Dr. YK Amdekar details on the necessary steps a doctor should take when a patient does not recover as anticipated and how to communicate such news with patients and their relatives.

Medicine is a science of uncertainty and we doctors act by probability supported by knowledge, experience and even an intuition. Naturally it is important to convey to a patient that best efforts are guaranteed but not equatable to best outcome. However, it does not mean that you paint a gloomy picture each time to be defensive; it may fire back.

What is important is to anticipate, inform, counsel, and document. Be honest and don’t hide mistakes. To err is human. Be answerable to yourself and do not blame others.

What is the meaning of getting well?

To a patient, it connotes total recovery back to his/her original state of health. To a doctor, it refers to recovery to whatever extent possible depending on multiple variables such as type of the disease (curable, controllable, or incurable), stage of the disease (early or late diagnosed) and response to standard treatment if available (response also depends on individual patient’s health and immunity). In other words, “getting well” is as per the expectation – patient expects total recovery and doctor expects what is best possible in a given situation.

Doctor must anticipate progress

Once final diagnosis is achieved and standard protocol of treatment is defined, a doctor must make time-wise anticipation of expected progress, considering variables related to disease and health status of the patient. Time to time assessment during treatment period would ensure that a patient is progressing as per anticipation. In case of any deviation from the expected course of events, the doctor is warned about likely change in management that would again ensure necessary correction. Such anticipation is important as much are the correct diagnosis and treatment.

For example, a patient diagnosed to have acute bacterial pneumonia is expected to show improvement of tachypnoea first, within 2-3 days followed by reduction of fever over the next few days and cough which may worsen for a while at that stage before it resolves completely over the next few days. Such anticipation would not worry a doctor and in turn a patient, even if the cough worsens as it was anticipated as a course of right direction of recovery. However, if fever is reduced first and tachypnoea persists, your antenna should go up to trace the cause. Similarly, first symptom to improve in correctly treated typhoid fever is the feeling of wellbeing and return of appetite and the feeling of the abdomen improving, even though the fever may continue to be high at that stage. So even though the patient who has sought treatment for fever feels he hasn't gotten better, the doctor would know that recovery is on the right path. Such is the importance of anticipation of course of events during treatment.

Need to counsel and document anticipated progress

Not only is it enough to know the diagnosis, treatment and prognosis or anticipated progress but, it is equally important to counsel the patient and document the same for records. Every doctor must develop the skill of counselling and make a habit of documenting patient treatment. It signifies honesty, transparency, accountability, and responsibility.

It instills faith and mutual trust that has a positive impact on outcome. As discussed above, the patient must be informed about the best possible outcome which may change over a period of treatment because of many variables. At times, the patient may not be happy with the best possible outcome. In such a case, if the patient is well informed about it, problems don’t arise as he has a choice to seek another opinion.