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Advancements in medical technology have given rise to medicalization, a process where ‘non-medical’ problems have become understood and treated as ‘medical’ issues.1 This potentially objectifies humans, leading to “deindividuation”2, where doctors identify patients by their disease or procedure. The distancing of doctor-patient relationships have been worsened by limited doctor-patient interactions.3 Humanization of medicine is critical to ensure patients receive adequate care because they are reliant on the doctor’s competence and good will.4 This is where the BH1002 module contributes to my development as a good doctor. It increases my awareness of patients’ needs and the complexities of the healthcare system. The essence of this module is encapsulated in three learning points: a) Professionalism; b) Communication in Doctor-patient relationships; and c) Patient safety.
My role as a future doctor is to heal. Professionalism exemplifies the contract between society and medicine as it is the foundation of doctor-patient trust.5 In the BH1002 tutorials, I was exposed to three fundamental principles of professionalism, namely, the primacy of patient welfare, patient autonomy and social justice. Professionalism requires honesty with patients, empowering them to make informed medical decisions; it requires trust and having patients’ interests at heart; it involves equal distribution of healthcare resources to all patients.5
In my opinion, medical professionalism involves demonstrating humility and compassion. Modern medicine has established a culture defined by entitlement and conceit, and humility indicates weakness or false modesty.6 Having the confidence to tackle my insecurities is paramount to my development as a doctor. However, I am aware that self-confidence can develop into overconfidence as my level of clinical knowledge and skills increases. It can cause me to overestimate my capabilities, breeding incompetency and arrogance.
As a future doctor, I strive to remain grounded and be accountable for my blunders. I will avoid finger-pointing when mistakes occur. Being humble makes me mindful of the limits of my knowledge, allowing me to recognize opportunities for improvement. I will consider things from my patient’s perspective, prioritizing the well-being of my patients. Humility and confidence are not mutually exclusive.7 To strike a balance, I will constantly evaluate myself in clinical encounters. Through introspection, I can work towards being a more gracious person. I understand that when I am tired, I may have a temporary lapse in humility and be rude to someone. In response, I will take time to apologize sincerely, fostering better work dynamics in the medical setting.
Compassion is an important aspect of medical professionalism. It involves both empathy and the desire to improve the current situation. The Society for General Internal Medicine describes empathy as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”8 In this module, I was taught to strive for detachment with my patients to ensure that my feelings do not hinder the quality of care I provide.8 Nonetheless, it is essential to be sufficiently vulnerable to my patient’s suffering. When my attention is focused on my patients, they will be able to feel that I care. In contrast, being emotionally-detached could be interpreted as being indifferent, increasing their suffering due to the lack of understanding.
A study on the effect of forty seconds of compassion on patient anxiety noted, “The enhanced compassion segment was … effective in decreasing viewers’ anxiety”9. Compassion builds trust between the doctor and patients, encouraging them to recall and disclose significant details about their conditions.8 Increased awareness of the patient’s situation allows for more accurate diagnosis and effective personalization of treatments, improving the quality of care.8 Patient satisfaction is increased, enhancing the doctor-patient relationship.
I strive to exhibit medical professionalism by being compassionate. As a future doctor, I am responsible for the welfare of my patients. Having compassion will make me attentive to their needs. I can understand the situation from their perspective, and think about how I can ease their suffering. Consequently, my patients will not have to face their difficulties alone.
The doctor-patient relationship is a keystone of care. Built on trust and compliance, it exists when a doctor serves a patient’s medical needs, providing support and healing.10 There were two key reasons taught on why effective communication is crucial: a) provision of quality care; and b) medicine adherence. I believe patients benefit most when there is mutual trust and respect – doctors set aside time to listen to their patients; patients provide information about their medical condition to the best of their ability and comply with prescriptions. This can only be achieved with effective communication.
In the provision of better healthcare, it is important to focus on the medical interview between the doctor and patient. This is the main medium through which doctors gather information about the patient, make diagnoses and develop the doctor-patient relationship.3 During the tutorials, I was introduced to a famous painting, The Doctor by Fildes. The painting exemplifies the qualities of an ideal doctor. Despite the inadequacy of medical technology, and thus inability to save the patient, he remains by the patient’s bedside, providing reassurance through his presence.
This is a huge contrast with the modern physician, who, because of the large number of patients to see every day11, is often unable to set aside time to stay by the patient’s side. In his book, Being Mortal: Medicine and What Matters in the End, Gawande laments the deterioration of care in the medical setting. He attributes it to the shift in focus to curing diseases quickly using modern technology, highlighting that “fast, solution-oriented care accounts for approximately one-quarter of Medicare expenditures”11. Moreover, the time spent on write-ups is threefold the time spent in direct contact with the patient12. This means that little time is spent on communication with the patient. For this reason, patients feel neglected and even more miserable when doctors are unable to listen to their emotional needs and address their concerns.
What I wanted … was a doctor … who understood that a conversation was as important as a prescription; a doctor to whom healing mattered as much as state-of-the-art surgery did. What I was looking for … was a doctor … who is able to slow down, aware of the dividends not just for patients but for herself and for the system.11
In the introduction to the course, I was taught that doctors have an ethical obligation to prioritize the best interests of the patient. This means alleviating their suffering and minimizing patient dissatisfaction. When doctors take the time to listen carefully, the quality of information obtained increases, enabling a more accurate diagnosis to be made.3 In mastering communication skills, I can clearly explain my patient’s situation, preventing misunderstandings that may occur due to the lack of understanding of “basic health ideas, medical terms or medical information”13. I can provide emotional reassurance to those involved, facilitating the process of healing and enhancing the doctor-patient relationship.
Medicine adherence refers to whether patients follow the agreed recommendations and whether they take their medication for the entire duration.14 Effective communication is the major determinant of compliance.15 Doctors struggle with communicating information effectively, as seen in a study that reported, “40-80 percent of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect”15.
In this module, I was taught the teach-back method to improve medicine adherence, which relies heavily on communicating information to patients in a way that is easily understood. In teach-back, patients are asked to describe the information taught. This involves them in prescription decisions and serves as confirmation that they understand what has been explained, such as the prescribed dosage of their medication. Patients can then make informed decisions regarding their use of medicines. By engaging patients in their care, they are more likely to comply with the prescriptions, leading to a higher quality of life and higher satisfaction.14
As a future doctor, I strongly believe that patients have a right to make decisions in regard to their health. This means that if patients refuse to take the prescribed treatment, that choice must be an informed one; if they accept the recommendation, I am responsible for facilitating the appropriate adherence to optimize the efficacy of treatment and reduce risk of side effects. Using what I learnt, as well as the “SPIKES” model detailed in WHO Multi-professional Patient Safety Curriculum Guide16, I will provide uninterrupted time for patients to share their concerns and ask questions about their conditions. This will help me understand my patients’ beliefs and assure them that I am listening. After which, I will provide the necessary information, in a comprehensive manner, using the teach-back method to check their understanding. This will facilitate shared-decision making, where patients can effectively voice concerns about aspects of the treatment they disagree with. This allows me to tackle the issue of limited health literacy of patients and negotiate a treatment they are agreeable with.
A large proportion of the BH1002 module was spent discussing patient safety. I was exposed to the idea of human limits and reasons why healthcare systems fail. My greatest takeaway was being constantly reminded that doctors are not infallible. In fact, great doctors are people who expect errors to occur and take measures to prevent them before these errors can happen.
Humans have limitations that can predispose them to error. Through the lectures, I learnt about memory constraints, confirmation bias in perception and selective vision. The recalled memory is reconstructed, changing according to what we perceive; we tend to seek evidence to support our decisions, even if the decision may not be correct; we do not notice when something unexpected enters our field of vision, especially when we are focused on something else. These cause difficulty multi-tasking and recalling detailed information quickly15, creating room for error.
Now that I am aware of these limits, I will put in greater effort to reduce the impact human limits have on my patients’ health. I will use writing aids, noting important information immediately, reducing the reliance on human memory. This also removes the uncertainty that I could have remembered the wrong details. I believe this habit needs to be cultivated while I am a medical student. Therefore, I have begun with the lectures I attend, jotting down points raised by lecturers and reviewing them for greater understanding of the content taught. To reduce the risk of confirmation bias, I will make sure to gather information from reliable sources, analyze the data carefully before reaching a conclusion, instead of drawing a conclusion before finding evidence that tally with my opinion.
In a medical practice study conducted in 2000, To Err Is Human: Building a Safer Health System, it is emphasized that to assure patients that they are safe from accidental injury, concerted effort by all professionals is required to “break down traditional clinical boundaries, the culture of blame, and systematically design safety into processes of care”.17 There are several reasons why healthcare systems fail. First would be the traditional intolerance for error in the medical setting. Doctors are held personally accountable even if the error was systems-based and beyond their control. The medical culture of blaming encourages doctors to underreport errors out of fear of disciplinary measures.18 The BH1002 module taught the importance of sharing the burden of guilt. If a doctor makes a mistake, sharing creates opportunities for everyone to review the problem objectively. Improvements can then be made to existing systems to prevent a repeat of the same mistake.
I learnt about the “Swiss cheese model of system accidents”. This model compares the different levels on which mistakes occur with slices of cheese. Each slice represents a layer of defense against potential errors. In the real world, each slice has holes in different places, each representing a loophole. A catastrophe will occur when the holes align to permit an opportunity for accidents, directly bringing patients in contact with hazards.19 These lapses in defense arise from two types of errors. Active errors are unsafe behaviors committed by people that lead directly to a given error. Latent errors are errors that remain dormant in the system until ‘triggered’ by other events. These occur further away from the action itself, such as flaws in the healthcare organization or faults in the equipment used.
Active errors are often unpredictable whereas latent errors can be prevented. The persons-approach, which focuses solely on active errors and individual blame, is therefore of limited benefit because it deals with errors only after they occur. In contrast, the systems-approach revolves around the idea that errors are to be expected and designs a resilient system to reduce the risk of incidence of error before it happens.
The systems-approach is important to my development as a good doctor. It reminds me of the need to adhere to standard operating procedures in the medical setting. Simple practices such as hand hygiene can reduce the risk of spreading infections among patients. I understand that patient handovers are an integral part of the healthcare system. There are an average of 50-100 steps between the doctor’s decision to order a medicine and the delivery of the medicine to the patient, causing an overall 39% chance of error.20 I will do my part by making my case notes comprehensible and legible to prevent miscommunication between doctors. I will clarify expectations before undertaking any tasks and consult my superiors should I be unsure of any issues. When reporting critical laboratory results, I will use the read-back method, noting and correcting any discrepancies to ensure the relayed information is accurate. This will reduce the risk of harm brought to the patient.
The healthcare environment is a very complicated one. In the beginning, I was fearful of the rigid and complicated hierarchies that exist. The BH1002 module has equipped me with the necessary knowledge of what it takes to be a good doctor, as well as how I can understand my patients better and ensure their safety. I believe being accountable for my actions is the best way to exhibit professionalism and help people. I look forward to overcoming the trials I will face as a doctor. I hope to become a doctor who can serve my patients and peers well, by providing quality care and becoming a pillar of support.
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