DEC 17 — Madam Joanna, 73, was my first patient on a recent shift. She was taken to the Emergency Department (ED) — her daughter, Petrina, called 995 when Mdm Joanna vomited and became unconscious due to her low blood sugar level.

Earlier, Petrina had called one of our ward colleagues to discuss whether an insulin injection should be withheld because her mother was having a fever. My colleague advised that a reduced dose of insulin should be given, but even that was unfortunately still too much for Mdm Joanna, whose reserves were depleted after her recent hospitalisation.

That had been an eventful three weeks in hospital, during which she survived severe pneumonia requiring several changes of antibiotics, difficult-to-control diabetes mellitus requiring repeated titration of insulin dosages, acute kidney failure requiring dialysis, and episodes of delirium requiring infinite patience and care. At the end of it, she was much weaker, had lost weight and needed more help to sit, move, eat and bathe — activities that she had been able to do on her own before her illness.

Later, after she was taken to the ED, the medical student on rotation asked me if I thought the patient or her next-of-kin would lodge a complaint against the colleague who had given the advice about the insulin.

But Petrina had been at her mother’s hospital bedside and had witnessed the imprecise art of insulin titration; she understood that the risk of hypoglycaemia (state of low blood sugar) was very real in someone as frail as her mother. She was not angry at the advice or at my colleague.

Daunting task of coordination

Mdm Joanna is typical of patients in our public hospitals: An elderly person with two to three chronic illnesses that remain stable until an acute event.

The doctor-in-charge needs to coordinate multidisciplinary care by other doctors — endocrinologist for diabetes, infectious diseases physician for severe pneumonia, nephrologist for kidney failure, and lead an inter-professional team of nurses, therapists, pharmacists, dieticians and so on.

The team must ensure that upon discharge, a compatible level of care, therapy and support is available to the patient to transition her from acute hospital to community-based care. To train medical students and doctors to be capable of such coordination and leadership that centres on the patient remains a tall order.

The competence to diagnose and treat diseases is no longer enough. The new norm for doctors is the capability to lead a team to jointly manage several illnesses in a patient, possibly in the face of challenging psychosocial, family and financial issues, at the right site/setting and at a cost that is affordable to the patient and sustainable for Singapore.

Medical school education started in 1905 in Singapore and specialist training has a 50-year history, and we have done well. Doing more of the same and working harder at it, however, will not nurture the kind of doctors capable of meeting Singapore’s needs.

Education for healthcare professionals must ensure that our students and young professionals — doctors, nurses, pharmacists, therapists and allied health — learn how to care and support not only sick patients but also the healthy and pre-illness population.

Our healthcare education system must prepare the next generation of professionals to integrate patient and population health management across disciplines, settings, sectors and the severity of disease.

Doctors with such a capability will only emerge when medical schools and the graduate medical education system review their curricula, instructional methods and performance of clinical teachers regularly to ensure alignment with evolving national healthcare needs.

The humility to listen to patients, families

While Mdm Joanna is a typical patient, Petrina is an unusual next-of-kin. She is knowledgeable about her mother’s health issues (such as key diagnoses, names and dosages of medications) and deeply engaged in her care.

Unlike many families where the maid is the spokesperson for the sick elderly, Petrina’s presence is reassuring to her mother, helpful in translating the consultation into the dialect Mdm Joanna understands — and humbling for me to learn shared decision-making anew.

The vomiting and fever left Mdm Joanna dehydrated and in need of intravenous (IV) hydration. After Petrina understood the need for IV cannulation, she held her mom’s hand gently and translated my request. Mdm Joanna whimpered and her daughter soothed her as she signalled for me to proceed.

The odds were stacked against me because Mdm Joanna’s veins were small. Several veins had not recovered fully from cannulation during the recent hospitalisation and the skin was loose with areas of dryness and cracks that would become infected easily if an IV were inserted.

After two failed attempts, I apologised to both mother and daughter and explained that I would re-attempt after the chest X-ray was completed.

Petrina then said to me: “Doctor, is it okay if we give my mum an injection in the muscle to stop the vomiting, after which I’ll persuade her to drink water and take medication? The doctors and nurses in the ward have said her veins are difficult, so please don’t feel bad. Once the vomiting stops, I think she would not resist the water.”

As I listened to her, several emotions chased one another across my mind: Momentary confusion because such a suggestion should have been made by me, the doctor, not Petrina, the daughter; respect for Petrina because her suggestion was clearly workable; and humility, in realising I had learned a precious lesson in shared decision-making.

I said “yes” and thanked Petrina for her suggestion.

As my nurse took Mdm Joanna to the X-ray suite, Petrina said: “Doctor, if you have a chance, please teach young doctors to accept suggestions from family members like you did. Sometimes there is more than one way to deliver care and medication.”

Indeed, medical education has some way to go to teach us that discussing options and risks openly with patients and family is the new norm; sharing the decision-making process with them ensures safer care.

It is not the pride in knowing how to do things, but the humility in being wise enough to know when to and when not to do certain things, that must undergird the medical profession. — Today

(Names of the patient and daughter have been changed to protect their privacy.)

* Adjunct Associate Professor Tham Kum Ying is Senior Consultant, Emergency Department, Tan Tock Seng Hospital, and Assistant Dean Phase 2 and 3, Lee Kong Chian School of Medicine.

** This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malay Mail Online.