The Odds of Uncertainty

A couple of weeks ago, I encountered an interesting case referred by my medical colleagues for review. The patient initially presented to a private hospital for fainting spells. He was seen by the cardiology service and was subsequently referred to a government funded hospital because of financial constraint.

The on-call physician saw the case at 4pm and wrote in the notes: For urgent cardio referral cm.

The 'coming morning' was in fact on a Saturday. My medical officer received this referral early in the morning and narrated the case to me. We went to see the patient together and I must say, I was amazed at the subtle signs of uncertainty displayed by my medical colleagues.

The patient was diagnosed as having non-ischaemic dilated cardiomyopathy with an EF of 20%. The private cardiologist's assessment was that this patient might have recurrent ventricular tachyarrhythmia hence causing recurrent syncopes. They did an MRI to rule out an intracranial pathology. The MRI showed an incidental benign cyst which could not have accounted for the symptoms. But because of the 'obvious' finding on brain MR, the patient was 'siphoned' to the neurology service.

The physician in-charge of the neurology ward was almost certain that the incidental benign cyst would not have accounted for a more serious problem. On the other hand, it was quite clear that she hesitated on the 'urgency' of referral to the cardiology.

It was half past four in the afternoon, I must admit that it is a 'semi-taboo' to make non-urgent referrals at these hours. People are packing up, preparing to take rest after a long day work. Any non-urgent referrals at this time are pretty much unwelcomed.

Nevertheless, URGENT referrals must be made instantly, regardless of the time of the day!

The very fact that she chose to write: Urgent referral coming morning, simply reflected the uncertainty of urgency in that sense.

Well, to me it's simple. We all will become uncertain when confronted with problems out of our specialties. The solution is simple. We walk to the nearest phone, pick up the dialer and ring up the specialty in regards. One call would clear out the uncertainty.

Unless, of course, ego and pride set in to hinder that walking up to the phone, picking up the dialer and engaging in a consultation.

Unfortunately it happens all too often in the service, sad to say.

Hidden Agenda

Very often, we're faced with patients and relatives not telling the truth in the first instance. The reasons are plentiful. Some of them might need more time to develop trust. Some might simply prefer not to tell the truth. Some will not like that particular doctor for no apparent reason, and will promptly tell everything to another. For some, there are hidden agenda..

Well, I must say, the word 'hidden agenda' is sort of a magic word for us the Membership holders. We're forced to adopt the thinking that hidden agenda are there to stay for every Ethics & Communication Skills cases. Hidden agenda is hidden concern by the patients or relatives in regards, which serves to be the key to open up opportunities for further discussion or sometimes, it might well be the prerequisite for task accomplishment.

Allow me to share an atypical 'hidden agenda' incidence which was experienced by one of my colleagues days ago.

A young lady was admitted for allegedly ingested detergent liquid for parasuicidal attempt. She was otherwise well apart from some epigastric discomfort. A lavage and all other proper management measures had already been undertaken. My colleague needed to move on to see the rest of the wards before moving on to run the clinic.

As an MRCPian with extensive 'awareness' on the issue of hidden agenda, my colleague of course had elicited the very reason behind her parasuicidal attempt, ie, she found out that her husband was having an affair (Of course, this is after some repeated questioning, not volunteered). Her relatives were practically encircling her with intense concern, asking repeatedly about her conditions. My colleague practically failed to carry out his ward rounds, in the presence of so many visitors. Worse still, the relatives at one point were trying to suggest that NO EFFECTIVE treatment had been given, and threatened to take this matter to a complaint.

Nothing happened eventually. But an interesting point to illustrate here.

The patient committed suicide because of his act of seeing another women. You brought her looking for help and treatment. We gave help and treatment. You still have guilt (logically, he should). The patient refused to talk to him. He sensed a even stronger share of guilt and wanted a way out. The way out is simple - repeatedly showed concern by questioning the medical staffs, even to a point of irrelevance. And if they refused to hear anymore, it's their fault! Not my guilt anymore! How about the care of other patients? Don't care, not my problem!

This might be a over-simplified attempted deciphering of his thoughts. Nonetheless, one should recognise that some patients or relatives are just inherently selfish. It's their nature. Especially so, at the very juncture of escaping from guilt.

To Ministry With Love

Of late, I have reason to believe that this blog has been perused by the Ministry people. A close friend of mine had told me. To be honest, I am very pleased by this fact, as one of my intention of writing this blog is to get some attention from the ruling party ie the Ministry policy makers.

I told my friend that the primary aim of this blog is indeed to tell the relevant people the various interesting events happening in a hospital, whether too smart or too lame..

More importantly, I was also 'warned' not to write on issues criticizing the system again. Frankly, I wasn't surprised at all. This system has always been one with people yelling high speeches of democracy, freedom and human rights on the outside, but in reality, a lot of things we are expected to keep quiet and cease public discussions.

The people in support of this would say that it's for the greater good. Hmm.. sounds familiar isn't it, and how about some addition of words to the sentence that goes like this: 'For the greater good so that we could maintain the state of peace, harmony and prosperity!'

Sweet deal and a real music to the ears! While I am totally a peaceful person, nonetheless, I think keeping quiet all the time and taking no heed on the reality is not something that we should be endorsing in the long run.

I think the Ministry is able to do better than this. Some helpful voices from the inside and some sincere comments from the outside would be good.

I have come across very high-ranking officers in the Ministry who is much willing to accept critics and views. If one who is at a higher post is willing to accept, why shouldn't his subordinates?

That is absolutely a useless attribute to hum and sing 'I wanna know the truth' day in and day out, but in reality stays contented with a world full of lies and illusions. Someone is already on the verge of getting his final paycheck. Would you be the next?

A New Wave Of Change

The recent nationwide general election results took us by a surprise. Nothing medical here. At least not directly related. But I must admit that everything and anything is essentially connected, in some ways, to politics in this modern civilisation.

Rather often, we clinicians do find ourselves in a tight spot to fulfill some special 'uninvited' demands from the local politicians. Some might not be the politicians themselves, but they were their friends, neighbours, relatives etc.

Queue-jumping, requests for early consultation, early appointments, special attention, demand for the 'best' medicine available... these were invariably some but not all the things that were happening over the years that I've been serving in the ministry.

Worst still, when I was serving in one of the smaller district hospital years ago, I was repeatedly confronted by outpatients who claimed to be the close friends or neighbours of our Prime Minister!

"Best medicine for me, I'm his close friend." This statement was utterly too familiar to hear.

"Don't worry sir, I am already giving you the best." Admittedly, not much of a choice, I need to use a rather 'political' statement as well. Interesting, isn't it?

I do hope that this new wave of change be served as a humble awakening to all, not just the local politicians, but also the people who endorsed them.