It's all dynamic and fluid.

Angry Doc's recent post inspired me to write an entry. http://angrydr.blogspot.com/

In particular the part about a doctor diagnosing appendicitis reminded me of a problem which many patients and people in Singapore take some explaining to in order for them to understand.

Most Singaporeans think of the doctor as a "God" or "deity". They ask pretty impossible to answer questions. Now I totally understand this, because as a child and as a teenager I used to think doctors would know the answers to those questions too. And believe me after entering and exiting medical school I was a tad bit disappointed that there is still so much mystery with regard to the human body and disease in general. There is much more we DO NOT know than what we DO KNOW.

Anyway let's talk about appendicitis first. The reason why appendicitis is difficult to diagnose and treat is because of 2 main reasons. In my opinion the first reason is that the treatment is surgery - an appendicectomy. Now it's not the operation is difficult and dangerous, in fact it is pretty straightfoward 90% of the time (and I have done many myself as a surgical trainee), but really that hey it's a FREAKING OPERATION! You get a tummy ache and the doctor says you need to be admitted, stay in hospital and have a surgeon put you to sleep and cut open your abdomen and cut out a piece of your gut! Come on, it can't be that bad right?

Well, you're wrong, a ruptured inflamed appendix can kill you. Dead, finished and buried.

But how does an appendicitis present? And this is the second reason; that the disease progresses from an initial mild presentation to a mroe serious one later and thus it depends on when the doctor is checking you for him to make his decision that you need surgery. Well in the early stages, just like any tummy ache, pain in the abdomen. It could be really quite mild at the start and indistinguishable from other milder causes eg constipation colic, gastritis, urinary tract infection etc.

Are there any investigations to confirm or exclude it? Well the closest is probably a CT scan. But you won't find those in a GP clinic and neither do they come cheap. And even then they can be inconclusive.

Face it, many patients who have "classical" signs of appendicitis get admitted, stay for 24-48 hours and sometimes get better! Then the surgeon discharges them. And these patients would go "What the heck was all that for?"

But you see, the disease is dynamic. At the start you have maybe just some slight central abdominal pain, and then it may get more severe and localize to the right lower abdomen. But it doesn't always happen in all cases after a specific set time. Some progress faster, some slower, some rupture earlier making you a lot more sick and dangerously ill and some are just damn resilient and don't rupture, thus buying you more time.

Which is why patients are still admitted for observation and regular checks by the doctor to see if symptoms and signs have progressed and then make decisions for surgery.

The key word here is regular checks by the doctor. We garner far more information regarding the trends and changes in parameters about ANY disease than at just one single consultation.

Eg Fever trends. Those that go up and up and up vs those that go up and down and then up and down. Blood pressure is the same. So is blood glucose (diabetes) readings. Think which gives you more information, a photograph of an event or a video recording?

But our system and culture in Singapore doesn't work like that. Doctors are expected to make one single "definitive" decision when you see them. Think making a big decision like cutting you open based on a photograph or a very very short video.

Which is why we tell patients to come back when if they are not better, or to go to the A&E if certain symptoms develop etc. It's a very important part of the consult when the doctor tells you that.

It's not that the doctor is lousy because he is unsure, inexperienced or too young but that he is being professional and honest with his patients. Unfortunately most Singaporeans would think of the former. Hence many doctors have developed a "minimalistic-communicative" style of consult. You go in, the doctors checks you and out you go with the medication or referral letter to the A&E.

Personally I feel communication is the key between patient and doctor for things to be clarified. Mutual trust and respect is also important. Patients and their relatives have to take some role in the care of the disease at least in monitoring it. Personally if I find patients or their relatives extremely anxious and repeatedly asking if they should take their loved one to the hospital, I'd recommend they go to the A&E straight away no matter how unlikely the condition is deemed to be dangerous or how sure I am of it.

Most of the time, that's what they want to do anyway, they just want a doctor to reaffirm that it's the right thing to do. And why isn't it the right thing to do? It's always good to be safe than sorry right? Then you have those who are serious and don't want to go to hospital, but that's a whole different story.

I recently had a patient come see me and then complained that there was another GP who had seen his uncle twice and never recommended that he go to the hospital, even when they asked him. He thought that they needed the GP's "permission" to take the uncle to the A&E. They subsequently did bring him to the A&E on their own, where he was admitted and subsequently died in the ICU after a week.

The patient could not tell me very much details (aside from a lot of cursing of the GP). I gathered that the uncle had been weak, later jaundiced and died of multiple complications and was found at the hospital to also have TB (dunno which organ site).

Now I dunno about other doctors out there, but it sure does not sound like it was a simple straight foward case, what with TB being mentioned in there. (For lay men : TB does not always present as people coughing coughing and then cough blood. It can affects various systems and is a very slowly progressing disease)

Anyway I told the patient that I could not really comment on the doctor's medical decisions but I would say that he should have been more communicative and discussed more with him rather than as he claimed "kept quiet". I also told this patient that in future, if he comes across a doctor (including me) who he disagrees with, please question and express his views. If the doctor (including me) is dismissive and uncommunicative, then change doctors, and seek a second opinion. If he feels he wants his relative to be admitted or seen at the A&E, just go directly (there is no need for a doctor to refer you to the A&E, you can walk right in) regardless of what the doctor says.

As a parting shot, I once had the head of emergency medicine in a hospital tell me that many times in his career he has made decisions based solely on "gut feeling" and found to be right. In most of those cases, if he had failed to do so, the patient would have died.

There is a joke : "Your doctor may claim he is God. But God has never claimed he is your doctor"

That could not be more true!