Tag Archives: diagnosis

“Is The Diagnosis Wrong, Doctor?”

“Is The Diagnosis Wrong, Doctor?”
© Dr. Rajas Deshpande

“Doctor, there is no improvement at all” said the angry husband, throwing the case-file upon my table.

Well this is not an extraordinary sentence for any doctor, one must be prepared to openly deal with this. I had been quite polite and well mannered with them, there was no reason he had to cross that line. I could understand though. When they pay my fees, they expect some result or satisfaction.

While teaching my students, I have always insisted that if the patient / relative says that there is no improvement or change with the prescribed medicine, one must first consider the possibility of a wrong diagnosis, a missed condition or a misinterpreted finding. Doctors are humans, and do commit mistakes, or misinterpret findings. This is normal, and happens with every doctor. Medicine is far more complicated than most people think they know. A good doctor knows this and learns, while all the time keeping patients safe, but a doctor with ego kills his own practice, and may cause harm to the patient.

I asked them to sit down and reassessed the case in detail. A 28 years old female. Headache, giddiness, imbalance, palpitations, breathlessness. Lack of sleep and bouts of crying. Past and family medical history not contributory. Physical examination completely normal. MRI of brain normal, Vitamin B12 and D levels low. I had started vitamin supplements, anti-anxiety medicines and an SOS for headache.

She told me all her earlier complaints had improved, but now she had a severe backache. I told the patient that I was trying my best to understand her condition, and to resolve her problem, but her findings and complaints didn’t match. She looked at her husband, and asked him “May I speak frankly to the doctor?”.

Openly agitated, the husband sarcastically offered to wait outside if she needed privacy. However he stood glued to the chair as if he knew her answer. © Dr. Rajas Deshpande

The patient thought for a moment, told him it’s ok he can wait inside, then started to talk. She revealed that she was the only child of her affluent parents, had passed engineering, but now had to quit job and stay at home to raise children. They lived in an extended family, with grand in-laws, in laws and an elder brother, his wife and two children. This patient was the ‘last in the line’ to take orders, all others being senior to her. Her husband and in-laws were perfectionists, and she was tired of their continuous expectations. She had dreamed of making a career too, wanted some free time outside home for herself, but year after year, she didn’t get even a minute for herself. She was tired of it all and there seemed no respite. © Dr. Rajas Deshpande

“I am not averse to hard work, but the continuously condescending and fault-finding attitude makes me feel that I am useless”, she said, and added cautiously: “We were in the same institute and my ranks were always better than him. Look at where I am now” she started crying.

I offered them water and coffee, and waited for her to settle down. The husband became restless and defensive, but his tone was far lower. “I understand her problem, doctor, but what can I do? I cannot leave my family. My work pressures are quite high too, the IT industry is going through a bad phase”.

“I can assure you that she has no neurological problem now’ I replied, “she should improve with lifestyle changes, counseling for the family, and adequate free time for herself. I will refer you to a good counselor” I told them.

The husband laughed. “I can understand, but my parents will not. We will see what best we can do for her”. A bitter tone in his voice didn’t escape me.

‘Sir, she told us what bothered her, and must not be held guilty for trying to speak her mind. It will only help identify and treat the problem better. Please see a counselor together and avoid discussing this at home right now” I requested the husband. © Dr. Rajas Deshpande

There are many reasons why a patient does not improve. Untreatable medical conditions, depression, seeing the wrong specialist are the most common reasons, but there also are patients who want medical leave,those who want to avoid work, who want attention, so will keep on complaining of false symptoms. They do not improve with drug treatment.
On the other hand there are many who keep on taking the wrong medicines for years, those who self-medicate, do atrocious / injudicious dieting and exercises, yoga that doesn’t suit them, and do not follow the doctor’s instructions about abstinence, who keep on indulging salt, sweet, oil, alcohol, tobacco and other drugs freely available in India. © Dr. Rajas Deshpande

A doctor remains a lifelong medical student. A doctor who thinks he / she is always correct is most dangerous. It is not uncommon to meet doctors who are angry / upset with the patient / colleagues when their diagnosis, treatment is questioned. The first thought of a doctor when the patient does not respond positively should be to consider a misdiagnosis, reevaluate the case in more detail, reassure the patient, and obtain a second opinion if necessary. All this done, one must look into other possibilities, with an approach to resolve the issue rather than trying to shove down the patient’s throat their own faults.
We all go through bad patches in life, doctors and patients. If the child is wrong, the parents correct them still with love. A doctor’s attitude should be similar, with due care to also protect themselves. If not the doctor, who will understand the patient whose family refuses to understand them? In so many ways, especially in the Indian society, the doctor must don the role of an elder brother/ sister. Although patronising is legally discouraged in medical practice, and should be refrained from in cases where trust is questionable, one can make exceptions for some cases that need reassurance where the family fails to do so.

The nobility of our profession also lies in reassuring the patients that they are well cared for by their doctor, through the thick and thin of their life.
© Dr. Rajas Deshpande

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Worse than Death

Worse than Death
(C) Dr. Rajas Deshpande

“Doctor, I have started to die. Can you help me somehow?” he asked, calmly.
In his late twenties, a handsome young man, well dressed, but with a certain painful gloom upon his face that was a mismatch to an overall nice and clean appearance. What could this be? I started thinking, hoping he was wrong.

Then his shoulder twitched, and arm had a slight jerk. A pang of suspicion bit my heart immediately. He confirmed it in few seconds. Those who take life for granted are often so full of anxiety, and here he was, who had initiated a countdown to his own death, talking to me in a low but clear voice.
“Doctor, I have been diagnosed with Huntington’s disease over 7 years ago” he said, “Till now I had only these jerky movements. Now I have started having some mood problems and also memory issues. My parents died in an accident when I was three. My uncle’s family cared for me till I could go to a boarding school. I stay alone in a rental apartment, I work in an IT company”.

Examination and review of reports established that his diagnosis was correct. There is no treatment.
This illness of brain degeneration starts with abnormal movements, then causes loss of memory and other cognitive functions, mood swings, depression, finally causing complete immobility and usually death ensues due to blockage of windpipe because of food while swallowing. A patient usually survives less than 13-18 years after the diagnosis. Some commit suicide.

What do I tell someone aged 28 who knows he will definitely die soon?
Yes there are research options and support groups. Yes I can send him to a professional counsellor. Yes I can use some mood stabilising medicines and antidepressants.
But can I emotionally detach from this event as a doctor? (C) Dr. Rajas Deshpande

Diagnose and treat with empathy, educate and move on. Don’t take home the burden of your patient’s illness. Don’t get emotionally involved in your patient’s lives and problems. Never. But is that possible?

Shall I ask him if he has any bucket list of things he wants to once experience, before he forgets who he is? Is there something there that I can help him with? Has he planned anything about his life when he is mentally or physically disabled?

I told him that some medicines can help him, and wrote a prescription. Also referred him to an expert counsellor.

What would I do in such a situation? What is it that I would like to hear from the doctor, knowing the obvious too? What is so important in life when one knows that there are only a few years remaining?

Those who have the luxury of ignorance can laugh and superficially answer. Those who answer immediately have seldom used thinking. Those who are assured of their health have changing answers.
But those who know it?

I decided to ask him. (C) Dr. Rajas Deshpande

Next time he visited, he told me that he has resigned from his job, as he had problems dealing with the responsibility. He could not ride his two wheeler too, he had sold it off.

“I am going to my ancestral village, doctor. A dharamshala (religious sanctuary) has agreed to allow me stay and food, and help me as much as they can. I am also willing to donate my body for research, so at least others don’t suffer this. But I have to finalise yet”.

In India, just as there is no scope for genuine research, there also is complete lack of any infrastructure for the care of such patients.

I decided to ask him what troubled me.
“Is there something you wanted to do?” I could not bring myself to say “before you go”.

He tried to smile. His eyes welled up as he thought about the question.
“Yes, Doctor. I wanted to feel someone loving me madly at least once. In fact I had a girl in my office whom I liked. I think she liked me too. But then my diagnosis was confirmed and I didn’t want her to suffer, so I never told her. I met her before resigning, and told her the truth”.

“Everyone will only degenerate,” he continued, “I am ready to see myself degenerate early. But the one purpose, the one good memory of life that one can wrap himself with when facing the decline, is love. Everything else only reminds of loss”.Dr. Rajas Deshpande

Then, wiping his tears and sobbing, for once, openly, without the restriction of pride, he held my hand, and said, “Thank you doctor for all your help. I came to know just now, that not having loved is what I regret most. It feels worse than death. Even if I had felt true love once, I won’t have regretted this early death”.

He had only echoed what every particle, every corner and every breath of life always reminds us of, while we keep on searching for everything else.
Dr. Rajas Deshpande