It was the day before Labour Day and the clinic was exceptionally crowded. The work week had been shortened because of the public holiday. As patients on chemotherapy had been scheduled for their consultations and treatment according to planned treatment protocols, it meant that we had to squeeze more patients than usual into each working day in that week.
The waiting time was very bad that day. I trudged along at my usual pace, refusing to be distracted or rushed by the crowds. Most of my patients are familiar with the waiting time. Time and again, I have explained the importance of me spending as much or as little time as each patient needed, depending on the complexities of the case and needs of the patients.
Some patients spend barely five minutes in the room as they come for their routine follow-up and all is well. Other patients could end up taking up to an hour, it there were problems that needed to be addressed.
On that day, I thought things were running pretty smoothly. Most of the consults were straightforward and there were no major issues or crises.
The zen in my room was broken by loud shouting in the waiting room. A patient in her 60s, whom I shall call Mrs Dewi (not her real name), was screaming at the counter staff. In my 18 years of private practice, I have never heard such shouting in my clinic before.
My distraught staff came running into my room to say that Mrs Dewi was unhappy about the long wait.
I first met Mrs Dewi nine weeks ago. She presented with abdominal discomfort and was diagnosed to have Stage 4 stomach cancer. The PET-CT scan had showed a thickened stomach wall with spread of the cancer to the abdominal lymph nodes. More importantly, almost half the liver had been replaced by metastases.
Clearly, the cancer could not be cured. But it could be treated. Mrs Dewi was reluctant initially to have treatment but after lengthy deliberation, she decided to proceed.
Cycle one of chemotherapy went well. However, she was unhappy after the second cycle – she felt that the nurse ignored her concerns that her arms felt cold during the infusion of intravenous fluids.
She complained that her left leg was also aching and blamed it on the attending nurse.
When I examined her leg, I noted that the left leg was slightly more turgid than the right. I explained to her that she could have developed a deep vein thrombosis (DVT). DVT is often described as “economy class syndrome” as it can occur in passengers who have not moved their legs for long periods on flights. The sluggish flow of the blood leads to the formation of blood clots in the legs.
In cancer patients, this can happen because cancers can cause the blood to be stickier, thereby resulting in blood clots in the legs.
These clots can migrate to the heart, leading to a pulmonary embolism (PE) – when the clots block up the vessels leading from the heart to the lungs. The patients often experience shortness of breath, chest discomfort and may even die suddenly, just as in a massive heart attack.
We did a Doppler ultrasound of Mrs Dewi’s leg – and indeed it was DVT. I started her on a blood thinning injection (to make it less sticky) and by the next day, she felt better. I made it clear to Mrs Dewi that the DVT had nothing to do with the nurse or the infusion.
I explained the need to place a filter in the abdominal vein, called the inferior vena cava (IVC), to prevent any clots from migrating to the heart. She agreed to have the procedure, but wanted it done back in Indonesia.
When she turned up for her third cycle of chemotherapy, I was shocked that she did not have the IVC filter and had missed her blood thinning injections.
I spent a long time explaining the dangers of DVT. In the end, she had the IVC filter done in Singapore. Everything went well.
On that day of her outburst, she was scheduled to come in for review of her post-treatment PET-CT scans. When I heard the shouting at the reception counter, I immediately called her into my room. Before she came in, I quickly reviewed her medical records and PET-CT results.
Despite her shouting outside, Mrs Dewi entered the room with a broad smile and a friendly greeting.
I showed her the PET-CT pictures and explained that she had responded very well to the chemotherapy. Almost all the cancerous lesions had disappeared.
I was elated at the results, but also dismayed at her behavior towards the nurses. I explained to her that her behavior in the waiting area was unacceptable. I went on to prepare a medical report detailing the treatment that I had given her and explained that I could no longer continue to look after her.
To be honest, as I reflect on my decision to discharge her from my care, I question whether I made the right decision. Till today, I am not sure.
Part of me tells me that I should have just carried on my duties as a doctor. The other says that once that special doctor-patient relationship in broken, it is better for both parties to part company.
My wife, in her usual wisdom, reminded me that I should also watch how I behave myself. In his May Day message, Mr Lim Swee Say, Secretary-General of NTUC said, “We must strive to be a nation of better customers and better people”.
Indeed, behaving well to one another is reciprocal, but should a doctor’s care be non-conditional? I have long told myself that part of medical care is to be able to withstand any emotional or physical weight that patients place on me.
Does that include tolerating poor behavior in my clinic, towards the nurses and causing distress to other patients? This is a question which I answered in haste on May Day, but one which I continue to ponder on today.
Written by Dr Ang Peng Tiam