A Doctor’s Point of View on the Doctor Patient Relationship

I recently did an interview on the doctor patient relationship. Here I reproduce just a small part of it.

You can read the whole interview on Multiple Sclerosis Central.com by clicking on the following link.

http://www.healthcentral.com/multiple-sclerosis/c/73302/70302/patient

I have asked Doctor Nitin Sethi to contribute to this discussion through an interview about this very topic of the doctor-patient relationship.  Doctor Sethi will discuss this relationship from a doctor’s point of view and in part two of this series we will examine the same relationship from a patient’s perspective.  The patient will be me.   I do encourage you to offer your viewpoints through the form of comments to these articles.

 

I introduce to you:  Nitin K Sethi, MD who is the Assistant Professor of Neurology at New York-Presbyterian Hospital of Weill Cornell Medical Center located in New York City.

 

What do you feel are some of the personal qualities which are important for a doctor to develop rapport and trust with patients?

 

A lot has been written about doctor patient relationship and what qualities define it. Nowadays in medical school itself there is a thrust not just to produce smart doctors but also to produce more humane doctors. A study had shown that student doctors (medical students) have the highest levels of empathy. As they go through their long training (residency and at times fellowship), this empathy progressively decreases. One may argue that “experienced” doctors become less humane. I do not buy that argument. I feel the empathy gets replaced by knowledge. You know what you are dealing with and you understand disease pathology better. This might make a doctor sound aloof and like a “machine”.  He is very good at what he does but he is cold and aloof.

 

My patients frequently tell me that they left their previous doctor because he would not hear them out or he was not caring enough. They rarely say I left him because he was incompetent. I want to make this point to answer your question. Some of the smartest doctors I know (people I would go to if I had a neurological problem) do not have the greatest bedside manners. They are not most suave. But as a patient I would rather go to a competent doctor than to one who says all the right things in the right way but is not the smartest light.

Paging Dr. Google

Paging Dr. Google

 

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

 

I get quite a few patients who prior to coming to see me for a neurological consultation have already googled their disease or at least the disease they think they have. Many of the readers of my blog too, it seems spend a significant amount of their time searching the internet for information about their medical condition. Paging Dr. Google to come to the rescue can have its pros and cons. Lets start with the pros.

 

 

Dr. Google obviously is well informed, a vast sea of knowledge, thousands and thousands of pages of health related information is available at the click of a mouse. He is quick, rarely moody (unless you have a slow connection) and moreover cheap. One can spend hours with him, for even esoteric neurological conditions he has an answer, he sees patients 24/7 and even does house calls (though a café is at times his favorite de novo office). The internet already has and continues to revolutionize medicine and how health information is disseminated. When I did my internal medicine residency in India in the late 1990’s, the internet was still not available. I remember spending long hours in the National Medical Library in New Delhi pulling up articles I needed to research my thesis. The work was tedious, back breaking (big volumes of dust covered journals to be pulled off the shelves) and painstakingly slow. Even though I was a medical resident, I found it difficult to find relevant articles and information. A lay person had it even tougher. There were a few books available which touched on general medical conditions like how to take care of your diabetes and blood pressure. For anything else, you needed to pay a visit to your neighborhood doctor or to a specialist in a tertiary hospital.

 

Then along came Dr. Google. Smart and tech savvy. A few search words and up pops the answer, pages and pages of it too. For doctors, the internet has being a blessing. We can now share and assess each other’s work so much easily. When confronted with a difficult case, sitting in my office in New York City, with a click of the mouse I can find out if any of my colleagues have seen something similar. How did they treat this vexing neurological problem foxing me, what were their results and is there anything new on the treatment horizon? No more going to the medical library and trying to search through the journals. All the journals are available on the internet and Dr. Google makes my life easier by listing out which article appeared in which journal. In fact recently someone raised a relevant point, are the days of the medical library numbered? For the patient too, Dr. Google is a blessing. There are many good patient oriented websites which come up when Dr. Google is called upon for an opinion. Patients can learn more about their disease and this information gives them confidence and a hence of actively doing something to help themselves. Apart from health and disease related websites, Dr. Google also churns up blogs and various foundations providing much needed information to patients and caregivers alike. But does Dr. Google have any chinks in his armor?

 

Yes, he does. He can be wrong just like any of us mortal doctors. If you feed him the wrong history, he shall make a wrong diagnosis. Patient’s frequently search Dr. Google with key words. If the key words themselves are wrong, the diagnosis shall be flawed from the start. Here in lies Dr. Google’s weakness or rather our weakness. Dr. Google may diagnose you with amyotrophic lateral sclerosis (ALS), a fatal neurodegenerative condition with no cure currently because your history to him included key words like muscle twitches and weakness. It is only after a visit to your mortal neurologist that a correct diagnosis of benign fasciculations is made.

 

So the moral of the story is that Dr. Google is indeed a physician extraordinary but he is no substitute to an actual visit to your physician. You may read about the disease you feel you have but always, always do consult your physician because unlike Dr. Google he has the advantage of sitting down in front of you, taking a thorough history and conducting a clinical examination.  Dr. Google’s services are most helpful when he is paged with the right information in hand.

 

 

Concussion during sports and return to play decisions

                                      Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.

When and how to seek a second opinion-a patient’s perspective

When and how to seek a second opinion-a patient’s perspective

 

NK Sethi 1, PK Sethi 2

 

1 Department of Neurology, Comprehensive Epilepsy Center, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

2 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)

 

 

 

 

 

 

 

Address for Correspondence:

NK Sethi, MD

Department of Neurology

Comprehensive Epilepsy Center

NYP-Weill Cornell Medical Center

525 East, 68th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com

 

 

There are times when a second opinion is not only appropriate, its necessary. This is true both from the patient’s as well as the doctor’s perspective. Since the patient technically has more to lose, it is imperative that patient’s know when and how to seek a second opinion. This is more significant in clinical neurology especially when one is handed down a diagnosis of a neurodegenerative condition like young onset Parkinson’s or Huntington’s disease. Diagnosis of a disease like amyotrophic lateral sclerosis (ALS) is essentially like signing off on a death sentence. Patients and caregivers are distraught and may not know what to do. Some may trust their doctor and agree to his or her management plan. But what if he is wrong? Maybe there is something out there that may help me. Maybe my doctor does not know about it. Even if the diagnosis is correct some may not be comfortable with the line of care. It is at times like these that the question of seeking a second opinion crops up.

Is my doctor right? is frequently he first question that comes up in the minds of many patients when handed down a diagnosis of a chronic or life threatening illness. Could he have made an error? Patients and caregivers may approach this in a couple of different ways. Some will inherently trust their physician skill entrusting themselves to his care. Others may seek to reassure themselves of the certainly of the diagnosis in one of many ways either by asking more questions of their physician or seeking information on the Internet. A fraction may decide to seek a second opinion. A question, which arises in the minds of some patients and caregivers, is would my doctor mind if I request a second opinion. Would he take it personally? Most doctors do not get upset if their patient requests a second opinion but some do. Many doctors may actually encourage their patients to get a second opinion especially if they have a rare condition or an atypical presentation. In these times of increased medical litigation, one form of defensive medicine practiced by doctors is to get a second opinion.

Now the question arises whether you want your doctor to suggest a specialist or do you want to do the spadework yourself. Having your doctor refer you to a specialist for a second opinion has many advantages. It may cut down on your time and effort and more importantly ensure that you are seen by someone who truly is a specialist in the malady that plagues you. Your own doctor may be willing to pick up the phone and call the specialist to apprise him of your case history. Relevant investigations can be quickly faxed to the specialist office. This ensures you are seen in a timely manner. Importantly the specialist has all pertinent records including results of tests down at his disposal at the time of your visit. Remember if you go to see a specialist without lab results, his opinion is at the most limited.

One must ask oneself what do I seek from the second opinion? Is it confirmation of my diagnosis? My diagnosis is confirmed but I want to know what treatment options are available or I just want a better explanation for my disease. Stick to what you seek from your second opinion and do not get side tracked.

Go prepared at the time of your second opinion visit. As your time with the specialist is going to be limited so make the best of it. Have your case history summarized. A good way is to have it typed out in a chronological order. When did the problem start, how did it progress and the treatment options that have been pursued. This shall save precious time and ensure that the specialist has all relevant data at his disposal prior to giving a second opinion.

Are there any cons to seeking a second opinion? While there are no real cons to seeking a second opinion, certain issues should be borne in mind. Remember there is no guarantee that a second opinion is right. The specialist may or may not voice the same diagnosis as your primary doctor. One can get side tracked and end up wasting precious time and money. Time and money that could have been used to begin treatment earlier. Do not get into the trap of doctor shopping, shopping till you get an opinion that you want to hear. Too many opinions have the potential for confusing you and leaving you undecided.

Seeking a second opinion is your prerogative as a patient but use it wisely.

When and how to seek a second opinion: a patient’s perspective

I originally wanted to publish this in the New York Times as I wrote it primarily for patients and care-givers. They did not accept it. It seems they rather devote a page to which model makes how much money or who is dating who rather than publish something like this. I always wanted this to be freely accessible to patients and care-givers. That is the reason I started this blog and my website http://braindiseases.info in the first place. It is my way of giving back to my patients. I owe a lot to them and they are my first and foremost teachers. The article is hopefully going to appear in the Internet Journal of Neurology soon. Here is a small piece of the article. I cannot publish the entire piece as then I would be in copyright violation.

 

When and how to seek a second opinion-a patient’s perspective

 

NK Sethi 1, PK Sethi 2

 

1 Department of Neurology, Comprehensive Epilepsy Center, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

2 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)

 

 

 

 

 

 

 

Address for Correspondence:

NK Sethi, MD

Department of Neurology

Comprehensive Epilepsy Center

NYP-Weill Cornell Medical Center

525 East, 68th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com

 

There are times when a second opinion is not only appropriate, its necessary. This is true both from the patient’s as well as the doctor’s perspective. Since the patient technically has more to lose, it is imperative that patient’s know when and how to seek a second opinion. This is more significant in clinical neurology especially when one is handed down a diagnosis of a neurodegenerative condition like young onset Parkinson’s or Huntington’s disease. Diagnosis of a disease like amyotrophic lateral sclerosis (ALS) is essentially like signing off on a death sentence. Patients and caregivers are distraught and may not know what to do. Some may trust their doctor and agree to his or her management plan. But what if he is wrong? Maybe there is something out there that may help me. Maybe my doctor does not know about it. Even if the diagnosis is correct some may not be comfortable with the line of care. It is at times like these that the question of seeking a second opinion crops up.