1. THE DOCTOR’S NAME IN OUR BEAUTIFUL ARABIC LANGUAGE
HAKIM ( THE WISE PERSON)
حكيم
SO DOCTORS ARE WISE PERSONS

2. How ARE YOU GOING TO USE YOUR WISDOM ?
If you are called to see a case in E.R
And you haven't seen a similar case in your carrier
Do not panic. Do not get nervous. Do not start thinking who to call.
A very good history may lead you to solve the problem.
Think rational and analyze every symptom and sign.

3. SO WE MUST USE OUR WISDOM
Relax & be your self when you see the patient for the first time.
Think rationale & do not panic.
Do not let the patient lead you especially if the patient is bad historian.
Remember that you need to take action according to the case in front of you.
Do not let the thoughts of medico legal consequences direct you in ordering too many lab & x-ray investigations.

4. Before ordering any investigation ask your self the following questions
Is this investigation necessary?
Will this investigation help the patient?
Will the result of this investigation help me to reach a diagnosis?.
Are we suspecting a treatable condition?
Will the result of this investigation change the line of management ?
If the result is positive am I going to prescribe medication? Or send the patient to O.R ?

5. Instead of asking the Specialist or the Radiologist to come at midnight , why don’t you spare them for a possible RTA after some time?

6. Medicine is common sense
What is this?
SHORTNESS OF BREATH AND DILATED VEINS ON ANT CHEST WALL.
Are u going to waste time by doing CT scan in the middle of the night?
Are u going to bring the ENT consultant for urgent tracheostomy?
OK take a second look at the patient and think RATIONAL.
Ask your self why this guy is having dilated veins on the anterior chest area?
Why he is having shortness of breath?

7. ?
Then what is this?
Dilated anterior chest veins, and whole neck swelling.
Why the Dyspnea
Does he have any thing obstructing that blood vessel which drains this area?
So their must be some thing wrong in side his thorax
I Will do a simple, cheap quick CXR

8. That is it,
So it is a SVCO
Are u going to call the CTS consultant for tissue diagnosis? Which will not help the patient now and will keep him in agony for a week?
Or say let us comfort the pt and give him some thing to relieve this condition?

9. So u have chosen to give a very high dose of Dexamethasone 24 mg stat and then 8 mg q 6 hourly.+ Mannitol + O2
On the Next day in the morning u will feel how satisfied u r .
Ask the CTS consultant to provide histology very quickly. Ask your Oncologist to come and see patient.
If this is due to Lymphoma then He might be able to give him the first course of chemotherapy before his referral to KFSH.

10. Think always wisely What is this ?
What is this huge mass under the chin?
And why she is having difficulty of breath?
What are we going to do?
Send her for CT scan in the middle of the night?
The CT will show u the mass. but will not solve the problem.

11. Are u going to Take a biopsy and wait for one week for the result while she is in agony?
Then start asking your self what conditions can give a similar picture? But u r still wasting precious time.
Instead PHONE the ENT on duty to come for urgent tracheostomy and ask him to take a piece of tissue for histology during his work .
Relive the pt’s agony and give her high dose of steroids.
Next morning discuss her with your colleagues . They will agree on one diagnosis :Anaplastic carcinoma of thyroid.

12. Consult your Oncologist and he will advice you to write an urgent fax to KFSH for quick course of palliative radiotherapy

13. A young pt comes with severe Haemoptysis
He is loosing a lot of blood and coughing blood all the time.
Suddenly he starts complaining of symptoms of pulmonary embolism.
Are u going to request an urgent lung scan?
If there is P.E are u going to give him anticoagulants?
The answer is NO . Then why request L.S in the first place?

15. If your colleague is presenting a case during the morning report
Do not ask questions you already know their answer .
Try your best not to interrupt him/her
Do not try to irritate your colleague: He is having enough stress so don’t increase it.

16. If the patient’s case being presented was hospitalised elsewhere :
And the colleague presenting the case says: the xxxx investigation was not done for this patient at that hospital .
Then do not ask him why this was not done at that hospital……………..

17. Because :
That question implies two possible answers and a sarcastic insinuation The two possible answers will be:
How can I know how that hospital’s doctors think
Or : I do not know

18. “why they did not do it at the xxxx hospital” ?
If your colleague presenting the case thinks that your question was a sarcastic insinuation:
Then this question means from in between the lines: “Are you better than that hospital doctors”?

19. If your colleague is presenting an advanced lung cancer case with metastases
Do not incest in which lung lobe the primary is. what difference does it make to you or to the stage IV patient.
Unless if you are going to prescribe now a palliative radiotherapy course

20. COMMUNICATION SKILLS – DOCTOR-PATIENT RELATIONSHIP
A Letter to all residents and junior specialists preparing for exam By
(Dr. Mohammed Zakaria,)
Snr. Consultant - Clinical Oncologist)

21. what kind of person ???? (patient you are dealing with.)???
Before you reach a diagnosis and opt:
For
A treatment modality, you will have known by then what kind of person: The (patient you are dealing with.)

22. What type of pt you are dealing with ????
In a 5 year study I conducted about patient delay in presentation in Jordan:
Among the other results discovered we also noticed that :
There are only 3 types of patients

23. What type of pt you are dealing with ????
The strong patient: Asks about his/her disease and wants to know everything about his/her sickness.
He/She goes to the public library to search and read about his/her disease. Now they are using the internet which will give more than enough details.

24. The strong patient
The good thing about these patients is he/she brings to you the latest news about his/her illness.
Do not refuse to take these papers from him/her and read them or you can do the following:
Look at the article and say Oh Yes, I have read this article and I will read it again.

25. The weak patient The weak patient always asks about his illness like
1-“is it fatal, is there any treatment for it,
2-when I am going to die”
In this case, use your diplomacy in answering these questions.
You can fight this disease only with courage & co-operating with us.
FOR ALLAH’s sake do not tell the Pt. about the prognosis or life span.

26. The indifferent patient
The indifferent patient – she/he does not want to ask you
nor wants to be told.
He/she will do anything you tell, but deep inside them they know what is going on.
Be always serious but with a smile.
Don’t joke with patient..

27. Talking to patients at different times for different purposes:
First meeting - Give a smile and introduce yourself to the patient by saying your name and post . (Resident, Specialist , Consultant)
Show the patient that you are very much concerned about him/her.
Read the referral letter carefully and write a note on the new patient’s file.
Don’t undermine the referring doctor.

28. TAKING HISTORY
OK, I read your referral letter but I want to hear from you. What brings you here ?
Do not ask the patient using medical terms. Let’s start from head to feet.
Do not say – Do you have migraine, but say instead is your Headache on one side
Do not say – Is it regular or irregular, but say instead how often it comes to You.

29. TAKING HISTORY
a. Very gently tell the patient that you are going to ask some questions
b. Do not start with personal questions – as period in female, sleeping habits or
Night performance,
c. Don’t ask direct questions (Are u Alcoholic? Are you a heavy smoker) etc.
d. Ask about the age in very delicate way as when you were you born etc.

30. Do not say – Nostril, but you can say nose opening
Do not say – Haemoptysis, instead ask “did you notice red streaks in your saliva after coughing.
Do not say – I am going to examine your cervical regions and supra clavicular areas, instead say “may I have a look and feel your neck and the area above and below your collar bones.

31. Examination:
According to the case, i.e. if the patient is referred to you for a lump in the breast and you have asked her all the relative questions in simple plain words,
(do not say – Can I have a look at your breasts?. The examiner will tell you – come to see us back again next year…….caution).
Say, “now can I have a look at that lump”

32. Do not say – When did you start having shortness of breath or (SOB).
How on earth the patient will know our abbreviations, but you can say “when did you start feeling difficulty of breathing”.
Do not say – Trachea – but say your wind pipe.
Do not say – Oesophagus but say gallot
(or food pipe)
Do not say – Dysphagia, but say difficulty in passing foods through your Gallot.

33. TIP…..1 I cannot list all words, but my dear colleagues, remember
NOT to talk to patient in medical names or terms
Especially if you are being examined and the examiner is witnessing your history taking and patient examination.
The examiner will get irritated and may tell u come & see him again next year…….

34. TIP …..2 For example, if the examiner shows you a short case of Ca lip
Do not hesitate to ask the patient if he is a pipe-smoker
(so the examiner will take a good impression about you).
This is only an example. Always ask the Pt. relevant questions.

35. EXAMPLE
If you encounter a basal cell carcinoma on the inner canthus or else where
ask the patient if during his career or in holidays was continuously exposed to sun light.

36. Now you have examined the patient and you are thinking of a specific disease. Explain to the patient that you want to make some TESTS confirming results.
“I will ask for an x-ray of both breasts to compare and this x-ray is called Mammogram.
This will tell us a lot about that lump we felt”.

37. THINK VERY CAREFULLY OF WHAT U SAY: THE Pt. will memorize every word
You reached a diagnosis and you want to tell the patient what are you thinking of:
“Look, you have cancer, we are going to take your breast away – then you will receive chemotherapy which will cause you vomiting, tiredness, loss of appetite, hairloss and you may be prone to infections which might be very serious”!!!
All the above statements are brutal, inhuman and barbaric.
Oh, my God, you have just killed that patient.

38. BREAKING BAD NEWS
(Break bad news in nice words, so the patient will accept them and will have more confidence in you.)
In stead say: Both breasts x-ray showed a lump in your breast, then as you remember, we took a sample from that lump,
The cell report is back and talking about having some abnormal cells which do not follow your body’s rules and act on their own - by increasing size, or going to………..

39. other organs. The best treatment will be removing that breast followed by chemicals + radiotherapy.

40. Breaking bad news:
Suppose that your patient is 19 years old girl.
She has osteosarcoma of lower femur.
You have requested all work-up investigations and she does not have metastatic cancer elsewhere.
Your team chaired by a Consultant and other specialists have decided that the best way of management will be amputation.

41. The verdict.
Now the patient with her mum and dad are sitting in front of you waiting for the verdict.

42. Your can break the news in two ways and you tell me which one is better, if you were the patient.
“Look, you have nasty cancer in your Rt. Femur and needs above knee amputation (cut your leg) ….

43. Or you can say “I have bad news and good news for you (with a smile on your face)…..
You remember when we took a piece of your lump which was examined under the microscope and after that we all had a meeting together to decide about what is best for you..

44. You have in your Rt. Leg bone: a group of abnormal cells that do not follow your body’s regulations and behave on their own.
These cells together made that lump which affected part of your leg bone and the best treatment will be removing that bulk of bad cells before they start to spread elsewhere in your body……..

45. So there is an operation and after that your problem will be solved completely by our colleagues who are very expert in doing prosthesis!”

46. By now you have told her what is necessary and she and her parents got the idea of amputation (from in between the lines)….
then proceed in talking with a smile too. “So, my dear miss …. (surname only – don’t you ever break the doctor-patient barrier by calling her by her given name - Mary, Sue or whatever)

47. this operation is called amputation followed by injections of
chemical materials which hopefully will kill all the bad cells in your body and in the meantime you will be doing
physiotherapy and have
measurement for a similar leg prosthesis and you will be able to walk again and nobody will notice it.

48. The patient is a human being and she will ask you “Is there any other operation to save my leg”
What will you say,
“yes, there are many but in your case the good news is that al your tests have shown that this nasty lump (you can call it cancer if you want) has not gone to any other part of your body”, and she asks
“ what about chemical treatment, is it what they call chemotherapy with hair-fall, vomiting, being tired and feeling bad?”
“Yes, it is but now we have solutions for every problem

49. , so you will get an injection of anti-vomiting before each course,
you will be monitored during the treatment and if you have drop in the blood cells which are responsible for defense against infection.
There is another injection to raise them up.

50. Your hair will gradually start to fall so why don’t you go to the beauty parlor and have a marines hair-cut so you don’t feel bad when you see smaller hair coming out and …… 3-4 months after stopping this chemo, your hair will grow again,

51. mind you, you can wear a nice wig and nobody will notice that
mind you, you can wear a nice wig and nobody will notice that. Believe me, your gain by all these treatment options will be less than loss”
The girl – Can I think about it and take another opinion, doctor
The doctor – yes, sure by all means, your disease’s name in medical term is “Osteogenic sarcoma”. You can even visit some web pages in the internet and know even more about it.
By now, the girl and her parents will think that you are the savior

52. Guidelines for effective communication:
Ask what the patient has already been told and establish the level of understanding for further discussion.
Avoid Jargon (e.g. prognosis, adjuvant)
Avoid euphemisms (misbehaving cells) after you are 100% sure of the diagnosis – say this lump also is called cancer.

53. Avoid closed questions (i. e
Avoid closed questions (i.e. those which are answered with yes or no, open ended questions)
Involve the patient in decision making.
Don’t tell the patient (“do you understand”).
but (e.g. “tell me what you can remember of the things, I have said”)
The next of kin person may ask you to withhold information (please do not tell him).

54. Tell them:
All information about test results is primarily the property of the patient.
I will respond to the patient’s questions with honest answers.
I will not force unrequested information on the patient.
If the patient does not ask, I ill not tell.
Give the relatives to understand that most patients realize the gravity of this situation from in between the lines and withholding information will lead the patient to sense of isolation.

55. The angry relative may be having anxiety or fear or as a method for gaining attention.
Do not respond to anger with anger
Calm the situation down by being pleasant an express a desire to help.
Point out that you want the best for the patient

56. Tips for the exam
Warm the stethoscope before using it over the patient’s skin.
The examiner will not like you if he notices that the patient says “your stethoscope is cold” !!!
Always talk to the patient about your next step during the examination.
Do not joke with patient or with the nurse during and after and throughout the whole visit.
Listen to the patient carefully and let him/her understand that all your attention is in the patient himself/herself.

57. Tips for the exam Do not do any extra move during examination.
Always use the 3 Golden Rules of (never) during examination of a lady.
Never examine a lady in the presence of her husband if there is no female nurse at that moment.
Never examine a lady in the presence of male assistant.
Never examine a lady alone, always have a female nurse with you.
Good Luck.

58. GOOD LUCK
THANK YOU

59. THANK YOU