The Super Cooperative Patient

Life is about checks and balances, positive and negatives, Ying and Yang. The negatives in life are many times balanced with something positive. If there are uncooperative patients such as in  ‘The Un-Cooperative Patient’ then there must be extra cooperative patients to restore balance in the world.

 

For the sake of medical ethics and doctor-patient relationship I cannot recommended such behaviour. Therefore read only for knowledge and not for practice.

One of my very senior colleagues, Dr. Ramesh Sharma (Fictional name) recounted his experience during his MBBS exams.

When he appeared for his final MBBS Medicine ward clinical exam, Dr. Ramesh was allotted a patient suffering from heart (cardiac) problem.

On reaching the allotted patient’s bed, Dr. Ramesh become dismayed. The patient was calmly having his food and seeing the full plate it appeared that he had just started. Dr. Ramesh estimated that it may take 20 to 30 minutes before he will finish his lunch.

In India, the majority of the older generation treats eating food as a ritual or homage to Food God. Just like while praying to God, they do not get up, talk in between or take break once they started eating food. This will amount to disrespect to food and God who have provided the food.

The patient looked up and noticing Dr. Ramesh asked, “Are you a MBBS student?” Dr. Ramesh glumly nodded his head. “Have you been allotted my case for your exam today?” the patient enquired. Again Dr. Ramesh nodded his head in affirmation.

“Look doctor,” the patient calmly proposed, “You can either disturb me while I am taking my food and take my history and do examination on your own, or  you can wait I have my food. While you are waiting you can write my clinical history on your own. I am suffering from moderate Mitral Valve stenosis with mild Aortic valve stenosis (heart valve disease), symptomatic for last 10 years. You must have at least studied so much that you know what history to write in this condition. If you cooperate with me, I will tell to your examiner, that the history written by you is given by me, and confirm whatever you tell him. Once I have finished my food, I will also tell you what findings to write in my clinical examination, including heart sounds and murmers.”

In India, most patients (at least at that time), did not knew English language. So, they were not aware what the doctors and students discuss during ward teaching and exams. They were also not able to read what was written in their case sheet record.

But this patient was engineer by profession, well versed in English language and having a keen mind. Because of his clinically important disease he was discussed many times in the ward rounds, clinical classes and was allotted multiple times during exams.

The patient was now well aware what his diagnosis was, what was his clinical findings and what questions were asked regarding his illness from the students during exams.

Dr. Ramesh weighed the options of either disturbing the patient while he was having food, antagonize him and take a history and examination from an irritated uncooperative patient, or agreeing with the patient’s suggestion.

Finally Dr. Ramesh deicided to let the patient have his food in peace, while he constructed and wrote a fitting history.

True to his words, once the patient had finished his food, he checked Dr. Ramesh’s history, gave some helpful suggestion to enhance the history, and dictated his physical findings to him.

Once the examiner came, Dr. Ramesh presented his history and examination and needless to say, passed with flying colors.

(Based on true incident)
— ND
© Author. All rights reserved. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Un-Cooperative Patient

Medical students are allotted patients during their ward postings and practical exams. The medical students are supposed to take detailed medical ‘history’ of the patient’s illness and do a detailed examination of the patient. They are assessed on the basis of this history taking and examination skills and viva based on their findings in history and examination.

Sometimes the patients are very cooperative with the students, but often they find the learning process of the medical students as intrusion in their privacy and unnecessary for their treatment. 

This problem becomes further compounded if the patient is staying in the ward for quite some time and has been seen by other medical students.

These patients become uncooperative and refuse to talk with the medical students or give any detail of their illness. They refuse to let the students examine them superficially let alone in detail.

One such patient who was examined by batch of student two days ago was allotted to a student from a new batch for history taking and examination. The patient was uncooperative and refused to even talk with the student or let herself to be examined.

The student reported her problem to Dr. Jolting. (Dr. Jolting is so called by his friends for the weird and shocking statement he makes).

Student:      Sir, the patient is very uncooperative. I am not even able to get a proper history from her.

Dr. Jolting:  I feel very sorry for you.

Student:      Because, I may fail in exam as I was not able to take a proper history?

Dr. Jolting: No. I feel sad about your future. If today you are not able to get out the history from a patient’s mouth, tomorrow, when you will become a doctor, how will you get out your fees (professional charges) from the patient’s pocket?

Jokes apart this is a serious problem for the medical students and a nightmare if this occurs in exam. 

When faced with an un-cooperative patient if efforts to convince him/her to cooperate in the learning process by appealing to their higher nature fail, the student should first try to find out the cause for this non-cooperation. 

Has the patient has been kept in exam before today? Is the patient in actual physical pain or discomfort therefore cannot cooperate? Does the patient consider himself VIP for any reason, such as connection to some consultant or staff member, or he himself is some high ranking officer or politician. 

Faced with such patient, the student should immediately contact the senior resident or the consultant allotting the cases and bring this problem to his attention. 

While telling about the non-cooperation of the patient, they should tell the probable cause for this non-cooperative behaviour, otherwise the consultant may blame the student that it is his fault that the patient is not being cooperative. He may hold the student responsible that he does not know how to talk with patient, win their confidence and form a rapport with the patient.

Dr. Jolting recounted a case told to him by one of his fellow surgeon, of such a non-cooperative patient and how the doctor dealt with him. 

For the sake of medical ethics and doctor-patient relationship such behavior cannot be recommended. Therefore read only for fun and knowledge and not for practice.

In the state of Rajasthan in India, the entrance to post-graduate (PG) courses after MBBS is through an entrance exam. To attract more doctors to government medical services, there are some seat reserved in this entrance exam only for those MBBS qualified doctors who have at least worked for three years in the government medical service. Also the upper age-limit is also raised for those doctors.

One such doctor, Dr. X (fictional name) after more than a decade of government employment and multiple attempts in the entrance exam, got selected for PG course in  MD Medicine, while in his forties. 

For his final MD exam, he was allotted a case of chest infection. When he approached the patient flatly refused to give any history or allow himself to be examined by him. On inquiry it was found that he was allotted to many students in the final MBBS exam just few days ago and was irritated by the process.

Dr. X attempt to appeal to the patient higher ethics met with flat refusal and hostility. 

Not knowing what to do he asked the patient where he was from. The patient replied he is from Bundi. Dr. X warmed up as he had lived and worked in Bundi for many years and had many contacts there. He further what work he does there? The patient replied that he works in a factory and told the name of the factory.

A smile broke on Dr. X’s worried face. With a new found confidence and authority he said, ‘The factory you mentioned is owned by the father of my good friend Mr Z.’ ‘I am going to phone my friend and get you kicked out of your job for your non-cooperative behaviour with me.’

The patient became crest-fallen. With folded hand he requested Dr. X, ‘Please Sir, do not do such a thing. My family will die of hunger.’ ‘You may ask me a thousand questions and examine me thousand times. It will be my great honor to be of any use for the friend of chote saab (the young boss).

With the now super-cooperative patient Dr. X was able to pass his MD Medicine exam with flying colors.

(Based on true incident)

— ND

© Author. All rights reserved. 


DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Fever Case: Attending Classes - Part 2

Dr. Dev (fictional name) while a MBBS student had attended few classes of Dr. AM (fictional name), a strict but fair teacher during his ward posting in the Medicine Department in AIIMS, New Delhi. When the time for end of ward posting came Dr. Dev was allotted a case of fever. Dr. Dev examined the case but could not find any abnormality on physical examination of the patient.

When his turn came, Dr. Dev presented the history of the patient. While presenting the physical examination findings, Dr. Dev presented his normal findings and added that he has not been able to find any abnormal finding in this patient.

Dr. AM was surprised and called the senior resident allotting the case during the exam. He asked the senior resident that why has he allotted a patient without any physical finding in the exam. The senior resident replied that the patient is having the physical finding of enlargement (increase in size) of both the liver and spleen organs.

Instead of castigating Dr. Dev for missing this physical finding and failing him directly, Dr. AM, perhaps taking in account Dr. Dev’s attendance in classes, asked to re-examine the patient’s abdomen and tell him the physical findings.

With his attention focused, Dr. Dev was able to feel the minimally enlarged liver and spleen which was difficult to feel at MBBS level, presented his revised findings and gave the further viva based on these clinical findings and managed to get reasonable marks in the exam.

A favorable impression is created on the teacher by the student attending the classes, which may useful in exams. A positive bias may be created in the teacher’s mind which may lead to higher marks / score in exams or may save the student in difficult or borderline situations.

Therefore attending classes may be some time life-saver to the average or the borderline students.

(Based on true incident)

— ND
© Author. All rights reserved. 


DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

You can share this post on Facebook, Twitter, Pinterest, Google +, etc, using the Buttons above 'Labels' and below 'Posted by:'.

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See also the first article on attending classes at 'The Rabies Class'