They are patients, not disease presentations.

Having Family Medicine as my first clinical rotation felt like a cursing and a blessing. A curse because of the extensive gap in my clinical knowledge and reasoning, and a blessing because it’s a rotation that really makes one think about the type of doctor and ultimately person they want to be. It made me question everything I thought I knew about doctor-patient interaction. It was an amazing experience seeing the actual practice of Mcwhinney’s principles; a doctor who knew his patients’ names, history and diagnosis before he even read through their files. Being committed to the patient, the patient’s family and understanding the psychological, social and environmental background from which they come from. Both the acute and chronic management was founded upon a relationship where the patient’s opinion and views were considered and discussed, allowing for the decision and commitment to be mutually made by both parties.

However the high of the experience only lasted so long, shortly into my first day at the general practice I was allocated to, I started feeling an overwhelming sense of sadness. I had seen sick patients before during hospital practice day in third and fourth year but somehow it felt differenct this time. I guess I realized that my experience of sick patient was mostly being told to percuss their chest for a pleural effusion after 3 members of my clinical group had already done so. I’d greet and ask for consent all the while knowing that the choice has already been removed from their hands. For as long as I can remember I’ve always looked at a disease as an isolated organ or a system, imagining the changes, breakdown and death of tissue. The way the drugs would interact with receptors, how systems would get blocked and how pathways would proceed. As I stood in that consultation room, all of a sudden it wasn’t an organ or a system that I saw, it was a 65 year old woman named Marie* who had gotten diagnosed with hypertension 10 years ago, her blood pressure has been getting worse in recent months and it’s not because she had been defaulting on her medication. She also reported getting this left sided chest pains for the past month, but the hypertension and chest pain were not her reasons for encounter. Today she brought with her 3 year old great granddaughter, Sarah*. Sarah’s mother and Marie’s granddaughter died from Tuberculosis after months of struggling with AIDS two years ago. Marie has been looking after the child since. She’s complains that Sarah has been acting different for a few weeks now and just two days ago while bathing her, she noticed vaginal discharge and a swollen labia. She’s been having nightmares and more frequent chest pains since then. Although she’s suspicious, she refuses to believe her own gut feeling because the only male in Sarah’s life is Marie’s son 38 years old Paul* who moved in with Marie 3 months ago to help her out financially. I quietly sat in that consultation holding back tears, feeling helpless as I realized that I lack the emotional maturity to handle such a delicate situation.

I found myself asking a very important question, ‘do we receive the proper psychological training to deal with our clinical years?’ Or is it just estimated that in a difficult situation we will know what to do, that our skin will be thick enough and that the decision we will make will be the right one. The only conduct that I have is that I must respect autonomy, make sure that my practice not only uphold justice but is also non-maleficence and therefore completely beneficent to the people I serve. I’m supposed to be patient-centred but what happens when my baggage becomes too much to bear, how do I tell Marie that her only son and household provider is also abusing her great granddaughter? This is the part where I should rely on my community resources; refer Marie to the Teddy Bear clinic at Charlotte Maxeke Academic Hospital or an equally equipped organization to deal with the matter. How do I even say it out loud? I’m supposed to follow queues but she has a blank stare on her face. What do I say? How do I go on with my day and see another patient after this? I do not know how to keep going and ignore the feelings that I’m not supposed to have. I don’t know how to smile when I really feel like crying. I don’t know how to tell you it’s going to be okay when I can’t begin to imagine what you’re going through. I can’t minimize your situation, pain or anxiety to a statistic. 

I was never told and I was never ready. How could medicine hurt me so much? We are taught everything from a scientific point of view, it isn’t infertility until you’ve been trying for longer than a year, HIV is not a death sentence if you take your ARVs, changing your diet and exercise reduces morbidity in hypertension etc. We’re so focus on dealing with the disease but we fail at addressing the illness. We don’t know what the inability to conceive, even if it isn’t scientifically diagnosed as infertility means to a couple or the family dynamics. We don’t understand a person’s ability to grasp that their lives will never be the same because of their status. We don’t understand that sometimes it isn’t a lack of will but rather the feasibility in having dietary changes and exercise, especially when we don’t engage the patient in details; substitute for food types and what type of exercise to do. We’re told to be biopsychosocial doctors in a biomedical setting.

Over the past two years, I’ve learned about diseases’ pathophysiology, presentation, complications, differentials and management. My main priority has always been to remember it in that order, essentially make a diagnosis and treat the disease. I never learned to remember a patient’s name, I never learn to address their illness, help them understand or come to term with their condition and how it may be impacting their livelihood.

I also understand that it doesn’t help me to point fingers at the ‘system.’ I am a student doctor and it’s time for me to take responsibility for my learning and the type of person I want to be. At what point do I stop allowing myself to be a product of a system I consider flawed? I needed to ask myself ‘what makes a good doctor?’ is it someone who has the highest possible marks in pathology but struggles with the patient interaction and expressing empathy or is it someone who’s great at expressing empathy and social interactions with patients but struggles at pathology? In my opinion, we have to thrive at both, we have to be socially aware, trade with caution and understand that we are trusted to deliver healthcare, to promotes health and rebel against the mediocracy seen in the public setting, in our schools and even amongst our peers. How long are we going to continue to hide behind the lack of resources as an excuse to continue providing a poor service?

A good doctor is more than a healthcare professional, a doctor is a teacher, a leader, an advocate and an agent for change. We need to stand for the very patients we treat, we need to promote ethical and moral behaviour. Challenge structures that we disagree with in the hope to transform the medical world not only for ourselves but for those who are coming after and those that are coming to us. Academics will make me a great scientist, social awareness makes you a great socialist and empathy makes you a great human being. As an aspiring doctor I need the all package, I need to pursue and learn more than what is made available to me in the classrooms and in the ward setting.

I am truly grateful for this experience, I’m grateful for having learned how to look at patient as a whole rather than a disease. I found myself trying to remember at least one detail about the life of every patient I saw, their spouse’s name, what their children are studying etc. And after a patient had received a negative prognosis, I’d sit with them in silence and let my presence represent a sense of support. I do not know that I’ll become a family physician, but I know that I’ll take their values with me everywhere I go.

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