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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Poignant Patient Interactions
Radiology residents recount their experiences with patients
In March 2023, we asked residents in the department to write essays recounting their moving , poignant, memorable experiences with patients that may have occurred in the recent past. Two of those essays, adjudged at position 1 and 2 are reproduced below.
Essays by other residents have been added here
I’m not scared of making mistakes
Swastika Lamture PGY 3 : 2023
Two years back I entered this institute as a new radiology resident, full of hopes and dreams, with a sense of achievement and pride to have entered the institute of my choice. Its easy to forget very easily, that this ‘sense of achievement or pride’ also comes with a baggage of expectations predominantly from our own selves. You start with enthusiasm setting unrealistic goals, ideal expectations and rightfully so, but soon you realise the complexity of the system and your limitations as a human in being in alignment with your ‘ideal’ expectations. Once this reality strikes you, how you carry yourself forward is a conscious choice you make. Some may tire themselves out to keep up with their expectations, some may choose self preservation. There is no right way or a blue print when it comes to this choice, and life goes on.
Pre-residency I was told, to interact with patients. I always thought of this advise as an attempt to improve my skills as a ‘Clinical Radiologist’. But over the course of next few months, I grasped a new aspect to the ‘Patient interaction’ bit. Here is an account of the same.
This incidence is from the first year of my residency. I had newly become the ultrasound registrar. During one of the calls there was a young man in his mid thirties who had come with a typical history of liver abscess. He was advised percutaneous drainage by pigtail insertion. He was a very quite guy who co-operated during the counselling process. I started assessing the patient for a safe window. I discussed the case with my colleague and we decided to go ahead with the procedure. As I started to drape and clean the patient, a discussion started regarding few of the interventions carried out by us, and the new techniques that we learnt recently. However, during this particular procedure, despite taking utmost precautions and assessing a safe window for intervention, the procedure was inadvertently complicated by a pneumothorax. I immediately ran to my senior with a sense of urgency and scared about the course ahead. First up, I was counselled that it is an expected complication and I need not be harsh on myself for making a mistake (Yes, I needed to hear that, thank you for making my palpitations go away. But what do I do next?) He later explained me the protocol to be followed in such a situation, which I followed diligently. And the last step was to inform the resident and carry on with the call. The primary resident was informed and I was expected to continue the remaining call.
However, there was something that kept bothering me. This was a young man who came walking to me for the procedure and there was a very high chance that now he would require intercostal drainage. I accompanied the patient for his radiograph. As I saw the pneumothorax, my heart sank. I rushed to the ESR asking my surgery colleagues if this particular patient would require an ICD. The response was disheartening. As I was returning, I realised that I still had his radiograph, so I decided to return the radiograph. I went to the ward and he was sitting in his bed, a little breathless already (Gulps. I don’t know how I’m going to face him). I started explaining him how the procedure had gone south and the likely management henceforth. He was very patient as I talked. Once I finished explaining him, he said ‘Madam, naseeb ki baat hai. Ab mere naseeb mein 2-3 naliya (tubes) hai toh ab aur kya hi kar sakte hai. Idhar anaa hi nahi chahiye tha.’ After hearing these words, it was a long, difficult night shift for me. And the worse was yet to come!
The next day I could not gather courage to face the patient. I decided to ask my colleague about his course. I was told that ICD was inserted and the breathlessness had settled (Phew). The patient ultimately decided to discharge against medical advise (Yes, I felt responsible). Few days passed and I met a friend and I was sharing this incident with him. It so happened that he was the one who inserted the ICD, and he told me the relative’s version. They were okay with the complication as they had been counselled about its possibility. But they were not happy with the discussion that was going on during the procedure. We as fellow residents sharing our experiences, was in a way looked upon as a distraction and possible reason for the complication. They felt that their procedure was not taken seriously enough.
Was it true? Absolutely not. Instead the discussion was supposed to bring in confidence and motivate. We had the best interest in mind. But what did I learn from this? Human suffering is difficult, and it needs to be handled with utmost sensitivity and empathy. When dealing with patient, the only thing that matters is how you empathise, comfort and counsel him/her. Sure, you’ll get stuck at some point, but when you consult someone else, how you COMMUNICATE it to the patient will also determine his/her acceptance towards you.
Some other day I would have looked upon this as a mere skill- related mistake. Rather it was a lesson about sensitivity and empathy. Professionalism around the patient is something that we all possess to some extent. But the associated soft skills, non-verbal actions and attitude is not something that can be taught, it is acquired, by experiences, by mistakes, by courage. I was told many times, that your mistakes will define you. But I’ve come to believe that what you learn from your mistakes defines you.
The Real Challenge
Samvid Kotiya PGY4 : 2023
If you change the way you look at things, the things you look at change.
And “looking for things” is an important aspect of every doctor’s life especially when one is training to be a radiologist. But then there are certain moments that have the power to transform our perspective and alter the way we think. These experiences can come in various forms, whether it be a significant event, a chance encounter, or a personal revelation. For me, one particular experience stands out, which taught me not only to read digital images or films, but also to focus on the patient – who is not just a suffering human, but undoubtedly the most important human in the reporting room.
It was the second month of my residency period, and I was posted as a houseman in Conventional Radiography/X-ray Department. This meant that it was my first posting in that department and was just the beginning of taking baby steps on the vast path of knowledge that lay ahead of me. It also, meant that I was the juniormost doctor in the room and was responsible for the task of “patient management”. This included ensuring proper collection and dispatch of reports, guiding patients through the process of radiography, and sometimes even calming down an irritated patient. And so there was a lot of patient interaction, a thing which radiologists are infamous for not doing.
One day, as I was returning from lunch, I saw a lady standing outside the reporting room. She held a baby in one hand and a dusty, old, but heavy plastic bag in the other. Dusty old plastic bags usually meant zillions of serial x-ray films that needed comparative reporting, and this one was no different. Except in this case, the patient was a three-month-old boy. The boy’s face was abnormal, with distorted facial features, and he was wrapped in a pink shawl. Attached to the bundle of x-ray films was a note from the paediatrician that they suspected something called “skeletal dysplasia”. I had never heard the term before, but the nerd in me was excited. After weeks of mundane images, there was something challenging.
I quickly Googled and went through some articles to find that it was a group of rare genetic disorders that cause abnormal development of a baby’s bones, joints, and cartilage. I also came to know that it was a particularly difficult topic in conventional radiology, which was evident from the intense brainstorming discussion that my seniors and consultant had later on. I wanted to chime in with my newly found knowledge but decided to keep quiet as I saw the discussion becoming increasingly confusing. The films were then referred to our head consultant and other experts in the field of paediatric radiology which usually takes a few days. The woman had to come daily for four to five days. “Theek toh ho jaayega na daac saab?”, she asked each time. Each time, she brought the baby in a pink shawl. There was never a father accompanying. It was later that she confided that, after the birth of the child, her in-laws made her choose between them and the “weird-looking baby”, which they thought was an embodiment of the devil. She happily chose the child. The pink shawl was the only patrimony the child had received. However, it was balanced by the immense love, hope, and optimism from his mother.
The final verdict was that the child had rhizomelic chondrodysplasia punctata. I was enthralled by the whole process, the fancy-named syndrome, and the fact that we had overcome the challenge of diagnosing a rare case. But the main challenge still remained, and it stuck in my mind when I found that this variant of dysplasia is a lethal. And that the challenge was disclosing the disease to the mother, a disease where the child will most likely not be alive for its first birthday.
My transient sense of fulfillment of diagnosing a rare disease disappeared when confronted with the fact that there was no definite treatment, drug, or surgery that we could offer to save the kid. The lady followed up in hope that we had found a miraculous cure. Unfortunately, there were none and we couldn’t give her false hopes either. But then I realised that we did have something to offer her, something that was beyond the realms of logic and medicine. Empathy. A listening ear to which she can let her heart out. The emotional resonance that she could feel when she felt we were able to understand her perspective. Most importantly, she needed a safe place to express her feelings without being judged, so she could face the challenge with confidence. After the initial emotional support, we tend to her technical doubts regarding the situation and disease in general. With a clearer mind she was able to assess the palliative management options for her child, even when she knew that they will not change the inevitable. Finally, she was offered genetic counselling, and it was explained how regular antenatal check-ups can help prevent such outcomes in the future.
Upon retrospection, this experience always taught me the importance of the emotional aspect of patient care. It taught me to look beyond the images and diagnosis and see the bigger picture. And that sometimes the real challenge is not just the diagnosis and management of a patient’s condition, but something beyond…
I’m afraid of saying, “I’m afraid…”
Satyam Barchha PGY3
I have learnt a lot in five and a half years of my MBBS and almost three years of my residency, but there is one thing I haven’t been able to learn. And I am not sure if I am going to learn it in foreseeable future!
This apprehension started in the first month of my residency. It was a routine day, when a well-groomed man in his forties came and requested us for an ultrasonography of his abdomen because he had some vague abdominal pain. He wasn’t much worried about it, but he said he better get it done, just to be sure. He sure looked educated, but we didn’t think much and my senior started doing the scan. I’m sure as soon as he put the probe on the liver, he had made a diagnosis. But he did not tell me what it was. Now I could see that the liver was not normal and there were a lot of lesions, and even asked him about it. Ideally, he would go on and teach me about the abnormality, but he subdued my curiosity with a cold look and a subtle nod expressing that he will soon explain the case to me once he was done screening the whole abdomen. Or maybe after the ‘patient’ (who told us during the scan that he was a doctor himself, and a faculty in the PSM department) has left.
It was this time when there was a twist in the story, much to the dismay of this handsome doctor. There came rushing into the ultrasound room, one of our senior residents, who thought he was a bit late to work. He looked at the ultrasound screen even before completely entering the room and blurted out, “arre yeh to Mets hai…” (“This is typical of metastasis”). My heart sank. Could there have been a worse way for this doctor to know that he had a malignancy which had spread to the liver! I could see his face getting wet with sweat. I could see the blank stare and the blacked-out state of his mind. He immediately got up and asked for a glass of water. The senior resident came to know that he was a doctor and tried his best to explain the findings to him. He took over the scan and completed the screening with utmost care and attention. There was an awkward silence. It was mostly because of our guilt for the situation. And our failure in being able to help him out of the emotional turmoil he must have been going through. Could anything have helped! He was explained what should be done further and referred back to the OPD.
Now of course we discuss cases while doing scans, but most of the patients are unaware of the medical terms we use. But I couldn’t get this incident out of my mind. What if the diagnosis wasn’t revealed accidentally and we would have to answer his questions after he read the report? We couldn’t have withheld the report and asked the clinician to explain it to him, which is the normal escapist attitude we have as radiologists. I suddenly remembered my internship days, where I had to explain to the relatives if a patient had expired after days and days of attempts to cure him. Or even worse, if the patient was brought dead, and we didn’t even have a chance to try and treat him. As an intern, the onus of the revelation of this mayhem was on my seniors. But what would I have done if I was the only one present there? One of the reasons I had opted for radiology as a career was not having to face this situation. But it didn’t take me long to realize that I can’t go on avoiding such situations even as a radiologist.
I decided to be a sport and face it. I decided to tell a patient if he has a problem that needs attention. But what could I have said to that expectant woman with a precious pregnancy after multiple abortions, when she had another miscarriage after eight months of pregnancy? Of course, I could have said that there is no heart beat as subtly as I could. But doesn’t the obstetrician have much more expertise in this aspect of doctor-patient relationship?
I remember having a patient with aortic aneurysm during my interventional posting. He was stable and needed a huge amount of money (five lakhs to be precise) for the repair. He was explained about the disease and its treatment. He came back after three months saying he could collect thirty thousand, and it was the best he could do. With more help from the government schemes and charity, he was still short by three lakhs. Could I have said to him face to face, that he could not be treated for this time bomb because he was poor? I did explain to him, that we wouldn’t be able to treat him with this much amount of money and he need not worry much because he was stable at that moment. But was that the truth? Wasn’t it a dire emergency that needed urgent attention?
But was there anything else I could have done? As doctors we are taught to not get carried away. We are taught to be neutral and not let emotions take over. But it also comes with the fact that you have to be stern and heartless while handling these situations. And at the same time not hurt others.
I have started taking baby steps. I recently video called my parents to tell them I won’t be able to come home for Diwali, instead of texting them and avoiding their sad faces.
But I was really afraid of telling my grandpa, “I’m afraid they might have to cut your leg for the gangrene”.