A Doctor’s Point of View on the Doctor Patient Relationship

I recently did an interview on the doctor patient relationship. Here I reproduce just a small part of it.

You can read the whole interview on Multiple Sclerosis Central.com by clicking on the following link.

http://www.healthcentral.com/multiple-sclerosis/c/73302/70302/patient

I have asked Doctor Nitin Sethi to contribute to this discussion through an interview about this very topic of the doctor-patient relationship.  Doctor Sethi will discuss this relationship from a doctor’s point of view and in part two of this series we will examine the same relationship from a patient’s perspective.  The patient will be me.   I do encourage you to offer your viewpoints through the form of comments to these articles.

 

I introduce to you:  Nitin K Sethi, MD who is the Assistant Professor of Neurology at New York-Presbyterian Hospital of Weill Cornell Medical Center located in New York City.

 

What do you feel are some of the personal qualities which are important for a doctor to develop rapport and trust with patients?

 

A lot has been written about doctor patient relationship and what qualities define it. Nowadays in medical school itself there is a thrust not just to produce smart doctors but also to produce more humane doctors. A study had shown that student doctors (medical students) have the highest levels of empathy. As they go through their long training (residency and at times fellowship), this empathy progressively decreases. One may argue that “experienced” doctors become less humane. I do not buy that argument. I feel the empathy gets replaced by knowledge. You know what you are dealing with and you understand disease pathology better. This might make a doctor sound aloof and like a “machine”.  He is very good at what he does but he is cold and aloof.

 

My patients frequently tell me that they left their previous doctor because he would not hear them out or he was not caring enough. They rarely say I left him because he was incompetent. I want to make this point to answer your question. Some of the smartest doctors I know (people I would go to if I had a neurological problem) do not have the greatest bedside manners. They are not most suave. But as a patient I would rather go to a competent doctor than to one who says all the right things in the right way but is not the smartest light.

Hypothermia and Brain Arrest Protocol

Hypothermia and Brain Arrest Protocol

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Recently I attended the American Academy of Neurology (AAN) annual meeting held in Seattle. One of the topics of interest was the use of hypothermia to improve the outcome of patients after cardiac arrest or traumatic brain injury. Since the neurological outcome of patients presenting after a cardiac arrest (whether in hospital or out in the field) is usually dismal, I thought this shall be a good topic for me to discuss here.

The brain needs oxygen to survive and does not do well if deprived of oxygen. Hypoxia (lack of oxygen) occurs after cardiac arrest (the circulation of blood to the brain is interrupted when the heart stops beating as occurs in a cardiac arrest). If the circulatory flow is not rapidly reinstituted (meaning the heart is not restarted) irreversible neuronal death ensures.  The usual scenario is as follows. A patient suffers an out of hospital cardiac arrest. A call goes out to 911. The EMS team is on the scene shortly. The patient is noted to be either in cardiac arrest (we call this asytole) or the heart is beating but ineffectively and there is no palpable pulse (we call this ventricular fibrillation). The heart is revived by either injecting drugs or shocking (with the help of a hand held defibrillator) and there is return of palpable pulse. Alls well you might say but the story is far from over!!!

Even though the heart has been revived the brain has taken a hit. During the time when the heart had stopped, there was a lack of blood flow and oxygen to the brain and irreversible neuronal death has occured. So we have a patient whose heart is now beating but the brain is dead. This patient may never make a meaningful neurological recovery. Some of these pateints end up in persistent vegetative state (PVS) or minimally conscious state (MCS).

By the time, I as a neurologist am called to see the patient, there is precious little I can do. The brain is already dead!!! I can just prognosticate and tell the family that their loved one shall never have a meaningful neurological recovery. In other words, I help them in deciding when to pull the plug!!! Nothing makes me feel more helpless. I did not enter neurology to prognosticate, I entered neurology and medicine to save a life and heal.

So that is why hypothermia for cardiac arrest sounds so promising. Recent studies have shown that if the brain is cooled (there are different ways to cool the brain from using high tech cooling blankets and beds to more primitive but equally effective techniques like bags of ice) to 32-34 degree centigrade for 12-24 hours following cardiac arrest, neuronal death does not occur. Till the heart is revived, the brain remains viable!!!

This research has led to the institution of a Brain Arrest Protocol in some big academic centers. Once a patient who has suffered a cardiac arrest is received, hypothermia protocol is immediately instituted. This has resulted in improved survival rates in these critically ill patients. Patients not only survive but they survive with good neurological outcomes.

If the hypothermia is prolonged or if the temperature is lowered too low it can cause complications and increase the risk for sepsis and cardiac arrhythmia. Hence this protocol is at present still in its infancy but I have a feeling this shall become a standard of care very soon.