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On the last day at Hospital Manjung, I learnt an extremely important lesson about taking time to listen.
In 3rd year, clerking in OnG ward works like this:
- You clerk the bed you’re assigned to, meaning basically history taking and physical examination. Find out their complaint, describe it in detail, and take down other histories such as antenatal, previous pregnancies, gynaecological, menstrual, past medical, past surgical, family, drug, social history. It’s basically a long list and can take up to an hour sometimes to clerk in detail. Do it together with examining the patient based on their complaint, to confirm your diagnosis and exclude differentials.
- It doesn’t matter when you clerk your case. Whether it’s the night before or just the morning (in case there were new patients who just came in), you MUST have your bed clerked before you have class. and this cycle happens everyday.
- Then, we’d present our case to our professor. This one particular morning, he decided to go for rounds. So he would choose any bed at random and ask us to summarize the history and present relevant information. If you didn’t clerk your patient, in short, you’d be dead.
830pm, I went to the antenatal ward and saw a patient at my assigned bed. She looked tired and very stressed and another lady, who I presumed to be her mother, was sitting beside her. They were talking quite heatedly in Tamil. I approached the patient immediately and asked if I can clerk her (the idea is if you don’t clerk, you’re dead). She gave a quick nod and I started my clerking immediately. Things like, “Why did you come to the hospital?” and the details that follow. As I continued my clerking, I noticed that she gave me very short answers and was very much distracted. Her mother suddenly stood up, walked to the counter and gestured for a medical officer (MO). An MO came to her bed and the patient said to the MO (in malay of course), “My mum wants to confirm what the specialist said.” And the MO explained. I didn’t catch much because I didn’t know the case beforehand but what I did find out was that she had to choose between a normal delivery or a C-Section, both of which had risks. I can see that even if I clerked her that night, she wouldn’t be able to answer since she was very much stressed with the decision that she had to make. I thanked the patient and walked away.
Sometimes we have ‘difficult’ patients who, when we clerk, refuse to talk to us or reject us immediately. Sometimes we have ‘easy’ patients who, even without us having to ask so many questions, they volunteer the answers and even tell more than what we ask for. This particular patient, she wasn’t a ‘difficult’ patient. She was just in a huge dilemma.
Next morning, 730am I arrived in the ward, as we all normally should. At 830am, we would have to present the case to our professor if he randomly chooses our bed. I only had less than an hour to clerk the full history plus come up with differentials, rearrange it and present it properly. All this, together will building rapport, and I wasn’t even sure she still wanted to be clerked, after being under a lot of stress.
Normally when approaching a patient, I ask general questions like, “Have you eaten? How’s your pain? Is it still there?”. But this time, somehow, eventhough I had only one hour (which would probably have been just right to clerk a full history), somehow my heart told me otherwise. I was once told that doctors nowadays don’t have time to look at patients, don’t have time to be humane, and I don’t blame them sometimes because they’re super busy. But this time I decided to drop being a student doctor for a while.
I approached her bed. She was lying on her side, staring at the curtains, but thoughts very distant. I closed my clerking notebook, crouched next to her bed and said quietly, “You must be very stressed right now.”
She glanced in my direction, then stared at the curtain again. She kept silent for a minute, then nodded, “Yes, I am. If I deliver normally, it would carry a lot of risks. Even if I do it through operation, there would still be a lot of risks.”
I nodded. After a while, I asked, “Where’s your mum? Is she coming today?”
She smiled. “My mum is at home. Yesterday it was her birthday. We were supposed to have a big family dinner. But since I got sick and was sent to the emergency, she came with me and she didn’t celebrate the dinner. All my siblings were there. She loves me. I’m her only daughter.”
It was like... I had found the right key and unlocked the tightly bolted door. She opened up and talked to me. She talked about her work, about how her sleepless nights and extra work was what was possibly causing her headaches. She talked about how she was worried that no one would be looking after her 5 children. About how her eldest, at 9 years old, still depends on her eventhough she tried making them independent. She wondered how they were going to school.
She told the story of how she had to give away one of her children to one of her siblings because they couldn’t conceive, and how that child of hers calls her “Auntie”. But most of all she said about how she was so worried about the outcome of this pregnancy. And she said to me, while pointing upwards, “Right now, there’s only God who can do anything.” Most of the time I only nodded, smiled and gestured her to go on.
She told the story of how she had to give away one of her children to one of her siblings because they couldn’t conceive, and how that child of hers calls her “Auntie”. But most of all she said about how she was so worried about the outcome of this pregnancy. And she said to me, while pointing upwards, “Right now, there’s only God who can do anything.” Most of the time I only nodded, smiled and gestured her to go on.
Time was ticking away and I still had 80% of the history not clerked. Sometimes I feel they’re very mechanical questions since we’re still training and have to refer to the questions. But I decided this time, if my bed was randomly chosen, then I’ll just present what little I had. Right now, what she needed the most, was not my questions. She needed someone to listen.
At 830am on the dot, I still hadn’t passed the first history; history of presenting illness. Of course, with palpitations, we waited for our professor to come.
Alhamdulillah, my bed did not get chosen.
But this was the lesson I had learnt today. Sometimes what people really need is for you to listen.
And what I had learnt so well from our specialists here is that... if you don’t take a good history, you wouldn’t know how to manage. And taking good history means listening. This patient for example had headache. You might want to prescribe her painkillers, but that wouldn’t be the correct management because actually, her headache is caused by excess work and what she needed more was probably an MC for rest. “The management will be different.”
I learnt, sometimes, it’s not that patients are difficult. They’re ill and they have a lot of worries on their mind. And when we just start bombarding them with questions one after the other, they don’t get heard. Yes, I do admit, sometimes we want to get to the heart of the matter as soon as possible for the patient to lead us to the diagnosis. But sometimes, just listening is what they need the most.
