Dealing with a Celebrity 1



Years ago, after I returned from Canada fully trained as a urologist, I set out to practice independently. Young as I was, I was very enthusiastic, but was obviously immature. Those were emotion-filled days of youth, of exuberance, of hope and, of course, to a certain extent of naivete too. Once I found myself in a very delicate situation out of my own doing. In trying to protect my patient from an emotional trauma, I, in fact, lost the trust of my patient.

Mr H came to me with a problem of urinary obstruction. After examining him per rectally, I felt the prostate gland did not seem quite normal. It appeared to me to be a definite case of malignancy, at least clinically. However, for a confirmation, I ordered a number of investigations, all of which confirmed my initial diagnosis: cancer of the prostate gland. Mr H wished to know what his problem was to which I replied that he had an enlarged prostate and that it was a common occurrence in men of his age (he was in his seventies). I also told him that a few more investigations were necessary to decide the line of treatment.

The elderly gentleman was extremely cooperative and subjected himself willingly for further investigations. The reason for my telling a white lie at that stage was that no surgeon likes to impart an incomplete information to his patient or to his relatives, especially when he is suspected to be suffering from a dreaded disease like cancer. Such premature information without doubly confirming the diagnosis can at times unnecessarily create a fear psychosis in the mind of the patient.

In the case of a prostate, the best method to confirm the diagnosis is by doing a prostatic biopsy, that is, removing a tissue of this gland and sending it to the pathologist for confirmation of the malignancy. Sure enough, the biopsy tested positive for malignancy in the case of Mr H. The other blood tests and X-rays of the bones had already alerted me not only about the cancer but also of malignancy of a terminal nature where nothing positive could be achieved by operation.

I informed his family about the nature of his disease and they accepted the sad news calmly. They did not betray their emotions to Mr H. Since surgery was not contemplated I decided to discharge Mr H in a couple of days. When I went to his room to prescribe the necessary medications, he caught my hand and said: "Dr Phadke, may I have a word with you?" and then requested his family members to leave the room. He wished to be left alone with his doctor, After making sure that the door was shut and there was nobody eavesdropping, he looked deep into my eyes and said: "Dr Phadke, please give me an honest answer. Am I suffering from cancer? I did not ask you this question earlier since various tests were being performed on me. But if it is so, 

Please tell me the truth. I have  lived a full life and I am mentally prepared to die if my time has come”.

Here was an understanding patient who in all earnest trusted his youthful doctor and wished to know the truth. Bing then a novice in the profession I had not faced such a situation earlier. I was worried that the old gentleman would break down completely on hearing the diagnosis. Despite his request to know the truth, I lied to him with supreme confidence, saying that he did not have cancer and that he would soon be well under my treatment. But even while I was talking to him I was feeling uncomfortable under his searching gaze. Without saying a word more, Mr H turned over on his side to face the wall. He had turned his back on me, literally! 

I felt foolish. Nothing can be more embarrassing and humiliating to a surgeon than to lose the trust of his patient. Yes, I knew my patient had seen through my game and had lost all confidence in me. I also knew that he would not thenceforth trust me for anything. I was a sad man when I left his room.

Similar situations kept cropping in my practice at regular intervals and I must say that I have learnt a lesson or two from them, although they were not without the accompanying embarrassment. Today I have reached a stage where I understand a fair amount of the patient's psychology. A patient who willingly gives himself in the hands of his surgeon does so because he has immense confidence in his surgeon and, to my mind, he has the right to demand an honest appraisal of his health from the doctor. Of course, a surgeon need not divulge it unless convinced about his diagnosis, but once the confirmatory tests are done he is morally bound to discuss them with, if not the patient himself, then certain y with the patient's relatives and if the patient demands, he too should be informed. There is no need to keep him in the dark. 

However, there are patients who do not have the courage to face a situation when a cancer diagnosis is announced. I have seen some who have felt devastated and lost the will to live. In such a situation, I now make it a point to call the relatives and explain to them the entire proceedings in addition to the nature of the patient's disease. As they are more conversant with the patient's psychology, I ask them if they themselves wish to convey the information to the patient or whether they wish me to do the job. Very often there is an unnecessary fear in the minds of the doctor and the relatives that the patient may take the news badly when the reality can be quite the contrary. Some patients turn out to have a very philosophical bent of mind and accept the bad news with equanimity and are, in fact grateful to the surgeon for letting them know the truth Half knowledge is always dangerous and rather than let the patient learn about his illness from some ignorant source, I now prefer to take an honest and direct approach in my dealings with the patients. The entire relationship between a patient and his doctor is based on mutual trust and nothing should be done to belie this trust.

Most Indian patients are a forgiving lot, more so when they are convinced about the sincerity of their surgeons. Their age-old culture has taught them to accept a doctor's human failings and they do condone the physician inadvertent lapses with an unparalleled grace. I faced another extremely embarrassing situation when Mr S an industrialist of high repute, came into my life as a patient. He came all the way from Indore and was referred to me by my teacher Dr U.K. Sheth for some urinary complaint. On examining and investigating him, I found him to have an enlarged prostate which was responsible for the urinary problem. I recommended surgery for its removal and Mr S accepted my decision without any reservation.

During the initial part of a prostate surgery we always inspect the urinary passage, the prostate and the urinary bladder through an instrument called the cystoscope, a kind of telescope, one may say, and the procedure is called cystoscopy. It enables a urologist not only to confirm his original diagnosis but a concommitant pathology like a tumour, stone etc. can also be visualised. In the case of Mr S, this revealed an enlarged prostate but in addition it also revealed a small growth in his urinary bladder which to me appeared suggestive of a malignant tumour. This growth had obviously nothing to do with his original symptoms and at best could be called an incidental finding. However, in order to allay my suspicion, I excised the small tumour and sent it to the pathologist for his review and then proceeded with the prostatectomy, that is surgical excision of the prostate gland, Mr S had an uneventful and rapid recovery. Just when he was relieved of his urinary symptoms and was extremely happy with his p gress came the biopsy report from the pathologist. It stated that the prostate gland was benign (non-cancerous) but the bladder growth which incidentally removed, was cancerous.

Mr S and his entire family were distraught on getting this unpleasant information. They soon forgot about the nice operation that I had performed and were now naturally anxious about the new intruder in his body. In confidence Mr S told me that he had chalked out various plans to expand his business and felt sad that now all his hopes and aspirations would come to nought. Not even in his wildest dreams did he suspect that he would ever get cancer, he said. But now that destiny had been so unkind to him he wished to know the exact course the disease was likely to take. He had a number of queries, and rightly so, as he had to make alternate plans vis-a-vis his family and his business. All the thoughts of All the thoughts of had to be banished from his mind, he felt. He kept asking me repeatedly whether I had removed the growth completely or not whether it likely to recur, what was his expected life expectancy and many such questions. The patient's life was totally thrown out of gear, In order to pacify him, I painstakingly explained that we, the urologists come across many patients who get completely cured of a bladder malignancy it is treated at an early stage. I also advised him about the need to undergo repeated cystoscopies to check if the disease had recurred or spread. However my explanation at best was a generalisation and I also warned him-as a matter of fact we warn all patients—that this may not hold true in each and every case. Most patients accept this explanation in the correct perspective and hope for a favourable outcome. So did Mr S.

I spent many sessions with Mr S and his family trying to build up their morale and at the same time taking care that I did not give them a false sense of security, a false hope. Gradually they recovered from the trauma and accepted the verdict in the right spirit. During their traumatic experience I was drawn very near to them emotionally. Mr S was very courageous, had fantastic business acumen and moreover had a very positive approach towards everything. He earned my respect and admiration. What had started off as a professional relationship between a patient and his doctor soon grew into a strong emotional bond. There was mutual trust and admiration-two ingredients very necessary for a satisfactory relationship. Mr S and his family finally agreed to my suggestion that they Visit Bombay every few months in order to have a check-up and after this advice, they returned to Indore. 

About a week or ten days later, Mr S called me from Indore and said that he was doing fine so far as his recovery was concerned, but that he had a surprise in store for me. And what a pleasant surprise it was! He had apparently sent the histological slides of his tumour to the United States for a second opinion and an internationally reputed pathologist had opined that Mr S did not have cancer at all! According to the American expert, Mr S in fact had a simple, innocent tumour in his bladder which I had effectively removed during his prostatectomy. The expert added that Mr S need not go for any more follow-up visits to Dr Phadke and that Mr S may well forget about his cancer-that it was a closed chapter!

After listening to Mr S, I too was relieved and felt very happy for him. At this, Mr S said: "Dr Phadke, I too am relieved, but the mental torture and agony that I went through was so immense that I wonder if I can forgive the pathologist who had so confidently given a wrong diagnosis". He then added, after a brief pause: "In fact, some of my friends are trying to persuade me to sue you and your hospital too!” I listened patiently when he added: "Dr Phadke, I silenced my friends by telling them that I have developed such a wonderful friendship with my doctor that I cannot sue him even in my dreams!” What better evidence can I produce than this to show how forgiving our people are inherently? Leave aside the poorer section of our society who do not have the financial backing to file suits against the doctors; even the literate and affluent of our society display a tremendous amount of magnanimity when inadvertent lapses occur on the part of their doctors. This is meaningful in building the right kind of doctor-patient relationship and in inspiring a doctor to work fearlessly and untiringly for his patient's well-being. I understand that in the United States, doctors face litigation in such cases at the drop of a kerchief. Are we then not fortunate to have such understanding patients? Are we not, then, morally bound to give of our very best professionally?

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar