specific topics to cover. Write to you next time!

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My first week as a medical student in the hospital

I wrote this post a long time back (February 2021), but resisted uploading it (grrr the resistance…). That said, I want to write a bit more about my journey in the hospital. Every week I end up in the craziest situations, so writing about it will be a good way to process what happened.

Witnessing a poor lady getting the diagnosis incurable pancreatic cancer, getting shouted at by a delirious patient, and performing a rectal examination were amongst the many adventures during the first week as a medical student in the hospital. As a medical student at Erasmus Medical Center in Rotterdam in The Netherlands, I’ve received 3 years of training on how the human body works. As a medical student you are taught which symptoms are linked to specific diseases, how to extract relevant information from a patient and how to perform physical examination. Nevertheless, when the time finally came to enter the hospital in my 4th year as a medical student, fear and doubt entered my mind.

I was sent to a faraway hospital in the south of The Netherlands. Since it’s a 1.5-hour drive from Rotterdam, I fortunately got allocated a room next to the hospital for 10 weeks. My first clinical rotation is in the internal medicine department. Every week I’m linked to a different doctor and tag along with them. Whenever a new patient is referred by their respective GP, I am allowed to first see them. I question them about the problem, perform the physical examination, discuss my findings with the specialist in the absence of the patient and finally the patient is called in to get the specialist’s opinion. One of the most intense consultations of the week included telling a patient in her 60s that she has got incurable pancreatic cancer (just to be clear, I simply sat beside the medical oncologist who gave the news). Seeing all the frail people in their 60s, 70s and 80s approaching the end of their lives is a strong reminder that time is limited. Even though I easily get carried away by all the minutia, this is a good moment to take some time to look back at my journey and acknowledge no one lives forever. Whether you’re 80 years old, 50 years old, 29 years old (like me) or just born, I’m sorry to say but time is running out. One-third of our lives is gone because of sleeping, what you do with the remaining two-thirds is up to you. We’ve got to spend our time consciously, because we don’t know what tomorrow will bring us. For the most us (including me), the problem isn’t that we don’t have enough, the problem is too often we don’t spend it well…

Let’s get rid of “patients”

I got into a discussion about the word “patient”. My colleague mentioned that the word has a negative connotation. She mentioned that the word makes us focus only on the disease rather than on the person as a whole. I was taken by surprise by this statement. It’s interesting how I’ve been using this word without truly realising how others might view it. It made me curious how others think about this issue…

The word derives from the Latin word “patiens”, meaning suffering or enduring. Julia Neuberger argued, in an article in the British Medical Journal, that

“The word “patient” conjures up a vision of quiet suffering, of someone lying patiently in a bed waiting for the doctor to come by and give of his or her skill, and of an unequal relationship between the user of healthcare services and the provider. The user is described simply as suffering, while the healthcare professional has a title, be it nurse or doctor, physiotherapist or phlebotomist.”  Deriving from this thought process she argued that, “The active patient is a contradiction in terms, and it is the assumption underlying the passivity that is the most dangerous. It is that the user of services will remain passive in sickness, allowing the healthcare professional to take the active part and tell the user what to do.”

I would agree that a passive user of health services is not the way to go in modern medicine. However, regardless of the etymology of the word, I’d find it a far stretch that the term patient would promote or provoke passiveness. For example, healthcare professionals usually don’t address the patient itself with this word, most often it’s used in communication with colleagues. This article received several rebuttals.

One of them was from Raymond Tallis who argued against changing the word “patient” into something else:

“Would change mean improvement? Even if there were a case for change, and a satisfactory alternative, would there be any reason for thinking that this would drive improvements in doctors’ attitudes and behaviour? Most linguistic reforms reflect rather than bring about changes in attitudes.”

I side with Tallis on the practical reasons for not changing the word patient, nevertheless for me this is not the main topic to be highlighted. Neuberger raises an important issue which can’t be overlooked, namely that the patient must be an active participant in their whole medical process. More importantly each person must be an active participant in their health before and after being diagnosed with a disease and being labelled as a patient. That’s what this newsletter is about after all. Being health conscious is not just about a moment in time or a period in your life, it’s a lifestyle. I would argue that being health conscious doesn’t stop when stepping into the doctor’s office. In most situations you will have options and hopefully you can decide the best treatment together with your doctor’s advice (i.e. shared-decision making), rather than being forced to choose something you don’t feel good about. I would like to urge you to stay engaged in your own medical pathway, try to understand what the pro’s and con’s are and ask questions if something isn’t clear. Try to be an active participant, rather than the passive patient.

Photo by Yaopey Yong on Unsplash

#8 How to be a better patient – Should I get a second opinion?

Your health is one of the most important things in the world. Even though healthcare professionals want the best for you, sometimes you might not agree with the recommendation of your doctor. What would you do if you’re in this situation?

You might want to consider getting a second opinion. This is the situation in which you would want to be seen by another doctor and find out whether the initial diagnosis and/or recommended treatment stays the same. Asking for a second opinion might be a right move in the following situations:

  • The patient-doctor relationship is irreparable
  • Your diagnosis and/or treatment plan is still unclear
  • You would like to explore other treatment options
  • You want more assurance about the initial recommendation
  • The treatment doesn’t have the wanted effect

As far as I’m aware, as a patient you have the right to choose a different doctor. Whenever you do request for a second opinion, ask you initial doctor to share the medical report (including the diagnosis and treatment plan) with you and the other doctor. I hope you don’t feel the need to ask for a second opinion, but sometimes it might be necessary…

Consider reading this interesting blog posts on the same topic: Navigating medical customer service – a reprise

Featured image credits: Photo by Possessed Photography on Unsplash

Note to myself: A growth mindset over a fixed mindset

The day we stop developing is the day we stop living. I believe that every day we are making a choice, whether we are aware of it or not, to choose to work on ourselves or to accept our own limitations. The future becomes far more exciting when we think about how we can use time to our benefit to compound learning and slowly but surely acquire new skills. This concept is explained in the book by Carol Dweck “Mindset”. People with a fixed mindset believe their current skillset and limitations are set and that it’s out of reach to improve. In contrast, people with a growth mindset understand that limitations are self-imposed and find ways to get better at something or acquire skills. In reality, no one has a pure fixed or pure growth mindset, we usually are a combination of both mindsets. Often we believe that we can’t improve in certain areas of life (for example perhaps giving presentations or socialising), whereas other areas seem more adept for improvement (perhaps something you enjoy doing, like playing games or cooking).

The beauty of living, is that we are presented with time in order to learn anything we want to. The difficulty of living though, is that we can’t learn everything at the same time, neither can we learn difficult skills immediately. Fortunately, if we consistently show up and put in the work, we can eventually compound skills. This all sounds very wishy washy, but this concept has been beautifully explained in the book “Atomic habits” by James Clear. If we aim to merely improve 1% every day, our growth becomes exponential and over a long period of time this can result in world-class performance.

Check out some nice blog posts for further reading:

Featured image credits: Photo by Mikel Parera on Unsplash

#7 How to be a better patient – Alternative treatments?

In modern day life so many aspects of the human experience is medicalised (meaning conditions and behaviours are labeled and treated as medical issues). The emphasis of medical training lays on how to solve problems through medical interventions (such as drugs or surgery). Quite often there’s a (commercial) treatment for your medical problem:

  • Are your blood sugar levels too high? Well, there’s a pill for that.
  • Are you feeling depressed? Well, there’s a pill for that.
  • Are you having trouble sleeping? Well, there’s a pill for that.
  • Are you feeling anxious? Well, there’s a pill for that.
  • Etc, etc.

Let me be clear: all these things are legitimate issues and need care. However modern medical treatments may not always be the only or the best option for your malady.

Whenever your doctor provides medical advice, when appropriate, request whether there are also other ways to resolve the problem. Take for example diabetes type 2, simply put, this is the disease in which your blood sugar levels become too high. Doctors can prescribe drugs such as metformin to lower blood sugar levels and sometimes they might not inform you that daily exercise and a healthy diet could have similar or additive effects. I’m definitely not advising you to ignore your doctor’s advice! Please do follow their advice, however also ask these extra question:

  • Is there something I could personally do on top or instead of the treatment you initially recommended?
  • Are there other treatment options available?

These questions force your doctor to list all the treatment options, instead of the “one-size-fits-all” recommendations. As a result, your doctor might be able to advise a less risky treatment or might be able to suggest lifestyle interventions in addition to the initially recommended treatment.

Disclaimer: All content and media on this website is created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice.

Featured image credits: Photo by cottonbro

#6 How to be a better patient – How to prepare for your doctor’s appointment (part 2)

Being caught up in the healthcare system, I can confirm doctors are just humans. Unfortunately, everyone will make a mistake at some point, whether it’s small or big. A major factor that determines whether a doctor makes correct decisions or not, is how the patient presents himself/herself. A good doctor will make sure not to miss important aspects, they will incorporate the following aspects in their judgement:

  • 1. The story of the patient: this is referred to as the “patient history”
  • 2. The physical examination: depending on the patient history the doctor will decide what kind of physical examination to perform (for example this could be listening to your heart or looking into your ears).
  • 3. If necessary, the doctor will request additional tests: the “patient history” and the physical examination will influence which additional tests need to be requested.

I hope you now understand that in most cases the story of the patient is the single most important clue in determining the correct diagnosis and treatment. A good doctor will try to guide the patient in communicating their physical complaints. At the same time, the patient also has the responsibility to communicate all relevant aspects of their illness. This is what you can do to help your doctor make the correct diagnosis:

  • 1. Write down your main physical complaints in advance (This was also mentioned in yesterday’s blog post).
  • 2. Explain how your physical complaints changed over time: did the physical complaints stay the same or have they become worse over time? Which physical complaints are new and which have you had for a longer time.
  • 3. Mention all the medication you are taking: some patients think certain medication aren’t relevant to tell because they think it’s totally unrelated to their current ailment. Nevertheless, make it a habit to mention all the meds you’re taking, it might as well be causing some side effects or it might have a bad interaction with the new medication your doctor wants to prescribe to you!!!
  • 4. Mention all your allergies
  • 5. Mention whether you have been diagnosed with some other diseases
  • 6. Mention whether you are currently being for some other illness

Don’t worry if you can’t manage to follow these exact guidelines, the training of becoming a doctor is extracting the relevant information despite a fuzzy description of the ailment. Nevertheless as mentioned before, doctors are merely human and can therefore make mistakes or fail to extract critical information. Try to prevent the mistakes made by your doctor by incorporating these tips and tricks into your next doctor’s visit.

Featured image credits: Photo by MART PRODUCTION: https://www.pexels.com/photo/people-woman-sitting-technology-7089401/

#5 How to be a better patient – How to prepare for your doctor’s appointment

Imagine you have an upcoming doctor’s appointment. You are seated, the doctor ask you to explain your physical complaints. Seven minutes later you are told you probably have this disease and 3 minutes after that you are sent out the door with a doctor’s prescription for a medicine with a weird name. You forgot to tell them some vital information that might have alerted the doctor to think about some other disease. On top of that you forgot what this medicine you are about to pick up is good for. I’ve seen many patients confused about their diagnosis and their treatment. Would you want to prevent this situation? Here are some tips:

  • 1. Write down your main physical complaints in advance (bulletpoints should be fine). This could be either on a piece of paper or on your phone. A piece of paper might be preferable. You could hand the paper over to them and the doctor could scribble some explanation on the paper.
  • 2. Write down your questions in advance.
  • 3. Ask your doctor to summarise the diagnosis and the treatment. Make sure this is clear for you before you walk out of the doctor’s office! You could even ask the doctor to write it down for you on the paper you brought along.

If you manage to stick to these 3 simple rules, you’ll be more informed than most patients. I’ll be writing more about how to maximise the utility of your doctor’s visit in future blog posts, so stay tuned!

Featured image credits: Photo by Nathan Dumlao on Unsplash

#4 How to be a better patient – What to do when you have a complaint?

Imagine you’re a patient with extreme pain and you therefore go to A&E (i.e. emergency room) in the hospital. Here you are sat down and not helped for hours. Or imagine you have had a very bad experience with a healthcare professional (doctor, nurse or whoever else in the hospital). What would you do?

You might hold a grudge against that specific person. It is then recommended that you discuss this issue with the specific healthcare provider. Don’t just keep your feelings to yourself. If unresolved, these experiences could erode your trust in the specific healthcare provider.

I was discussing this issue with a colleague earlier today. He mentioned that doctors should also play their part. Whenever doctors sense a patient is particularly unhappy with the healthcare service, whether it’s about yourself or a colleague, they should invite the patient to discuss this issue. Doctors shouldn’t shy away from having these difficult conversations. In the end the doctor-patient relationship might become damaged beyond repair if left unaddressed. My colleague mentioned that a good doctor invites the patient to discuss their complaint and if it’s a big error, they should even encourage the patient to file an official complaint. In general, this complaint is not intended to punish anyone, rather it will illuminate processes and behaviour that needs improvement. In the end, this will also benefit healthcare for other patients. Obviously both sides should try to stay respectful, we’re all humans and anyone can have a bad day and make a mistake. My colleague also mentioned that usually after having these kind of difficult conversations, these patients feel heard and understood, resulting in a stronger doctor-patient relationship than before.

In short, whenever you as a patient have a complaint about a healthcare service or provider, don’t shy away, try to communicate your feelings!

Featured image credits: Photo by Andre Hunter on Unsplash

#3 How to be a better patient – preventing colorectal cancer

According to UK statistics, 1 in 15 UK males and 1 in 18 UK females will be diagnosed with bowel cancer (i.e. colorectal cancer) in their lifetime. Sources from Cancer Research UK estimate that 54% of bowel cancer cases in the UK are preventable. They break this number down as follows:

  • 13% of bowel cancer cases in the UK are caused by eating processed meat.
  • 11% of bowel cancer cases in the UK are caused by overweight and obesity.
  • 6% of bowel cancer cases in the UK are caused by alcohol drinking.
  • 7% of bowel cancer cases in the UK are caused by smoking.
  • 2% of bowel cancer cases in the UK are caused by ionising radiation.
  • 5% of bowel cancer cases in the UK are caused by too little physical activity.
  • 28% of bowel cancer cases in the UK are caused by eating too little fibre.

These numbers are likely to be population specific, meaning that the exact numbers might be different for the people living in your region. Regardless of the specific regional differences, this list immediately shows what you could do to reduce your chances of getting bowel cancer. A Danish cohort study, suggested that one could reduce the risk of getting bowel cancer by 23% if the study population followed the following 5 lifestyle recommendations:

  • Physical activity: ≥30 minutes of moderate activity
  • Maintaining a limited waist circumference: ≤88 and ≤102 cm for women and men
  • Not smoking
  • Limiting alcohol: ≤7 and ≤14 drinks/week for women and men
  • Diet: eating plenty of fruit, vegetables and fibers, while limiting red and processed meat

The somewhat annoying thing surrounding this issue is that most people are aware of these lifestyle recommendations. However, often it’s too hard to get started or to maintain these healthy habits. Overturning your bad habits and substituting it with good habits doesn’t happen overnight. I’d suggest that you don’t compare yourself to others, simply start small and strive to be 1% better than yesterday. This concept has been popularised by author James Clear, check out his book “Atomic Habits“. It’s never too late to get started.

Image credits: James Clear

Featured image credits: Photo by Dan Gold on Unsplash

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