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Doctors must move beyond ‘prescription pad culture: Health educator

18 Aug 2021

  • Calls for better communication with patients and self-reflection in clinical practice
By Ruwan Laknath Jayakody The common practice of doctors scribbling some medications on a prescription pad, tearing off the page, and giving it to the patient, telling them to take these medicines, represents a gap in communication between the doctor and the patient, and should therefore be deplored, an expert on health-related professional education observed.  Professor in Internal Medicine attached to the International Medical University in Malaysia P.L. Ariyananda hence explained a set of best practices based on the World Health Organisation's (WHO) “Guide to good prescribing: A practical manual” to be adopted instead when issuing prescriptions for medications, in an opinion piece on “Compromising patient safety: Lessons learnt from some critical incidents”, which was published in the Galle Medical Journal 26th Volume 2nd Issue on 14 August 2021.  The first step involves the physician explaining the condition the patient is being treated for, with information being provided on how long the patient would be treated, how often the medications need to be taken, and how they should be taken. The second step concerns ascertaining any drug-related allergies and avoiding offending drugs, while in case an allergy develops, all medications should be stopped following an urgent visit to the doctor. The third step is with regard to checking whether the patient is already on any other medications, including over-the-counter medications and traditional medicines. The fourth step pertains to ascertaining whether the patient understood what had been told to them and whether they need any clarifications, and informing them on when to come for the next visit. The final step, which is only applicable in special circumstances, deals with the prescription of devices such as inhalers, whereby the physician should, with or without the assistance of pharmacists, demonstrate how they should be used.  He notes that from a clinician’s point of view, a critical incident is, as explained by W.T. Branch in the “Use of critical incident reports in medical education”, a clinical event where they think that something was wrong with either the diagnosis and/ or the subsequent management, including of holistic care, or simply put, a failure associated with the delivery of clinical care. Ariyananda points out that these critical incidents form a part of the clinician’s clinical experience, and are travails and challenges of being a doctor. However, what is important, according to Ariyananda, is that clinicians get into the habit of reflecting upon these incidents, and attempt to share these experiences and lessons learnt with colleagues.  Hence, critical incidents have educational value, which can in turn influence the personal and professional development of doctors, notes Ariyananda. Self-reflection, as elaborated on by D. Boud, R. Keogh, and D. Walker in “Reflection: Turning experience into learning” is a meta-cognitive process that involves thinking about one’s own thinking, and can be described as intellectual and affective activities that individuals engage in to explore their experiences, so as to reach a new understanding and level of appreciation. Ariyananda adds that such new levels of understanding can be arrived at after one has such an experience, by thinking about strengths and weakness, and thereafter learning from the experience, with the hope that such insights gained would pave the way for a better performance, the next time around.  In this regard, D.A. Kolb’s “Experiential learning: Experience as the source of learning and development” is applicable. Kolb’s Experiential Cycle Learning Model has four cycles, namely, concrete experience (which involves doing something or having an experience), reflective observation (reviewing the act or reflecting on the experience), abstract conceptualisation (drawing conclusions or learning from the experience), and active experimentation (planning or trying out what one has learned). Moreover, Ariyananda explains that with each reflective cycle, the performer is taken towards a higher level of performance, noting that repetitive cycles can be considered to be on an upward spiral trajectory, whereby the performer is taken from an amateur level to an expert level.  With regard to sharing such experiences, Ariyananda took four case scenarios, which touch upon lapses in history taking, incomplete physical examination, premature diagnostic decision making and inadequacies in treatment.  Scenario 1  The first patient, an unmarried female of around 20 years, was seen by Ariyananda in his capacity as a post-intern doctor at the former Kegalle Base Hospital, where she had been admitted to a medical ward with a rash on her face. The patient had on several previous occasions been admitted to the same ward, with the same complaint. According to her, the rash would regularly erupt on her face. However, she noted that the doctors had not told her as to why she was getting the rash.  At this juncture, Ariyananda queried whether the diagnosis would be systemic lupus erythematosus (a type of lupus, which is an autoimmune disease where the immune system attacks its own tissues causing inflammation and tissue damage) or endometriosis (tissue similar to the womb lining starting to grow in other places).  On detailed history taking, the consultant physician had elicited that the rash coincided with her menstrual periods, and that she only experienced it on the face. Upon further inquiry, she had said that she has severe dysmenorrhoea (painful periods), for which paracetamol had provided relief. Further, she added that the facial rash would erupt once the menstrual flow subsided. Ariyananda then questioned whether the diagnosis would now be a fixed drug eruption due to paracetamol allergy.  He explained that this case illustrates the fact that diagnosis can be easily missed if attention is not paid to detail when taking down the history, and that hence, it is important to probe into details within the context in which they arise. However, as H.B. Beckman and R.M. Frankel observed in “The effect of physician behaviour on the collection of data”, physicians do not often have the patience to listen to the entire story and tend to interrupt the patient within a minute. Therefore, Ariyananda pointed out the need for doctors to be good listeners.  Scenario 2 The patient in question was a teenage girl whom Ariyananda saw in his capacity as a medical registrar. She had had several hospital admissions for recurrent bouts of haematemesis (vomiting blood). Ariyananda had on a few occasions even seen fresh blood in her mouth. The patient had not given a history suggestive of a peptic ulcer (a sore on the lining of the stomach, small intestine, or esophagus), or a history of taking alcohol or non-steroidal anti-inflammatory drugs. She had looked well and did not seem to be too concerned with her condition. The physical examination and several upper gastrointestinal endoscopies that were done were normal. Ariyananda and the others involved had therefore been unable to arrive at a diagnosis.  Therefore, Ariyananda advised that if one is faced with a diagnostic dilemma, it is best to take a step back and revisit the basics. He further explained: “We need to remember that blood that gets coughed up (haemoptysis) or blood that drips down from the naso-pharynx (epistaxis or nosebleeds) due to nasal or naso-pharyngeal (upper part of the throat behind the nose) pathology can masquerade as haematemesis. She was not a smoker and did not give a history of cough, while her chest radiograph was also normal, thus effectively ruling out any lung-related pathology. Despite these negative findings, she was treated with a drug that inhibits stomach acid production, which was the drug of choice for peptic ulceration around 40 years ago.”  The patient was then referred to an ear, nose, and throat surgeon, who noted that “there were multiple bite marks on the inner aspects of both the cheeks. Nasal cavity, pharynx (throat) and larynx (voice box) are normal”. She was subsequently diagnosed to have the Munchausen syndrome (R. Asher’s “Munchausen's syndrome” – which is a facetious disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves with the main intent being to assume the role of the sick person, which results in them being cared for and thereby the centre of attention), and was referred to a psychiatrist. The patient had faked haematemesis by biting the buccal (the sides of the mouth) aspects of her cheeks, and manipulated her doctors.  Therefore, Ariyananda emphasised that in a situation such as this, lateral thinking (or thinking outside the box) could be useful, and hence is a skill to be developed. “When in doubt, always question oneself as to whether one is correct. Often, rather than revising the diagnosis and admitting that the conclusion is wrong, the tendency is to show that we, the doctors, are always correct, and we in turn start looking for evidence to justify our foregone and erroneous conclusions. This is reflective of poor clinical reasoning, and should therefore be avoided as it can lead to unwarranted mortality and morbidity, in addition to wasting time, energy and money. We need to lead by example and learn to admit that we can sometimes be wrong and be prepared to be flexible. It is always good to entertain a differential diagnosis rather than be dogmatic. As one becomes senior in the medical health service, there is a tendency to develop fixed ideas and to not be receptive to others, including junior colleagues and patients. We need to remember that the practice of clinical medicine evolves with advancements in science,” Ariyananda emphasised further. Scenario 3 This patient who was admitted as an emergency case to the medical ward of the Karapitiya Teaching Hospital was seen by Ariyananda as the physician on call. The young man, according to Ariyananda, looked very ill, and it was subsequently learned that he had been in good health prior to a fall from a coconut tree, three days ago. As a result of the fall, he had sustained a few bruises to his chest, but had not lost consciousness or sustained any head injuries. As he had pain in the chest, he had soon after the fall, visited a doctor in his village, who had reassured him and sent him home with painkillers.  He was tachycardic (heart rate over 100 beats per minute), tachypnoeic (greater than normal respiratory rate resulting in abnormally rapid breathing), hypotensive (low blood pressure), and had a very high fever. Sounds of breath were absent and the percussion note was stony dull on the left side. Chest radiograph taken at the time of admission had shown features suggestive of a left sided hydropneumothorax (abnormal presence of air and fluid in the pleural [pertaining to the lungs] space). As the patient was extremely breathless, the doctors had urgently inserted an intercostal drainage tube to relieve the hydropneumothorax and evacuated a few hundred millilitres of turbid, fetid fluid with fine particulate matter.  When the surgeons were consulted, they wanted the patient to be sent to the operating theatre for an immediate surgery for the treatment of a condition we had missed which was what they suspected to be a traumatic diaphragmatic (muscle below the lungs that helps move air in and out of the lungs) hernia (an internal organ or body part protruding the wall of muscle or tissue that contains it) on the left side, resulting in the herniation of the stomach and intestine with subsequent strangulation and perforation. As there was extensive intestinal gangrene which has resulted in septic shock, the patient died in the operating theatre.  Ariyananda notes that after the demise, they had found in the chest radiograph, evidence of multiple rib fractures and few small fluid levels in addition to the large fluid level on the left side. According to Ariyananda, the main reason for missing the diagnosis was the “lackadaisical approach of merely holding the radiograph against ambient light and reading it, while the other reason for missing the diagnosis was framing their thoughts to fit a preconceived diagnosis (a bottom-up approach) of a medical condition, disregarding the history of trauma, as the patient was seen in a medical ward with high fever, dyspnoea (difficult or laboured breathing), and signs of fluid in the chest. This type of clinical reasoning can be considered as a cognitive bias leading to confirmation bias with goal-directed behaviour – a failed attempt at pattern recognition”. As P. Croskerry notes in “Achieving quality in clinical decision making: Cognitive strategies and the detection of bias”, as a clinician gains experience, they tend to rely more on “pattern recognition” to arrive at a diagnosis. “In challenging clinical encounters, even experienced clinicians may have to resort to the ‘hypothetico-deductive' approach in clinical reasoning,” Ariyananda observed. Scenario 4 A middle-aged woman with bronchial asthma was seen by Ariyananda in his capacity as a physician in an outpatient clinic. As she had to take a metered-dose inhaler (MDI) several times in the night, Ariyananda had started her on a regular steroid MDI and reviewed her two weeks later. During the review visit, it was found that her asthma was not under control. Therefore, Ariyananda had sought to ascertain her level of compliance prior to escalating treatment. When she had been asked to demonstrate the inhalation technique, she had triggered the MDI without taking the cap off. When Ariyananda had told her to trigger it after taking the cap off, she was unable to do it.  Afterwards, when Ariyananda had attempted to take off the cap, he too had had to struggle to get the cap off, as it was stuck to the MDI with the spray that had collected, having condensed within and under the cap. In short, at no point had any medication been delivered to the patient. “Who should be blamed for this error? The doctor, the pharmacist, or the patient?” Ariyananda queried, adding that he was prepared to take the full blame for the situation.  In conclusion, Ariyananda noted that while clinicians should strive for zero error, such an approach should be adopted in light of understanding that there is room for improvement in the ways one acts and reacts, and hence it should always be inculcated as a practice and habit to reflect on how one could have treated each patient, and thereby make one’s clinical practice more reflective than relying on and resorting to thinking in a stereotypical manner. 


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