Life and medicine, reflections

life and medicine, reflections

The common divisor for life and medicine is that they are both ‘easy’.

The problem exists only when we make things complicated while they should not be so. But, on the contrary, a smooth and self-assembled and harmonized cascade of success should be there when we manage – even after quite long time – to lay such noise and artifact aside. You could be a famous and impactful physician because you show the readiness and willingness (sometimes fondness and passion); notice that many people do not show any of that all.

Do not be taken too far by those thick medical books full of ink and texts. These could be written by more than one person and/ or over long times, could be useful and interesting, or they may not contain an answer for your past, present or future curiosity and questions. You are, in every case, not meant to read every paper you find or to understand each word you may have ever heard – though it would be great if you were to do that –. Because, going from the easiness of medicine, you should (or very politely: must) stick to the basics of medicine (or life). This can be the line of demarcation between a trustful and artful physician and those who either dampen in their hesitancy or float in illusions of details and thoroughness: the true basics and ethics.

You deserved it because you knew it in advance; you got its essence and made it in the centre of your consciousness. What, when, why, how and where? It is (or should be) more easy than anyone can believe. As a physician you don’t fix machines but peoples’ health and life, you do not sell books or household goods but convey knowledge and culture, you do not stamp money or create gold but help everybody better appreciate their life and life as a whole.

A physician is a person who goes in life brilliantly and successfully in the best possible satisfaction through the honest practicing of medicine.

The clinical session algorithm

The clinical session algorithm

The excitement and challenge of the medical session are not to overlook especially for newly practicing physicians. Red cheeks, heart knocking, hand sweating and even head whirl may be typically experienced by many doctors even by quite experienced ones. The reason for such clinical session tension could be overestimation of the job and/ or lack of the successful scheme (algorithm) for medical management.

In this essay, I wish to emphasize that the tactful handling of medical care including clinical session is a matter of training and learning where the inherent talent influences the length of time necessary for such clinical mastering. About clinical session or examination questions regarding its duration, steps and order plus precautions and ethics are indeed worth noting. These together will shape out what is known as ‘the clinical sense’.

1- Context: what is the context of the clinical session?

By clinical session context I mean the time-place frame of the patient’s presentation. These circumstantial provisions may have influence on the clinical session as for professional progress and patient-doctor expectations. Besides care about medical perfection and contentedness the question whether a medical fee could or could not be considered can be quite sensible.

2-Patient type:  what kind of patient is this?

Broadly speaking patients may be seen as either chattering or serious. Because in some cases such definition and judgment of the patient may take time for the sake of fairness and respect to all patients, this question should be considered from the beginning and throughout the clinical session.

3- Presentation: what level of urgency does this case have?

The level of urgency may be graded in 4 levels: 1) life threatening problem, 2) potentially ailing problem, 3) naturally resolving problem and 4) intervention sparing problem.

In order to adequately define the level of urgency good knowledge and appreciation of the possible presentations (complaints) in the different diseases is required. For example, headache can be a symptom of different diseases like stress, constipation, muscle inflammation due to cold for example, fever, sinusitis, high blood pressure, etc. The level of urgency and, hence, appropriate management will vary for the same complaint from one disease to another.

4- Management plan: what to do for this case?

This question is answered at 3 levels: 1) immediate plan, 2) remote plan, and 3) Follow up plan.

The immediate plan is instituted for either therapeutic or prophylactic aspects. It can be omitted when there is no need for it or when the case cannot be yet well judged. Referral of the patient to a more experienced colleague and/ or medical care center is also possible option for immediate management plan. The remote plan may form a further management step or follow certain preparation with or without medications. The follow up plan can be needed for life long or relatively time lasting cases.

5- Clinical session closure:  what to do when you are done?

Considering the appropriate ethics, time and progress of the clinical session, the closure of the session should be smooth and well prepared ensuring that all the medical instructions and treatment plan given to the patient in writing and having the required and ‘allowable’ contact information taken by both physician and patient.

My physician is a human

my physician is a human.

It is nice to meet and know good people in a quite formal context, when customs and ethics are well applied and respected. You will like a smile, praise a shape or figure and admire a character. And so as a habit you will find somebody to like and almost find an excuse for possible light mistakes or a triviality. Sometimes, it is even more exciting to know about your idol something, but not so formal this time, as I would like to tell now about my amazing super physician. In one word I would like to shape out my physician as a mere human. A human who may have much cares about himself and about other people as well; who can make mistakes and suffer these terrible pains of conscience and self-criticism, and who may have chronic disease or very special health provisions.

And what a delicate human! My physician should train himself regularly how to help the sick so kindly and friendly without raising the least doubt or suspicion of any shortage as for medical proficiency and personal balance. Doctor’s work must be almost perfect. My physician does not like to work as much like a machine. The dehumanization technique, though logically important, is not absolutely working because my physician thinks that sharing the sick some of the pain is quite good for a guérison. My physician would experience and live inside some medical cases in a time to become quite exhausted and can’t see more cases. That is why a regular moral washout and physical and mental refreshment are very important. Not only concerned with bodily diseases, fighting infections, curing debilities, and ameliorating pains, but also and vey often sympathizing financially and engaged personally and socially.

My physician is very proud to convey a particularly beneficent message to the needy and sick people and insists to practice this job with much love and sincerity. As a mere human my physician can’t be blamed or insulted, but – on the contrary – should be honored and respected. My physician may succumb to any moral, physical or psychic concerns and devotes a whole life and resources to help fix or tame those defects or phenomena. That’s why my physician is deservedly described as mere human.

The ten golden rules in rescuing the (medically) troubled

ten golden rules

Situations in which medical care or advice should be provided vary considerably as regard place, time and the extent of the medical problem, i.e. patient’s state as regard consciousness, cooperation, presence of patient’s relatives, etc.

Here are 10 rules that I wish to conclude from my experience in the clinical field.

1- The sense of being attended: the health care provider should stress and make sure that the patient perceives that a good medical care is being present. This would be achieved by speaking gently and confidently with the patient and/ or with the relatives. The doctor may state clearly that he/ she would have no problem to see the patient for free when the patient’s condition money-wise is not favorable. The doctor should be cautious as much as possible to protect the patient from possible negligence by his/ her relatives.  In case of a patient with perturbed consciousness the doctor would call the patient by his/ her name (if known) and hold the patient hand warmly.

2- Resort and handing: the doctor would have preliminary assessment of the medical problem, and recalls his/ her knowledge and may need to find some source as a book or contact a colleague for consultation. The doctor may have to urge for a referral to a more experienced doctor.

3- Fulfilling continuum: the doctor may inspire that human body is one continuum with dynamically operating modes and proportionately distributed components. This should be very useful in determining the dose, rate, and intervals of the medicines to be used.

4- Hierarchical approach: the management plan should be almost clear from the beginning. The management should assume a hierarchical concept as regard the relevance of interventions/medicines to one another from one side and to the human body function from the other side. It should start from natural means to encourage the self-curing power in the patient, e.g. warming the patient, changing posture, etc., and proceeding from a less invasive to more invasive.

5- Multi-footed treatment: this means that using more than one point or target in the treatment, if allowable, would help reach a more smooth response with less likelihood of misfortune. This integrated approach would allow less and more tolerable medicine doses.

6- Proof tracking:  this means that on following certain treatment the doctor keeps an open eye checking back and forth for the consistency and appropriateness of a given step in the management for a possible need to change the treatment plan.

7- Case cliché: by the time the medical condition is being resolved the doctor should formulate a clear definition of the case (diagnosis) and inform the patient or the relative(s), orally and/ or in writing.

8- A Gift-outcome-art: this means that the outcome of the medical care is quite unforeseeable. Here, the outcome is usually expressed as percentages or probabilities and not as a definitely individualized result.

9- Non obligation: the medical care should not bear any obligation from both patient’s and doctor’s side.

10- Medical ethics: the doctor should be aware of and fulfilling the medical ethics applicable to the particular medical problem being managed.

A new Hippocratic oath ~2010AD

* I promise that my medical knowledge will be used to benefit people’s health. Patients are my first concern. I will listen to them, and provide the best care I can. I will be honest, respectful, and compassionate towards all.
* I will do my best to help anyone in medical need, in emergencies. I will make every effort to ensure the rights of all patients are respected, including vulnerable groups who lack means of making their needs known.
* I will exercise my professional judgment, uninfluenced by political or religious pressure, or the age, race, sexual orientation, social class, wealth, or celebrity of my patient. I will not put profit or my own career above my duty to patient.
* I recognize the special value of human life, but I also know that prolonging life is not the only aim of health care. If I agree to perform abortion, I agree it should take place only within an ethical and legal context.
* I will not provide treatments that are pointless or harmful, or which an informed and competent patient refuses. I will help patients find the information and support they want to make decisions on their care.
* I will be as truthful as I can, and respect patients’ decisions, unless that puts others at risk of substantial harm. If I cannot agree with their requests I will explain why.
* If my patient has limited mental awareness, I will still encourage him or her to participate in decisions as much as they feel able. I will do my best to maintain confidentiality about all patients.
* If there are overriding reasons preventing my keeping a patient’s confidentiality I will explain them. I will recognize the limits of my knowledge and seek advice from colleagues as needed.
* I will do my best to keep myself and my colleagues informed of new developments, and ensure that poor standards or bad practices are exposed to those who can improve them.
* I will show respect for all those with whom I work and be ready to share my knowledge by teaching others what I know. I will use my training and professional standing to improve the community in which I work.
* I will respect each of my roles, as expert, communicator, scholar, partner, manager, teacher, professional, and health advocate. I will promote fair use of health resources and try to influence positively those whose policies harm public health.
* I recognize that I have responsibilities to humankind that transcend diktats and orders of States, and which no Legislature can countermand. I will oppose health policies that breach internationally accepted standards of human rights.
* I will learn from my mistakes and seek help from colleagues to promote patient safety. While keeping within this framework, I will not be discouraged by failure, and will try to continue in a spirit of practical and rational optimism.
* While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all, in all times.

We take this oath not because we are doctors but because sooner or later we are all patients. Clause 1 is the central clause. It has a terrible beauty. For many, it is our family that is our main priority. Often we can strike an uneasy compromise with family life.
This page is dedicated to doctors for whom circumstances allow no such compromise: those who have not fled wars, or who have stayed at their posts during epidemics… The above is based on the BMA’s Revised Hippocratic Oath.

Reference: Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR: Oxford Handbook Of Clinical Medicine, 8. Edition; A new Hippocratic oath ~2010AD.

Twelve common pits for doctors

common pits for doctors
The relation between the treating doctor and the patient relies basically on mutual trust, respect and dignity. Some psychological element in the response of patient to treatment may be agreed on in this context. However, despite this fundamental requirement for such saintly doctor/patient relation some pits or traps may happen from either side.

Pits from doctor’s side:
1- Patient extortion is a striking sign of corruption when a doctor extorts money or other things from a patient so that the medical service would be provided.
2- Doctor’s egoism may manifest as a doctor cannot tell a patient that he/she does not know how to manage the case or when another more conservative decision has to be made as the case progresses favorably.
3- Defaming other doctors may be immorally made as a habit by some doctors in order to persuade patients to comply with their prescriptions or decisions.
4- Effecting vague symptoms is quite dangerous because many complaints, especially those made by parents in respect to their young sick kids, are exaggerated and need to be tested very carefully.
5- Effecting unclear medical directions given by some senior staff members can expose both patient and young doctor to undesirable and even fatal consequences.
6- Trying insufficiently tested approaches that may be potentially harmful.
7- Reluctance or dispensing with asking for help of other persons, colleagues or more experienced staff members.
8- So-called recommendoma circulates sometimes among doctors, usually as a bad omen, that patients recommended from some medical staff members or personnel would progress unfavorably.
9- Patient’s psychological insult by exaggerating the severity of the case, giving unduly too much medicines or resorting unduly to invasive approaches, e.g. injections.

Pits from patient’s side:
1- Chattering patient is usually a person who is more roaming around his/her luxurious and fulfilled life more than looking for some medical advice.
2- Abusing patient is a person who is trying to trick the doctor for some physical, materialistic or psychological gains.

Pits from both doctor and patient:
1- Driven treatment fault is almost likely to happen when a patient or relative of a patient persuades a doctor to provide some medical service which the doctor accepts on grounds of curiosity and professional itch rather than on scientific and ethical grounds. This problem aggravates in absence of appropriate assistance by other medical staff members.

The physician has to be keen on having the morals and attitude complying with the highly beneficent message of the medical profession through careful self-judgment and self-criticism and being well acquainted with the relevant ethical and social issues beside the up-to-date available medical knowledge.