Tuesday November 7 2017

Tool of good medical practice: Be humble, doctor. Be humble

Muniini K Mulera

Muniini K Mulera 

By Muniini K Mulera

Dear Tingasiga,
We have witnessed extraordinary medical and surgical advances in the 40 years since we graduated from Makerere University Medical School. The explosion of medical knowledge and the changes in diagnostic and treatment methods have been mind-boggling. However, these advances have not made us better or safer doctors.

There are timeless and unchanging tools and skills that doctors (and other healthcare workers) must utilise in order to provide safe and effective care to patients and their families. The most important tool is to genuinely like and respect all people and to treat them as we would want to be treated, always considering each patient to be as important to us as our own child, our sibling, our parent or our spouse. Second, recognising that our patients are God’s children, just like you and me, who come to us trusting that we shall work with them to resolve their illnesses or to, at least, relieve their pain and suffering, enables us to give our very best to meet their expectations.

Our patients are not sets of symptoms or “cases” of disease X or Y. They are people who honour us with their trust – their stories, their secrets, their nakedness, their hopes, their lives. We must reciprocate their trust with total respect and commitment to serve them with kindness, empathy, honesty, efficiency, confidentiality, ready availability and competence born of the most current knowledge and standards of practice. The greatest diagnostic tools in medicine and surgery are our ears, our eyes, our washed hands and our informed brains. We use these to take a thorough history, followed by a complete physical examination. These formed the foundation of medicine 40 years ago. They remain so today.
The laboratory and imaging tools are secondary supports that only help us to zero in on the problem, to plan and monitor the treatment programme and to add to our collective knowledge of health sciences.

Taking a good history requires active and respectful listening to the patient or their guardian. The patient or a child’s guardian knows her body and her story better than anyone else. So, we must listen to her with attention to every detail, guiding the interview but always with an open mind, and never seeking to confirm a preconceived diagnosis.
We must encourage patients or their guardians to ask us questions, to challenge our answers and action plans and to be active participants in the decisions about their lives. We must also listen to the nurses and other providers who have interacted with the patient.

The physical examination, even in the most challenging clinical setting, must always be done in a manner that respects our patient’s privacy and dignity. Our washed hands, gently applied according to long established examination methods, will either confirm what we have suspected from the history or help narrow down the possibilities and determine what tests, if any, need to be done to establish the correct diagnosis. We serve our patients well when we respect and promote teamwork. No doctor has a monopoly of knowledge and skills. Recognition that every member of the team is important is a critical component of good and effective practice.
The answer to a medical puzzle can come from the least expected person.

Thirty-three years ago, during my specialist training at the Foothills Hospital in Calgary, Alberta, Canada, my team and I were urgently called to the delivery room to attend to a newborn baby that was not responding to oxygen. Whereas both parents were European, the baby had a dark colour that was an obvious sign to me that he was not getting oxygen into his blood. (This was several years before portable oxygenation monitors became readily available.)

I promptly placed a breathing tube into his windpipe and began to administer assisted breathing. After speaking with its parents, we took the baby into the neonatal intensive care unit (NICU). As we started other invasive procedures on the baby, Phyllis, the NICU ward clerk, came to get basic information about the patient in order to prepare his medical record. Phyllis was a former school teacher from Trinidad who had never had medical or nursing training. Gifted with a great sense of humour, Phyllis was known to relieve tension with a well-timed comment.

“Looks like a black kid to me,” Phyllis said, as she walked back to her desk. “What did you say?” I asked, to which she responded: “Nothing.”
I called Phyllis back and asked her to repeat what she had said. I then examined the baby, my bias suddenly lifted by a remark by a non-medically trained clerk. Notwithstanding the parents’ European race, there were obvious tell-tale signs of a newborn of African ancestry. I sheepishly removed the breathing tube and our little friend let out a good cry, followed by normal, unlaboured breathing. The examination was completely normal.

After arranging with the obstetrician to take the father out of the delivery room, I returned the healthy baby to his mother. She readily confirmed my suspicion that her European husband was not the biological father of her baby. Phyllis never let me forget that experience.
That singular error transformed me from an over-confident physician to one who learnt to ask the question: “What else could this be?” It was not the last error in my career, but it remains my greatest lesson in humility that has only been entrenched by years of experience.

Phyllis taught me to listen to my juniors and to my colleagues no matter their role on the team. She taught me never to make assumptions about my patients. She taught me the greatest tool of good medical practice: Be humble, doctor. Be humble.
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