Communication skills may not be enough

 

Having good communication skills may not be enough for effective patient-physician relationships. Sometimes the situation may be unfavorable for the patient, that however hard we try to make the encounter pleasant, we end up failing and it becomes a bitter experience for both the patient and the physician. This happened to me a week ago and it took me quite some time to process the episode and gather my thoughts to write about it. 

 

Mr. K was a lean, tall, balding, middle-aged man from a town about 20 Km away from the clinic. He walked in with a pleasant smile. Right behind him came his wife and she had in her arms their 2 year old daughter. The baby was crying and his wife was standing with the baby in her arms, trying to comfort and quieten the child. 

“Do you want to take the baby out and calm her down? It is quite crowded in here and also not a friendly environment for a child.” I suggested. 

“No doctor, I want to be around. Ignore us. She will be quiet. You please carry on” she said and I turned to Mr. K. 

 

Mr. K is a 46 year old man with type 2 diabetes since 6 years. They had been married for several years, but had difficulties in conceiving a baby. During a clinical evaluation for infertility, the doctors had found Mr. K to have diabetes. After several years of treatment for infertility, they had conceived the baby by intra-uterine insemination in a private infertility clinic, 2 years ago and the product was slowly quieting down and sleeping in her mother’s arms right now. Mr. K had very high blood sugar levels. His fasting blood sugars were in 300s and post meal sugars were in  400s and 500s over the past 1 year. He has been consistently taking only one tablet over the past one year and has not been seeing doctors. I examined him and found that there were signs of significant weight loss with striations and wrinkling of the skin. 

“I am seeing you for the first time now. Which doctor have you been seeing so far?” I asked. 

“We have not been seeing any doctor for the past 1 year. We are just continuing the same tablets that the last doctor gave us” this was the wife’s reply. 

Mr. K was predominantly quiet throughout the clinical interaction, and it was his wife who was doing most of the talking. 

“His sugars are very high. Haven’t you seen any doctor with these blood sugar reports?” 

“No we haven’t seen anyone” said the wife. 

“We saw a diabetes specialist about 8 months ago near our home” Mr. K started saying. At that time his wife placed a hand on his shoulder in a gesture to quieten him. Mr. K turned back and up and saw her. She showed a facial expression of annoyance and prohibited him from talking further. I understood that the wife did not want him to tell me about the last clinical encounter with the doctor 8 months ago. I did not press any further. I reviewed all his records. I noticed that 2 years ago he had been treated with insulin. I asked him about it. 

“Yes doctor, during the intra-uterine insemination procedure, the doctor insisted that his sugars must be controlled. Otherwise, it will not succeed. So, he had to be on insulin for 3 months” said his wife. 

Those three months when he was on insulin was the only time when his sugars were under control. I charted out his entire blood sugar levels in my case sheet and it was not a good chart to behold. The sugars have constantly been high. 

“Your sugars have constantly been high. Looks like the tablets are not working on you. We may have to start you on insulin.” I said. 

Mr. K was quiet and listened to what I was saying. 

“I will start you on insulin injections. Since you have already taken insulin in the past, you must be familiar with using it. Aren’t you?”

“Yes doctor. I can start the insulin. I know how to use it.” Mr. K replied. 

I started writing out a prescription for insulin. 

“Is there no way we can avoid insulin doctor?” this was the wife. By now the baby was sleeping quietly. I gestured her to sit down in the chair in front of our consultation table. She sat down. 

“For almost a year he has been taking tablets in high doses, but his sugars are not at all controlled. His sugars have always been high, except for the time that he was on insulin in the past. This shows me that he needs insulin treatment. What is your doubt? Why do you want to avoid insulin?”

“No, we don’t want to use insulin. We saw a YouTube video recently that says insulin is a scam created by the pharmaceutical industry. The industry is exploiting vulnerable people like us to make us take insulin. Once a person is started on insulin, they become dependent on it. They can never get off insulin and therefore the pharma company gets profits perennially. Not only this, we also heard that insulin is harmful.” The wife said this and by now she had raised her voice and her facial expression had become one of anger. Mr. K was quiet. 

 

“I understand your concern. I have also seen such videos in which people say diabetes does not exist, diabetes is a scam, insulin is a pharma company scam etc. Unfortunately, such videos are not trustworthy. I am seeing hundreds of patients with diabetes in my clinic every day and some of them suffer from serious complications of the disease. In my clinical experience here over the past 15 years, I can tell you that diabetes and insulin are not scam. Insulin is a natural treatment. It is one of the safest medicines for diabetes. So, I wouldn’t be so apprehensive to use it.” 

 

I tried to keep my voice and expression neutral and professional. Though internally I was feeling a deep sense of anger and frustration with the false information that is being spread through social media and which influences vulnerable patients, I cannot allow this to affect my interaction with this patient and his family. They are after all innocent victims of the vicious misinformation campaign of inconsiderate people. 

“In that case can you guarantee us that you will stop the insulin as soon as the blood sugar is controlled?” His wife now got up and spoke in a high voice. Anger and mistrust was evident in her voice. 

This was a tricky question. Some people who have severe insulin resistance may require insulin in large doses for long periods of time. When we use insulin the sugar levels will come down, but we cannot stop insulin once the sugar levels come down. It is because of the insulin that the sugar levels reduce, and we may have to continue them, sometimes even for the rest of their lives. This is the appropriate answer for me to give to the family. But if I said this, I was only going to reinforce her belief that I am trying to push a profit-making treatment to them. I was thinking hard if there was any nice way of saying this. 

“It doesn’t work like that madam. We may be able to slowly wean him off Insulin and put him back on tablets eventually. But there is also the possibility that he may require insulin for a long time. Looking at his poor response to tablets, and the way he has lost significant weight, it looks like he may require insulin for the long run” I replied. As I was saying this I lowered my voice, leaned forward maintained eye contact with the wife and sounded as earnest and sincere as I was.

“Get up K! Let us leave. We got cheated into coming here. We should never have come.” The wife shouted in anger, and gestured at her husband to get up so that they could leave. The baby was sleeping peacefully through the whole ruckus. 

 

Mr. K slowly got up. I did not really know what I had to do at that moment. I watched as they got up to leave. 

“We came all the way from such a long distance, because someone told us that you will give treatment without insulin. Do you think we don’t have bigger and better doctors in our town? The only reason we came here was because we believed that you would avoid insulin. But it turned out that you are like them all.” The wife still had the volume of her voice raised. 

I was quiet and listened to her patiently. My silence irked her even more. 

“Don’t cheat poor patients like us. We all come believing that you will do what is best for us. Don’t exploit us” Saying these last words she walked away with Mr. K. Mr. K had an absolute sense of dismay on his face. He did not seem happy with the way this encounter had turned out. 

 

As soon as this couple walked out, the next patient came in. She is an elderly woman who has been my patient for a long time now. We exchanged pleasantries and after getting her prescription refill, she asked me, “I couldn’t help but overhear the shouting of the previous patient. Why did you not speak anything back? Her accusations about you were unfair and wrong.” I smiled at her and kept quiet. She understood that I did not want to discuss it, and she smiled back and left.

 

Should I have responded to the lady? Should I have explained that I am not a cheat? Should I have calmed them down and convinced them to take insulin? Or should I have given in to their request of ‘no insulin’ and adjusted his tablets and attempted a treatment with just tablets? Did I fail in communication? 

 

I am generally good in my communication skills. One of my strengths has always been my ability to talk and explain to patients about their treatments. This takes a lot of time and effort. But I like clear and open communication, and I like explaining disease processes and treatments to patients. One of the main reasons many patients come back to my clinic is because I talk to them and explain things. It is quite possible that I did not communicate well with this patient and his wife. Another possibility is the prior baggage with which this patient and his wife entered the clinical encounter. After experiencing the heights of commercialization of medicine that is typical of infertility treatments, and after going through several years of living in doubts of good outcomes, with very little in the form of trust in the health care provider, the patient and his wife came with a lot of mistrust in the health system. Social media had added to this mistrust by spreading misinformation about diabetes and insulin. Our clinic is quite popular (and at times infamous) because we actively avoid expensive, non-evidence-based treatments and unnecessary injections and intravenous infusions. So, this couple had come expecting that we would give them the non-expensive and non-invasive treatment option. Unfortunately, the clinical condition did not allow for a conservative treatment. Over the background of skepticism and mistrust in the health system, their expectations was also not met, thus leading to disappointment and dissatisfaction. There was no way I could have avoided this mishap with any of my expertise or skills in communication. 

 

Sometimes in our attempt to do the right thing, we end up being dissatisfying, disappointing and annoying to the patient. Talking and explaining to the patient during the dissatisfying episode may not be the solution for this. They may not be able to listen to or understand the explanation. A revisit after some time, or a community based approach through a social worker / community health worker who can visit them at home and try and explain things to them may help. Someone that the patient trusts can be brought into the dialogue and mediate the discussions. A doctor cannot bear the whole burden of producing a satisfying and good clinical encounter. Sometimes it takes an entire team to produce satisfying and fruitful clinical outcomes.