Jerry V. Marlin, M.D. F.A.C.S.

Neurological Surgery


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Effective communication between physicians and patients as well as the patients' families is extremely important. The Clinical Ethics Guidelines do not emphasize enough the need to initiate effective communication as a primary goal when establishing the doctor-patient relationship. Effective communication requires a complete openness between both individuals, physician and patient. Honesty must be maintained. A full disclosure of the patient's symptoms and associated conditions is expected by physician in order to determine the diagnosis of the patient's clinical condition. An excellent patient-physician relationship will ensure that effective communication is maintained throughout the patient's episode of care.

"The whole truth and nothing but the truth" is an old saying in our legal system but also should be in our assessment of a patient. The patient must disclose their condition completely. However the whole truth must be disclosed back to the patient by their physician. Not only does the physician have to communicate their diagnosis and recommend treatment but effectively help the patient understand their clinical condition. Also in 1999 alternative treatments have to be discussed. In surgery or obtaining consent for procedures, documentation of the diagnosis and treatment recommended or advice and full disclosure of the risks and benefits of the procedure and alternatives to treatment are required. A written signature by the patient and the physician makes such a consent a legal document.

In today's information age, patients are often already bringing with them massive amounts of information to the physician's office regarding their clinical condition. Often, however, patients do not reveal that they have already read up on the condition quite thoroughly using the Internet or other educational resources. The opposite is also true in that many patients have no access to the Internet or educational material regarding medical conditions.

In order for communication again be effective and quite complete, informational pamphlets, brochures and hand-out regarding drug usage and side effects or adverse reactions are routinely offered to every patient. Family members ask what did the doctor say? To effectively answer the family's questions, having printed patient educational handouts related to the diagnosis can be calming to the patient and their family, a real public relations value.

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An excellent patient-physician relationship, especially with completely open and honest communication becomes paramount if unfortunately the outcome is less than desirable. Family members may be present when a patient first talks with the physician. Family members are generally almost always present when a bad outcome occurs. Family members want information. Information received up to that point may be only from the patient. This represents another reason for effective communication related to the diagnosis, treatment recommended and alternative treatments and expected outcomes to be provided to the patient from the onset.

The patient may not be able to recall what was said and often can only remember a limited amount of their doctors' discussion or medical information. For this reason, handouts, pamphlets, books and directions to Internet resources are offered to the patient along with discussion of the care recommended .

An excellent example of patient information is the discharge form used here at Presbyterian Hospital of Dallas in which the condition, treatment, medications, potential problems, physicians phone numbers and follow up appointments and additional recommendations on care of the patient are written down for all to review.

In today's audience we are all physicians. If we or our spouses or children become ill, who is now the patient? If our treating physician discusses a serious disease process, I believe that we would all be closely listening to the physician's words who is caring for our loved ones. The physicians in this audience have access to almost all medical information available in 1999 through the Presbyterian Hospital System Information computer systems. This information today is almost instantaneous available through our Intranet and Internet resources.

The biblical phrase "In everything, do unto others as you would have them do unto you" to me exhibits the reason why I am speaking to you today. I want you to assume that you have become the patient or represent a concerned family member. Honest, open, effective communication with full disclosure of the diagnosis and treatment recommendations would be expected from your doctor.

There is another reason for effective communication or teaching the patient or the family about the illness. As you can read in my previous articles and others written on this subject, the patient's recovery can be significantly enhanced when the patient has knowledge of their disease process and can fully cooperate and participate in the treatment recommended. A good example in my practice are those patients that have a significantly painful spinal condition such as a disc herniation. I need these patients to follow my instructions and often change their habits, avoid strenuous activities, avoid neck or back positions that reproduce nerve root compression or increase the likelihood of further disc herniation.

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Continuation of these activities which reinjure the nerve root have to stop or healing will not occur and perhaps surgery will be necessary. In my practice the patient needs understanding of the spinal anatomy. Using spinal models and explaining how a specific movement can cause pain allows me to treat a high percentage of patients with disc herniations without surgery.

Again, on the subject of effective communication, end of life issues related to a patient who is dying or is severely incapacitated remains paramount. However, in end of life issues, family members, if present, often need to become involved in treatment decisions. Discussions regarding withholding and withdrawing of life sustaining treatments are often held with family members in attendance. Patient autonomy should be maintained. Often family members will have to interact with the physician directly on the behalf of the patient when incompetency or impaired consciousness occurs. Assessing the patient's understanding of their clinical condition remains important, but also assessing the spiritual needs of the patient who is dying is not always considered by physicians. Assessing the patient's level of pain and suffering seems obviously important to all. However our surveys show that physicians may not be effective enough in pain management when our patients are at the end of their life. Pain control and management issues will continue to be discussed and treatment guidelines followed, helping the patient remain comfortable at the end of their life.

These slides have selected information related to the Presbyterian Hospital survey results from 1998. In the upcoming years, assessment and documentation of pain and suffering will become extremely important for hospital accreditation from J.C.O.H.A. and even further analyzed by various insurers and the Medicare system. Failure to care for patients adequately and relieve their pain and suffering as discussed in a Journal of American Medical Association article may be considered equal to medical malpractice. These are strong words, but ethics articles on pain control has recently emphasized the need for further efforts by physicians to practice better pain management. Patients expect pain relief. However effective communication on the issue of pain and suffering has to include discussions of the patients' expected outcome. Often complete pain relief is not possible when dealing with patients who have chronic pain or cancer related pain. Please see my lecture on pain and suffering for more information

The clinical ethics guideline booklet has been handed out today in order to provide information to the physicians in the audience regarding ethical issues that may arise in their daily practice of medical care. I believe that the booklet, after read, will be a valuable guide to organize your thoughts related to ethical issues which may arise in the day to day care of a patient. The guidelines assist good ethical reflection when making decisions in clinical practice and research. The guidelines are not meant to replace your personal conscience or professional codes of ethics or the law.

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Overall the ethics of patient care still revolve around a physician-patient relationship. Understanding the patient's expectations and concerns remains important and also being responsive to the patient's religious, cultural and ethical values. The patients have their own responsibilities as well as rights. The patient should try to understand, consent to the treatment and participate in the care recommended. The patient needs to be open and honest in communicating with the physician. Physicians should not deny care because of race, color, religion, nation origin or insurance or monetary factors. The physician should treat the patients' medical conditions in which they have skill, knowledge or experience. The physician has to maintain competence in both the art and science of medical care in their specialty field.

I hope that this lecture has been helpful in your continuing medical education.