Someone close to me shared a poignant account of how her husband received the news of his cancer diagnosis. "The doctor had been making rounds for about a week, and Dan* was growing increasingly anxious from the prolonged wait. He just wanted to know what was happening," she began. According to her, the doctor, after reviewing numerous documents, muttered a few words under his breath while standing at Dan's bedside. He then abruptly turned towards the exit. Dan, in a desperate attempt to grasp the situation, called out loudly. When asked about his diagnosis, the doctor, with an emotionless expression, uttered, "Oh, it's cancer," and left. I refrained from probing into the depth of trauma Dan might have experienced during that encounter; it most probably was marked as a distressing moment that still haunts him years later. Fortunately, Dan underwent successful surgical and medical treatments, entering remission and living a cancer-free life thereafter. A Double-Edged Sword As someone in the medical field, I can assert that no doctor desires to deliver negative news to their patients. I vividly recall confirming metastatic liver malignancy in one of my favourite patients, whose cheerful visits to the clinic with his loving wife starkly contrasted with the grim reality of his life-changing diagnosis. Witnessing the pain my medical advice inflicted on his family left me with a lingering sense of guilt. Seeing posters of his family's fundraising efforts for his treatment added to my remorse, almost as if I had played a role in the illness that besieged him. Being the bearer of bad news is a daunting responsibility, and my heart goes out to clinicians who routinely face this challenging task. Death and pain have a profound impact on the mind and heart. Never forget this as you practice. Handle with Care Acknowledging this reality, there comes a weighty responsibility to manage one's emotions and approach. As a clinician, you must deliver health-related news with the utmost empathy, an integral aspect of the Hippocratic oath you took. May you never forget. Here are some tips to ensure professionalism and effectiveness in delivering difficult news: 1. Verify the diagnosis with relevant practitioners, ensuring confirmation through necessary tests like a biopsy for malignancies rather than solely relying on imaging reports. 2. Consider the atmosphere; the delivery of "bad news" is unforgettable. Control the setting to the best extent possible, opting for a well-aerated, quiet, and private room. 3. Have support on standby; involve a counsellor or therapist and keep them nearby for emotional support, but not in the room during the initial revelation as this may create panic which may make the process more difficult than it already is. 4. Maintain composure and dissociate from emotional outbursts; as a healthcare worker, remember that this moment carries with it implicit structures that state that you hold a position of authority at this point, and patients and their loved ones look to you for strength and guidance. 5. Speak slowly, avoid jargon, and use clear language, especially when conveying news of death, to prevent misunderstandings and foster clarity. I am guilty of this as many times patients' loved ones would ask me "So when can we see them?" after I broke the news of their loved one's death. This was because I would use colloquial statements such as, "He/she has rested now" which is misleading and unclear, leaving room for denial to fester. Try your best to be kind but direct as you express a factual statement. 6. Allow time for questions; don't rush away after delivering devastating news. Offer to address any inquiries and provide additional support, especially after a significant event like the death of a loved one. Opportunities for Growth In the ever-evolving field of healthcare, there's always room for improvement. Reflect on past experiences, seek feedback from colleagues, and embrace opportunities to shadow more experienced professionals. Learn from their approaches to this crucial aspect of clinical practice to enhance your skills in breaking difficult news compassionately. *: Not his real name.

In my years of clinical practice, I have messed up a lot of times and achieved success in equal measure. In all these years, though, I have learnt that there are things that do not change: Medicine is both art and science The heart of medicine is in the human heart Always keep pushing Your patient is your biggest teacher (who always has a trick up their sleeve, always be keen!) ALWAYS. EXAMINE. YOUR. PATIENT. We will address the fifth point today. General Examination often comes after taking a thorough history of illness from the patent. It involves looking at the patient and their behaviour and body language, feeling for anomalies on their bodies and possibly using instruments to further refine the examination such as stethoscopes, otoscopes, speculums etc. In the dynamic realm of medicine, the power of the general examination cannot be overstated. It serves as the foundation upon which accurate diagnoses, patient-doctor relationships, and holistic understanding are built. For junior medical practitioners setting out on their career paths, the art of conducting a thorough general examination might seem like a daunting task. However, the journey is well worth the effort. In this article, we delve into five captivating reasons why embracing and perfecting the general examination is an absolute must for aspiring medical professionals. 1. Diagnostic Accuracy: Unveiling the Hidden Clues Imagine a puzzle with missing pieces. The general examination is akin to that crucial first step of finding those missing fragments. As a medical practitioner, your keen observations and touch can reveal subtle cues that might otherwise remain concealed. The tender swelling beneath the skin, the barely perceptible limp, the whispered quiver of a heartbeat – these are the details that can lead to precise diagnoses. By mastering the art of the general examination, junior doctors equip themselves with the ability to piece together these clues, thereby ensuring diagnostic accuracy that sets the stage for effective treatment strategies. 2. Holistic Understanding: Beyond the Obvious Human beings are intricate entities, and their health concerns are often interconnected in ways that aren't immediately apparent. A comprehensive general examination can uncover these hidden connections. Consider a patient presenting with persistent fatigue – a symptom that might be attributed to various causes. By carefully assessing not only the physical aspects but also delving into the patient's medical history and lifestyle factors, junior practitioners can unravel the complex web of influences that contribute to their condition. This holistic understanding empowers medical professionals to formulate treatment plans that address the root causes, enhancing the likelihood of sustained wellness. 3. Early Detection: Nipping Problems in the Bud In the realm of medicine, timing can be the difference between a manageable condition and a dire one. The general examination is a powerful tool for early detection. By being vigilant and attentive, junior practitioners can identify the subtle changes that precede the onset of more severe ailments. A seemingly innocuous rash might be the harbinger of a systemic allergy, and a minor irregularity in a routine check-up might uncover an underlying cardiac concern. Armed with this knowledge, medical professionals can intervene promptly, potentially preventing the progression of diseases and ultimately saving lives. See this real life experience here! 4. Patient-Doctor Relationship: Fostering Trust Through Care Medicine is not just a science; it's an art that thrives on human connection. The general examination provides a unique opportunity to build trust and establish a strong patient-doctor relationship. When junior practitioners take the time to listen, to touch, and to genuinely care for their patients, they lay the foundation for open communication and mutual respect. Patients are more likely to confide in doctors who demonstrate empathy and thoroughness, ultimately leading to better cooperation and adherence to treatment plans. The art of the general examination, therefore, becomes a bridge that connects medical knowledge with the human experience. 5. Educational Opportunity: Cultivating Excellence The journey of a medical professional is one of perpetual learning and growth. Embracing the challenge of conducting a proper general examination not only benefits patients but also contributes to the practitioner's personal and professional development. By striving for mastery in this fundamental skill, junior doctors cultivate a mindset of excellence that extends to all aspects of their medical practice. Every patient interaction becomes an opportunity for learning, refining techniques, and expanding diagnostic prowess. This commitment to continuous improvement sets the stage for a fulfilling and impactful medical career. To Wrap it All Up In the intricate tapestry of medicine, the general examination stands as a cornerstone of effective patient care. For junior medical practitioners, the path to mastering this art may seem steep, but the rewards are immeasurable. Diagnostic accuracy, holistic understanding, early detection, enhanced patient-doctor relationships, and a commitment to excellence – these are the five compelling reasons to persevere in perfecting the general examination. As aspiring medical professionals navigate their way through the complexities of the healthcare landscape, they can rest assured that this foundational skill will be their compass, guiding them toward a future of success, fulfilment, and meaningful contributions to the well-being of their patients.

The time is 9pm. It is now two hours into my night shift. A call comes in. The nurse on the line describes a newly admitted patient who needs a doctor's review. I reach the ward and find the patient I had earlier been briefed about. He has a chronic medical condition that is notoriously associated with excruciating pain from time to time. He is wearing the pain rather well. He’s even smiling past the dry jokes that I am pulling (I think humour somehow lessens the blows of illness). We had a pleasant exchange and after the history, examination and brief explanation of some of the things he sought clarification about, he asked a rather odd question. “𝘋𝘰𝘤𝘵𝘰𝘳, 𝘸𝘩𝘢𝘵 𝘥𝘰 𝘱𝘦𝘰𝘱𝘭𝘦 𝘭𝘰𝘰𝘬 𝘧𝘰𝘳 𝘸𝘩𝘦𝘯 𝘵𝘩𝘦𝘺 𝘴𝘲𝘶𝘦𝘦𝘻𝘦 𝘮𝘺 𝘴𝘵𝘰𝘮𝘢𝘤𝘩? 𝘉𝘦𝘤𝘢𝘶𝘴𝘦 𝘮𝘰𝘴𝘵 𝘵𝘪𝘮𝘦𝘴 𝘺𝘰𝘶 𝘱𝘦𝘰𝘱𝘭𝘦 𝘫𝘶𝘴𝘵 𝘵𝘰𝘶𝘤𝘩 𝘮𝘺 𝘴𝘵𝘰𝘮𝘢𝘤𝘩, 𝘤𝘰𝘷𝘦𝘳 𝘮𝘦 𝘶𝘱 𝘢𝘯𝘥 𝘸𝘢𝘭𝘬 𝘢𝘸𝘢𝘺.” I almost laughed but for the seriousness in the air. He also said, “𝘺𝘰𝘶 𝘱𝘦𝘰𝘱𝘭𝘦” which implied negativity. At this moment, I am hit with guilt because I’ve done this too. I’ve let the awareness of the lack of time or urgency of the examination erase one of the most overlooked practices in patient examination: 𝗲𝘅𝗽𝗹𝗮𝗶𝗻𝗶𝗻𝗴 𝘄𝗵𝗮𝘁 𝘆𝗼𝘂’𝗿𝗲 𝗱𝗼𝗶𝗻𝗴. During OSCEs (Objective Structured Clinical Examination) in Medical School, you would be heavily penalised if you missed simple steps such as introducing yourself to the patient, washing your hands before touching the patient, explaining what you’re about to examine (briefly) and even caring to warm your hands before coming to contact with the body of the patient! These steps may seem time consuming but they go a long way in building patient-clinician confidence as well as slowing you down so that you increase your clinical accuracy. Do The Work: Do Not Fear! A simple “𝘐’𝘥 𝘭𝘪𝘬𝘦 𝘵𝘰 𝘦𝘹𝘢𝘮𝘪𝘯𝘦 𝘺𝘰𝘶𝘳 𝘢𝘣𝘥𝘰𝘮𝘦𝘯 𝘵𝘰 𝘤𝘩𝘦𝘤𝘬 𝘧𝘰𝘳 𝘢𝘯𝘺 𝘴𝘸𝘦𝘭𝘭𝘪𝘯𝘨 𝘰𝘳 𝘢𝘳𝘦𝘢𝘴 𝘰𝘧 𝘱𝘢𝘪𝘯 (𝘦𝘵𝘤)” creates a strong link of communication that can encourage the patient to give more history (often remembering things they may have forgotten earlier) therefore helping you get a better idea of what’s going on. The patient is one of your best teachers (experience is another!) Another key thing; when results to lab tests or imaging come out, do not find it wasteful to fully discuss findings with your patient. They are eager to know what is going on (perhaps even more than you are!). Going through this simple process helps alleviate anxiety and builds trust in your capacity as a clinician. You may not know it all, but inviting the patient into the process of treatment is crucial to your management. A Better Me Now this particular patient does not know this but he helped remind me of the basics that increasing knowledge can push off the cliff. He has definitely made me a better clinician. Dear healthcare professional in training, keep it simple! It is possible!

In my history as a Healthcare Practitioner, I have interacted with hundreds of patients who have seemed initially difficult to manage clinically only to peep further and factor in the existing confounding factors affecting treatment and circumnavigating the management issues successfully. Lady in Red I once had a patient who would come to the clinic every two or so weeks with the same complaint and would demand admission for specialised care. In a period of one year, the patient had been seen by over 5 specialists (a psychiatrist included) and now sought super-specialty recommendations. They had a diagnosis but it somehow was still not enough. I gathered this from her data on the Health Management System on the desktop before me. She seemed young and ambitious. She glossed over her presenting complaints with an assurance that I had already heard of her before. She dropped names of resident doctors easily and made casual statements about her multiple experiences in the psychiatry ward. She seemed alright until she started weeping when I asked her about her Social History. Her tears came from a deep place of pain and confusion. She was the breadwinner in her home but had become estranged from her mother on account of her romantic interest. She eloped with him and occasionally supported her family. However, her partner had begun physically and emotionally abusing her. He had access to firearms on account of his line of work and so he would occasionally threaten to kill her and then himself if she would ever leave. He would rise on her with violence after his regular visits to the bar and would strip her of her money in order to finance his indiscretions. She got signed in as a beneficiary in her partner's insurance scheme so she could manage to visit the hospital regularly. The hospital soon became her refuge when she had had too much. That night, the hospital was her home because she had been kicked out of their shared living space. She had been diagnosed with Major Depressive Disorder and was inconsistent with her regimen, most probably because of the scuffles in her personal life. Her symptoms were worsening and no one seemed to know why- until we met. Social Factors- et al When it comes to administering care, the clinician should always look at the patient standing before them as a whole person with a mind as well as a body. Oftentimes, illnesses mask a bed of worri some social (and other) situations and while the clinician may not be able to resolve them, it would go a long way in addressing the presenting illnesses holistically. It also matters to simply care for the human you are managing. I have found that many times some patients simply want to know that someone cares for them and once they see this, their illnesses somehow seem more manageable and less menacing. Take Time It is imperative to take time with each patient in order to fully address their needs. With the rise In performance-based assessments of clinicians and capitalism, a lot of softness has been eroded from care. Many clinicians gloss through the confounders of health (living conditions, financial status, geographical, cultural and social influences) and sign off patients as seen. What they do not know is that they have addressed just one part of the many that need consideration. For instance, your patient may not be taking ARVs (Anti-retroviral medications) because they face stigma when they do. You may keep wondering why their Viral Load is constantly off the roof and perhaps this is why. You may note an improvement in adherence after talking to their families or simply enrolling the patient into a HIV/AIDS support group. It may seem like a herculean task to try, but it is our work to make sure that each patient gets the best quality of care. May we remain vigilant and considerate in our quest for better care.