Reflections on a busy clinic

 

Yesterday, I saw a middle-aged woman, in the clinic. She was breathing heavily with a lot of difficulty even as she entered my room. As she came and sat down in the chair in front of me, she looked me in the eye and could not start talking for some time due to the breathlessness. Her main problem has been worsening breathlessness that has now prevented her from even taking small steps inside her own home. She is a person living with diabetes and high blood pressure since 10 years and has been on regular medications. She developed a heart attack 4 years ago for which she was admitted in the government general hospital and treated. She is taking medicines for that too. This breathlessness started last year, and it has progressively worsened over the year. 

“I am tired of this breathlessness. I cannot deal with this anymore” she said, broke down and took out a big bunch of thick folders, notebooks and loose sheets of paper and dropped them all on the table. 

 

One of the earliest things that my mentor Dr. K.P. Misra taught me when I was a young medical student was to “never open the file or review the tests and scans of a patient before talking to them and examining them”. He would push the folder aside and pull his rolling chair closer to the patient. That image is so strongly etched in my mind. I did the same thing. I pushed the heavy set of folders and notebooks aside and requested the lady to walk with me to the examining couch. Even those few steps were very difficult for her to take. 

 

My history and clinical examination told me that this woman is suffering from a severe form of lung disease, chronic obstructive pulmonary disease. This had seriously compromised the lung capacity. As the lungs were weakened she was becoming breathless even on mild exertion. I went back to the table and opened the files and notebooks. She had visited a diabetologist, cardiologist, pulmonologist and psychiatrist and all those records were there. Each specialist was treating a different part of her problem, and unfortunately nobody had put all the parts together and seen this woman as a whole person. While the cardiologist had put her on a drug called beta blockers to improve her heart function, the pulmonologist had put her on beta agonists, which do the exact opposite function of the beta blockers. They probably did not know what the other had given. While the cardiologist was trying to slow down the pace of the heart to protect it from another heart attack, the pulmonologist was giving her a drug to open her blocked wind pipes, which has the side effect of pacing the heart faster. Her blood was now a mish-mash of various drugs, some of which were doing opposing functions. This was such a sorry situation led on by the fragmentation of medical practice by specialization and super-specialization where it has become challenging to coordinate the medical treatment of patients who have multiple such problems. It took me roughly 40 minutes to see her, understand her problem and rationalize all her prescriptions and put them all together. Meanwhile the other patients waiting outside started a kerfuffle. 

 

It was almost closing time when a 65 year old man, with a dark brown shell rimmed glasses, white shirt and dhoti walked into the consultation room. He had a very pleasant smile on his face. He spoke in a very stylish English and greeted me, “Good afternoon doctor. How are you?” It is not often that we see someone who speaks stylish English and wears expensive looking glasses in the clinic. I reciprocated his greeting. He sat down and quickly shifted to the edge of the chair and said, “Doctor, I am from Chennai. I have a farmhouse nearby and we are doing some construction work there. So, I am staying here since the past two weeks. Yesterday, a community health worker had come to our village, and I requested her to check my BP. She said it is very high and asked me to visit the hospital to get it checked.” 

 

In our clinic, as soon as people come in, they are registered, their case records are taken out from the medical records department, and then the staff nurse makes them rest for 5 mins and records their heart rate, blood pressure and weight and writes them down in the case record and sends them to me. I looked at the record and it was 190/100 mmHg, a very high blood pressure. I spoke to the gentleman and he very cheerfully said, “I have no health problems doctor. I don’t have high BP or sugar. I have never been to a hospital before.” He asked me where I was from. I told him I am also from Chennai. Then he was asking me about where I live in Chennai, about my family and other information. I then recorded his blood pressure with my apparatus, and his blood pressure was 220 / 120 mmHg. I told him that his blood pressure is very high. I requested that we should do some blood tests and take an ECG to check out how his heart is working. He laughed and said, “It won’t be anything doctor. If you want, we can do those tests. But I won’t have any problems”  and went to the lab to get the tests done. When the results came back, it showed that the man had kidney failure and an enlarged heart. It must have been a long-standing kidney failure which has made the blood pressure shoot up so high and the high blood pressure leading to heart enlargement. 

 

“Sir, your blood tests are showing that you might have a kidney problem that needs to be carefully checked up. I will now give you some medicine to control your blood pressure. I will write a referral letter and give it to you; can you please visit the kidney specialist in the government general hospital tomorrow?” I suggested. Immediately the smile on his face vanished. There was a look of disbelief and he said, “It is impossible that I have a kidney disease. I am passing a lot of urine every day. I am not having any pain in my abdomen or back. Your test must be wrong.” When he said this the smile on his face was no longer there. He was angry and agitated. 

 

“I understand it is difficult to believe that there could be a kidney problem. Let us assume that there is no kidney problem at all and that the BP is normal. But please humor me and visit the doctor just once so that the doubt can be removed.” I was literally pleading now. He seemed like a nice man and his reaction of disbelief was normal when someone is given such a heavy news. 

 

By now he became dismissive and was getting annoyed. He raised his voice and said, “I shouldn’t have come to such a small clinic. I should have never listened to the community health worker. Your clinic is so small, and you have no facilities here. But you have the audacity to tell me that my kidney is failing.” He got up and started to leave. I got up along with him and walked with him as he moved out of the room. I handed the referral letter which I had written by then and said, “I know this must be hard, but please consider taking this letter and visiting the kidney doctor just once. At least to prove me wrong. If you don’t have kidney disease I will be as happy as you. Please consider this…” and placed the letter on his hand and walked back into the clinic. He crumpled the referral letter, threw it on the staff nurse seated in the reception counter and stormed out. 

 

This was an extremely hurtful and heavy way to end the clinic. As I packed up and boarded my bus to leave for home, I was filled with a lot of frustration. The man was very cheerful and happy when he came in. But within a few minutes, everything changed. I was wondering if I did not break the bad news well enough. I analyzed the good and bad things I did with this patient. 

 

Good things: I made him sit in a quiet room, ensured adequate privacy and gave him the news of the kidney disease. I maintained eye contact throughout the communication. I maintained a soft and professional tone and avoided alarming language. 

Wrong things: I gave him the news of the kidney disease suddenly without mentally preparing him for the bad news. I should have given a preliminary talk on how kidney diseases can be completely without symptoms and high blood pressure also could be silent. I should have probably asked him if he wanted to have a family member for the discussion as what I was going to say could be shocking. More than anything, I should accept the fact that denial is one of the commonest reactions for receiving bad news. I should have also known that this is not a simple encounter that could result in a follow up with a kidney specialist within 30 minutes. 

 

I have decided that I will follow up and check if he went to the doctor. I will remain in contact with him and gently reinforce the need for a nephrology consultation. I will also offer him emotional support if he wants it. My frustration and disappointment came from my sense of self and the insult that I perceived for my medical knowledge, and skill. But the focus here is that gentleman and this whole episode is about him and his reaction to the bad news. I cannot allow it to affect me. I sorted all this out in my mind by the time I reached home.