Reflections on Knowledge

McClenaghan, Heather

We are in an era of patient-centered medicine in which we strive to communicate information to patients so that they may make informed decisions for themselves. Yet no matter how hard we try, and despite what Dr. Google may lead some to believe, there is still an immense difference in medical knowledge between physicians and patients and family members. There are times when the knowledge gap is unavoidable. And there are times when we, whether consciously or unconsciously, have to make decisions on the timing and extent of interpreting this knowledge to patients. In the middle of patient-centered care, there still exists an essence of paternalism: a decision we have to make for our patients. I am uneasy about this responsibility.

I had multiple occasions in my first year of residency during which the information imbalance was acutely and unexpectedly felt, such as when I learned a patient’s test results before she did. How odd it was for me, a complete stranger, to be the one announcing to a couple that they were pregnant. Although I felt like an intruder, I was happy to share in this joyous occasion. My position in medicine had given me this privilege.

On the other hand it can be a burden when the news is not as positive. It is inevitable that a patient will see or experience signs whose medical significance he or she will not be able to interpret. A recent example for me was the silence that entered the ultrasound room when the staff physician was unable to find the fetal heart flicker at a prenatal appointment. Each medical professional in the room had an unspoken understanding of the situation, while the patient’s only understanding was from picking up on non-verbal cues that something was not right.

During that particular event I could not help but empathize with the patient’s future agony while the patient was not yet aware that the gestation was unviable. For those few minutes before we physicians opened Schrödinger’s box, both realities continued to exist for her and her potential unborn child. Physicians have the privilege and the burden of knowing information before and beyond the patient’s understanding. It is how and when we convey the information that defines us.

The skill itself of communicating knowledge, although it is approached in the medical curriculum, can only be gained through practice. Our practice starts in the clinic and often percolates out into everyday life. Our medical knowledge extends to those beyond our direct patient care. Once we learn about the anatomy, physiology and pathology of the human body, we cannot stop knowing it when we leave the hospital or office.

I had the unfortunate experience of having a family member diagnosed with stage 4 cancer. My family was told of the diagnosis. Unlike me, however, they did not comprehend the implication that the illness would likely end her life in less than a year. Did my relatives want to hear that information? How much did they want to know? And was I, their family member, to be the one discussing this with them? For a family that avoided talking about death and dying, this was a lot to handle, and definitely something I was not taught in medical school.

Even more frightening was the process of watching the illness take hold and seeing signs of disease that my relatives were not aware to recognize: the clubbing of the fingernails, the moon facies of long-term glucocorticoid-use, anorexic-cachetic syndrome, and finally the decreasing performance status signifying that death was approaching. Textbook diagnoses appearing in my beloved relative. I felt split in two: on one hand I was the objective medical observer, while on the other hand I was my subjective self that had to try hard not to cry. My family members, similar to patients, chose to a degree how much information they want to be revealed to them; I was denied that allowance for myself.

Knowledge as well as experience fosters a physician, creating the divide between us and our patients. As a resident physician, I may have knowledge but I have much experience to gain. I certainly can not reflect back without bias on the events surrounding my family member and wish I could have done better. All I can admit is that the experience has underlined even more the power of knowledge and the importance of communication between physicians, patients and their families.

The experienced family physicians who I strive to resemble are those who know how to use their knowledge and navigate their responsibilities wisely: communicating good and bad news to the patients, timing their delivery appropriately, informing patients to the extent that they want to hear, and most importantly recognizing the importance of putting their medical knowledge to the side while they live their lives as mother, father, uncle, cousin, sister, and friend.

Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Physicians | Médecins
Theme: Relationships | Relations
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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