July 3, 2011
A patient came to see me recently with a painful ingrown toenail. I see ingrown toenails quite frequently in my practice and have become quite adept at removing them. It’s the nature of my Middle-earth practice – Orcs and Ogres have poor nail hygiene and Elves with their long and thin toes are quite prone to them too.
For patient confidentiality purposes, let’s call my elvish patient Johnny. Johnny is a sprightly 340 year old wood elf. He had seen me for the past 20 years or so for various mild ailments. Otherwise, he was fit as a fiddle. Today, he stepped into my consultation room with an expression that was somewhere in between a frown and a wince. You could always tell he was in pain when the tips of his pointed ears turned red.
He showed me his ingrown toe nail. There was some paronychia around the nail with a small collection of pus and it was obvious it had to be excised. I would usually perform a digital block with lignocaine injections at the base of the toe with the help of a rubber band acting as a tourniquet. The whole procedure usually takes about 5 to 10 minutes.
But today was going to different. I started out enumerating the various benefits of the procedure is and the consequences of not going through the procedure. This of course included the piercing pain Johnny was experiencing round the clock as well as the possibility of getting chronic osteomyelitis from letting the infected ingrown toenail persist.. Frankly, from the look on poor Johnny’s face, I didn’t think Johnny needed any convincing.
Next I told him the risks of the procedure and that of the LA as well. Of course, the risks included cardiac arrhythmias and sudden cardiac death from the lignocaine injection as well as me possibly leaving behind tiny bits of my scalpel blade behind in his flesh for the next 400 years (elves can easily live that long and scalpel blade construction is not what it was with these blasted new foreign talent dwarves we are getting nowadays). Even though the chances were remote of these occurring (at least one reported case of retained scalpel bits) , but because of the severity of these possible risks, I thought I should tell him. I also told him about the other usual stuff like chance of recurrence, ugly nails, keloids, infection, fever, pain, allergies to dressings etc.
I also diligently jotted down all these benefits, risks and complications on his card. I then went on to the alternatives. I told him that he could also do nothing. I can refer him to another doctor or to the nearest A&E in Middle-earth. And since his ingrown toenail was not quite life-threatening at this juncture, I told him he could go home to think about it a day or two before deciding on whether he wanted to go through with the excision of toenail or not.
Johnny was flabbergasted and exasperated. The elves are never good with hiding such feelings. He uttered impatiently (trying as much to contain his frustration and anger as much as his otherwise congenial Elvish nature would allow him) “What’s wrong with you today, Doc? Just go through with the procedure and get the blasted ingrown toenail out. It hurts like hell!”
I then asked him with all the equanimity of Sir William Osler to acknowledge on his patient card with his signature that he agrees to the excision and he fully comprehends the risks, benefits, complications and alternatives which had been listed on his patient card to evince his comprehension.
He signs the card quickly. The process had taken 25 minutes. I then took another 10 minutes for the excision (including applying dressing).
He came back the next day for dressing. I could tell he was rather unsettled by something and I asked him, ”Is something wrong?”
“About yesterday. Why did you have to go through with the litany of risks and complications before the procedure, some of which were utterly remote and unnecessarily troubling? For goodness sakes’, it’s just a blasted ingrown toenail. I’m 340 years old and I have seen more than my fair share of ingrown toenails in elves”. He looked completely nonplussed.
“It’s what my medical council demands of me nowadays so that you can be considered to have given informed consent, if not I may run the risk of being found to be guilty of professional misconduct”
He winced a little as I removed the old dressing.
“Does it hurt?”
“Not as much as your bloody longwinded and scary consent-taking process yesterday”. He took a look at what he signed the day before and muttered “bloody stupid and ridiculous”.
I smiled and replied “I have no choice”.
“Of course you do, Doc. I trust you. I have been seeing you for 20 years!”
“It’s not so simple”. I applied the new dressing, gave him a pat and saw him off
It’s really not so simple. A good practice requires a good doctor-patient relationship. We always say it’s important that our patients trust us. But that’s only half the story. It is equally important that doctors trust their patients. But with recent events in middle-earth, I could not afford to. I still want to trust my patients, but my entire practice, my livelihood, and my family’s livelihood depends on me staying professionally alive. And hence I can no longer afford to trust my patients. All it takes is one of them to turn around and say “I did not give informed consent even though I have signed that I did” and I am dead.
Some folks say consent-taking is not a form but a process. That’s true. But consent is also documentation. And it’s pretty obvious some wise guys have decided for all of us that a patient’s signature and a form is no longer enough.
Some folks also say that specific circumstances lead to specific decisions and conclusions peculiar to those circumstances, so the principle of precedence may not hold here. Unfortunately, that is at best an opinion unless it is tested and tried again in the courts and seriously, I wouldn’t want to be that guy to put this to the test.
It’s not just that patients and doctors need to trust one another, but colleagues as well. How can there be trust if I cannot even depend on a relatively senior trainee and colleague to diagnose an acute abdomen? My colleagues in the hospitals now tell me they trust no one now anymore and the workload and decision-making keeps escalating upwards to the senior staff. Private practice seems the only plausible escape.
By all means, promote transparency and accountability. But we all also know that once trust is lost, it is extremely hard to get back. The fact remains that for trust to happen, the system and regulatory authorities must do what it can to foster this trust and not undermine it. The clear and present threat of professional misconduct is enough to radically change how doctors trust patients and colleagues. Call it kiasu-ism, prudent risk management, whatever.
As far as my medical practice goes, I can no longer afford to trust. It’s logical and inevitable, brought on by external events beyond my control.
For the record, my usual charges in the past for excision of ingrown toenail is about 80 to 100 bucks. I charged Johnny 140. That’s for the 25 minutes I needed to get “informed” consent, which I could have spent otherwise seeing another patient. Thanks to some doctors making decisions and setting standards for the whole profession, Johnny had to pay another 40 bucks which I derived no satisfaction from making. Like most doctors, I have to make rent and pay salaries and there’s only so many hours in a day. So much for healthcare cost-containment and improving productivity.
It’s really not so simple, Johnny.