Don't

In my mentor's blog, he discussed why we should not lay down written rule "Do Not Do Thing X," such as "do not kill your patient," "do not chop off your patient's head," "do not use four-letter words in front of your patient - and being heard!"

And so on. Imagine a manual for doctors or adults with an endless, often ghoulish, list of "don'ts."

With a creature as complex as grown-ups, it's easy to forget that sometimes the most effective rule can be learnt from the kids. I've been reading about applying neuro-linguistic programming in bringing up our children. Among the rules I learn, perhaps the most useful one is never say "Don't" in front of the kids. It seems that it is hardwired in human DNA to shout "don't do so and so." We will scream with outrage at the kids, for instance, when they're fighting, "Don't hit your brother!"

Every second spent shouting "Don't" is, in fact, a second taken off your life. Not that kids don't listen. But they simply pay attention to the phrase followed by the word "don't." That's how our brain works out what words mean. As every parent can attest to, the kid would then follow religiously the hypnotic suggestion "to hit the brother." Our tendency always is to hear the action but not the instruction "Don't," and positive instruction puts a helpful brake on this. In other words, we can rephrase the negative command "Don't hit your brother" by "Help your brother to finish the Lego."

Every second spent being positive is a second added on. Always the truth, from the alpha to the omega.

Birthday

It's almost instinctive – you count the number of candles on the birthday cake, and you start to gauge the age of its owner.

Which makes perfect sense. I should have forty on mine yesterday. With time, I learn to tell my friends that chronological age has nothing to do with one's real age. During the lunch conversation yesterday, my friend didn't believe that I remain young, and then looked me straight at a scar on my face.

Before she asked, I knew she wanted an explanation or the story behind it. I smiled cheerfully. "Oh good," I said. "My daughter is getting more energetic and charges ahead boldly. She waved her hand and scratched my face few weeks ago. You know, a nine-month-old has literally great leaps of faith, causing wounds here and there. Five minutes after the tenth topple, she's ready for number eleven."

"True. A kid's wound heals and vanishes quickly, unlike yours," my friend reminded me. "And perhaps that is the difference between Jasmine's wound and her father's scar. When you're no longer young, the wound lasts."

Reaction

If outsiders had to describe mistakes in medicine, they might use words like reckless, thinking of the seemingly endless stories of poor patients who suffered. Or, if they read the local newspaper, they could call it unacceptable, with a nod to the call for disciplinary action. Who could possibly object?

Actually, lots of people. After a recent headline story highlighting our loss of a patient's life in the hospital, there are some, of course, who seriously blame a doctor who prescribed too low a dose of anticoagulant drug supposed to prevent the dangerous blood clots that can travel to the brain, causing stroke. That is, broadly, the usual reaction from the mass media. But one important fact is left out of the scene – and that is the image of doctors. When people are being asked to say which professionals deserve the most respect, they usually put doctors at the very top of the list, way above clergymen and lawyers.

We agree that doctors are no longer free to practice away from the cruel scrutiny of the news media, not to mention the constant erosion of the trust in doctors. Admittedly, their biased emphasis can make it look like a nefarious crime scene, accusing doctors of having "committed the worst blunders, if not murder." I know, I know, that's disheartening. But let's think about how our patients – not the mass media – react. They are forgiving, if you ask me. In a way, we're fortunate to work with the growing realization that doctors are fallible. And that's why doctors are more open to our own mistakes. I'm one of them.

I will never forget the forgiving look on the face of my kidney transplant patient who nearly died because of my mistake. It all started with my prescribing him allopurinol, a pill supposed to work for his repeated attacks of gout. But I forgot the precarious drug interaction between allopurinol and another medication that he had been taking after the transplant. Because of that, the work of his bone marrow came to a halt and the number of his white blood cells dwindled to a dangerous level. This was only picked up by my colleague few months later. My patient was simply told that he wasn't tolerating the medication; there was no mention of medical mishap. My first instinct, after hearing what had happened, was not to sweep the mistake under the rug. I called back my poor patient and told him everything, I mean, my careless mistake. This may seem impossibility, but it is true, and he accepted my apology. He reminds us how far we've come and how lucky we are.

What's Wrong

One day, while discussing the mystery of our patient at the hospital corridor, my colleague who has a passion for automobile mechanic cautioned, "Oh man. If we want to be honest, let me ask you how many times are we doctors certain with what's wrong with our patients?"

Slushy nonsense? Not a bit of it! For some reason I'm amazed at his cruel and frustrating (though certainly true) statement. Consider an eightysomething man who came to the hospital with a bit of cough and not in his usual shape. Each numerical figure in his laboratory results was not very normal, but not too bad. At the end, for the hundredth time, for the thousandth time, the diagnosis, often loopy, would be a chest infection. It's hard to imagine any better diagnosis to be typed in the discharge summary.

Which brings me to the analogy of an auto mechanic, this time attributed to David H. Newman. Consider going to an auto mechanic about an unsettling sound coming from the car. The mechanic also suspected something (but not sure which) wrong. He then shrugged and produced a pair of earplugs - alas, quite similar to what we prescribe - and said, "Wear these while you drive."

Mechanic

"An auto mechanic's job is no different from a doctor's." That's a fair comment from a colleague of mine during dinner.

To pursue the mechanic analogy, he enthused, "Think about it. We were told the symptoms such as acute diarrhea or cramps, which are presumably external signals of a diseased or malfunctioning organ. A doctor examined the faulty organ whereas a mechanic rummaged around under the hood, figuring out a list of hypotheses to be tested one by one. Sooner or later, we're zeroing in on the ultimate problem. Case closed."

Tempting it is to think that such analogy is a true statement. That's not the right way; really, if you ask me, wrong. To say that a doctor can solve a problem under the hood, as what a mechanic does, would conjure up the image of physicians or surgeons who never talk. For goodness' sake, have you heard a mechanic talking to the automobile engine, "Good morning, how is the day?"

The problem isn't that the auto mechanic needs to talk, it's that a patient is simply different from Mercedes-Benz. A sick engine never responds to soothing voice or empathetic nod; our patients will. And the effect is riveting.