Any comments on this X Ray?
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thank you everyone for your responses

the objective of me sharing this xray was perfectly illustrated by the responses

notice how we got responses as "perfectly normal x ray" all the way to "covid 19"?

This was a patient i saw yesterday and the experience left a bitter taste

hence i thought i would talk about this

something which is affect us all in one way or another

This is the perfect time to talk about MEDICAL JOUSTING
#LongThreadAlert

A. What is ‘medical jousting’?

Medical jousting is
- the uninformed criticism of a healthcare colleague
- criticising the treatment that a patient has undergone so far before consulting you

The bitter truth is that majority of us have fallen at sometime or the other, into this trap, be it an obvious remark or a subtle one. Some of us do it through malice while others do it through ignorance, but our words make a permanent impression on the patient’s mind.

some examples include
1. Oh! What has been done
2. “If you had come to me first, I would not have treated like this”
3. Your case has been spoilt ; nothing can be done now
4. Who gave you this scar? This could’ve been avoided!

The scope of jousting can vary widely:

1. Direct verbal – Comments such as “you should take legal action against that doctor”.

2. Indirect verbal – For example, “that isn’t what I would have done”.

3. Body language - Signals such as a look of surprise or horror when a patient mentions something about their previous care.

4. Written in the patient record – Entries in the medical records such as “previous doctor should have asked for advice”.

5. Written outside patient record This includes social media, doctor review websites eg: “Doctor X was a moron at med school & remains a moron judging on what they did to Patient Z”. This has the added bonus of being open to public & unsecure in terms of patient confidentiality

All of this might sound familiar to both medicos and non medicos.

This might be because it appears that jousting might be more common than you might think.

One small study found that when comments were made about another doctor during a patient consultation, 67% of them were critical verses 29% which were supportive (4% were considered neutral). Criticism about colleagues in another speciality was particularly noted

A few of us at teaching institutes, unknowingly, pass certain remarks to students in front of patients, indirectly poisoning the minds of the patient and their families. Quite often, we comment on a treatment of which we hardly know of anything.

A simple example: A patient who has undergone radiotherapy for cancer cervix 20 years ago is visitng an ophthalmologist for cataract. During history taking when he comes to know that she has undergone radiotherapy, he broadcasts that her problem is a side effect of Radiation.

“Don’t criticize what you can’t understand.” Radiation was
offered to the pelvis & it has no bearing to cataract in eyes
I’d like to hope that jousting when it does occur is usually unintentional. However, it can also be intentional
Private hospitals are NOT immune to this either

In high stakes or stressful clinical situations, jousting may form part of a defensive strategy to divert blame should something go wrong. It also appears to be more common with privatised healthcare systems where colleagues can become competitors.

Negatively commenting about a competing doctors decisions (or lack of them) might be seen as a way to bolster one’s own business.

So what could be the implications on the patient side of this?

Patients get disheartened about the treatment; they lose faith in doctors and continue “shopping” for they are utterly confused as to which doctor’s advice should be followed, and continue getting increasingly disillusioned when they keep on getting conflicting opinions.

They start criticising doctors and this so called “noble profession” earns a bad repute
This has indeed led to an increasing prevalence of medico legal cases
It is reported 40-80% of medical information provided by healthcare practitioners is forgotten immediately by patients

Remember, educated families do understand this art of medical jousting and they may not form a very good opinion of the criticising doctor.

“Often those that criticise others reveal what he himself lacks.”
― Shannon L. Alder

How to avoid?

The first and the foremost thing is that one should take a resolution not to pass any negative comments regarding management offered so far. Remember that what you are doing to others, others may do to you.

Patients do take multiple opinions, and some of your fellow medicos may speak ill of your treatment too irrespective of the fact that you were right.

“Maybe you who condemn me are in greater
fear than I who am condemned.”
― Giordano Bruno

So how can colleagues try and get the full facts of a patient case before they make assumptions about poor care?

1. Transfer of the previous patient records – this can take time and may not accurately convey all the issues surrounding a clinical situation

2. Talking to the previous doctor – a face-to-face conversation is an option if you physically work together, but is not so easy if you work in different environments. A phone call might work if you find a mutually convenient time.

In addition, a call coming out of the blue from an unknown doctor may seem peculiar unless the conversation is framed correctly.

3. A letter or email to the previous doctor – this may come across as quite formal or threatening, perhaps interpreted as a prerequisite to litigation in healthcare systems where correspondence like this is not normal practice.

In fact, there appear to few viable options for doctors to gather timely informal insights about specific cases from colleagues, especially colleagues who they have never encountered before or who work in a different speciality.

In times of rising number of medicolegal cases and ‘doctor battering’ by patient families, it is all the more imperative for medical fraternity to unite for each other rather that mud slinging.

If asked by the patient whether treatment done so far was not on the correct lines, we may chose to keep quiet, or say that there are multiple options and when one strategy doesn’t work, other has to be tried in certain difficult medical situations. We should not be judgemental.

Your job is not to judge, Your job is to lift the fallen, to
restore the broken, and to heal the hurting.

Summary

Medical jousting is quite a nasty phenomenon and nearly not as courtly as it first sounds. It can taken many forms and represents a failure of communication. It is also a euphemism, a noble sounding term for a very ignoble act. They really should make a jousting emoji.

Further resources

Physicians criticizing physicians to patients
https://www.ncbi.nlm.nih.gov/pubmed/23715689 

Patients’ memory for medical information
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC539473/

Special Credit to Dr. Sheh Rawat, Editoral board
Senior Consultant and HOD - Radiation Oncology, DHRC
http://www.dhrc.in/downloads/DHRC-Newsletter-Feb-2017.pdf

Sati Heer-Stavert
https://unexaminedmedicine.org/2018/02/21/medical-jousting-and-the-art-of-uncourtly-clinical-criticism-a-noble-name-for-an-ignoble-activity/

as i combined their two works for this thread

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