Patients-not just Images

Introduction:

The Radiological and imaging sciences have come to occupy an increasingly central position, not just in diagnosis – but, with interventional radiology - in the management of patients too.

Radiology has long been considered a “back room” speciality with little or no patient contact. The wide spread use of the newer imaging techniques has led to situations of “findings aplenty” crying to be interpreted in the light of patients’ clinical problems. Radiology is always clinical radiology. When an investigation is performed on a patient, it brings the patient in close contact with the radiologist or a radiographer for variable periods of time from a few minutes to several hours as in the case of interventional procedures.

Given this intense contact between the patient and radiology care provider, it is strange that the radiology curriculum has little or no space for teaching the basic tenets of patient contact or equipping the radiologist in training to empathetically handle patients’ problems.

A curriculum in Medical Humanities does just that. Using humanities, social sciences and Arts skills, the student is sensitised to the humane aspect of medicine. The teaching of medical humanities (MH) is still in its infancy in India and limited to a few institutions. To the best of our knowledge, there has been no attempt at introducing MH programs in radiology residency.

In view of this, the following exercise was conducted to evaluate the response of a group of radiology residents to a clinical situation.

Subjects and Methods:

This exercise was carried out during radiology review courses for residents from all over India held in Mumbai, India in November 2010 and October 2011. This article is based on the response from about 420 radiology residents in their second or third year of residency.

I conducted this exercise during the afternoon session on the third day of a four day course. This course essentially included review lectures on various topics across radiology presented by multiple speakers.

The 'Poetry exercise' started with a volunteer resident who discussed the case in a 'film reading' session.

A 65-year-old man presented with right hypochondriac pain since six months and progressive weight loss and increasing jaundice.

There was tender hepatomegaly and ascites.

The sonography, CT, angiography and embolisation images were shown and then the photograph of the patient with his relative was shown.

At the end of this 10 min. 'film reading session', a poem was distributed to all residents.

Hepatoma by Alicia Suskin Ostriker

I come from visiting my once-blonde

friend in hospital with Hepatocellular

carcinoma the chemo is working

we chat about other women's husbands

suffering from Parkinson's

we laugh cry hug we feel a little lucky

down the hall an attendant rolls a gurney

yellowish old man skull glares

from under a blanket

now how in hell do I get out

can't find elevator or stairs

despite red neon EXIT signs everywhere

( Reproduced with permission - the original title of this poem is 'Lymphoma')

Till the residents actually opened the sheets and started reading, they had no idea what this exercise was going to be. After the poem was distributed, the residents were told “Read the poem, see how it affects you as a physician and a radiologist. What do you think the poem is saying?”

They were given 20 minutes to read the poem and describe their interpretation as well as their feelings on the back of the sheet. Participation in the exercise was voluntary The residents were not expected to write their names on their written responses.. They were also told that if they did not see the relevance of the poem they could say so or even return blank sheets.

384 out of 418 students present returned their sheets. 35 returned blank sheets. Approximately 60% (30% and 90%) of the residents had had their schooling in English medium school and the rest in the vernacular It was observed that a majority of residents spent up to 10 minutes reading the poem before starting to make their notes. Similarly many of them seemed not to have finished their comments when they were asked to ‘stop writing’.

After their responses were collected, one of the resident volunteers was called to discuss the poem and its interpretation for about 5 minutes. The whole session lasted about 40 minutes.

The 'open house' interpretation of the poem by the volunteer resident:

"Blonde is generally beautiful hair; and loss of it - conveys profound sadness at the loss of a 'precious thing' ". The "chemo is working" is a saving grace against this and is used to say "something gained, something lost".

For the second stanza, the resident commenting “We feel a little lucky". "How can you feel lucky with a terminal malignancy"(that's what a "hepatoma" is), he said and compared it with "Parkinsonism" a chronic, debilitating and non-fatal disease . He interpreted this to say that "at least here, after the chemo that is palliative, the patient's life will be short and the suffering will end for all -soon". This is better to than the suffering from a debilitating illness like Parkinsonism. This shows how to take solace even in a desperate situation. When we 'treat' patients, we should see if we are prolonging life or are we prolonging suffering" he said mentioning that "it is important not to play God".

He said that in the last stanza saying the use of the word "hell" was purposeful; that the words " exit" and "red" are profound and these means that the patient and relatives are caught in a no win situation - end of life with no hope. He further said "This could also mean, euthanasia though a good "exit" option is not available to the patient".Can I edit this?

Two other residents volunteered to interpret the poem. They agreed that loss of hair was a very profound loss for a woman with tremendous psychological impact and one has to be aware of that. They also felt that sometimes, a hepatoma which is a terminal illness is better than Parkinson’;’s disease that is a chronically debilitating diseases with tremendous impact o the whole family. The final stanza was interpreted by these resides in the same manner as last year that it indicates that in such situations as this patient, euthanasia should be an option.

There were two broad groups of interpretation. Those that literally interpreted the poem without relating it to their life as a physician; this group’s responses are not being analysed for the purposes of this research (76).. The second group interpreted the poem in reference to their own experiences as a person and a physician , sometimes, specifically as a radiologist and what it meant to them. From the latter group (274), broad categories of personal “feelings” and “ideas” were brought together in “headings” and the number of students expressing such feelings and ideas was tabulated. In some cases, the interpretations resulted in multiple such responses from each resident.

What the residents said:

I feel empathetic 57

Patients are not just a bunch of organs and diseases and images 51

Feeling bad unable to help 26

Dedicate more time to each patient 22

Inspires me to be a better doctor 18

Don’t understand the poem 17

Get into the shoes of the patient 16

Be humane 16

We have blunted our emotions 15

Masterly inactivity, relieve pain 15

Lucky we are healthy 13

Reduce physical and mental suffering 11

I will try my best to make early diagnosis 7

Always communicate truth 5

Never give up 5

English poetry will not help millions suffering 3

Feel guilty not having thought of such things 2

I do not want anyone to suffer this 2

Unable to express my feelings 2

Medical colleges don’t teach this 1

Touches my heart 1

We all have to face death sometime 1

You can view the some of the original hand-written responses of the residents at this link

Discussion:

It is apparent from the results that large number of students (84) have returned responses that reveal an empathetic side of a radiology resident in training. Others have expressed their feelings by relating the patients' and their relatives' quandary to their own being. It is interesting that five students said that they “did not understand” the poem. It is likely that they had trouble with the English language and or being unable to relate to the poem to their professional, life. It is difficult to interpret the “blank” responses. And no effort was made to elicit the reason for this. This could been any one of the following from being not interested in the exercise, to not being able to understand and or interpret the poem form a medical stand point.

MH has been common-place in Medical education in most universities in the Western world for many decades. In India however just a couple of Medical colleges have medical humanities courses. In a recent white paper, the MCI has commented that MH should be included in the mainstream of medical education.

Various authors has repeatedly emphasised, that though it is difficult to quantify the impact of MH programs on students, qualitative and semi quantitative assessments have revealed that the participants’ behaviour towards patients has been positively impacted after undergoing a course in MH.

At a time where there is more and more reliance on investigations, especially imaging studies and interventional procedures, there is proportionately less contact between the primary physician and patients. Radiologists tend to spend more time with patients explaining image interpretations or about interventional procedures. In view of this, radiologists’ skills and sensitively in handling communications with patients needs to be addressed effectively. We believe that this is an essential part of the Medicine set out by Osler and Hutchison and is innate to the practice of Medicine. There has been a general trend amongst many medical teachers to belittle the empathetic quotient in the minds of present-day medical students and this may lead to ”commodified and callous” attitude towards patients. As the study of MH has been shown to improve patient care on many fronts, this exercise was very preliminary effort to evaluate the attitude of residents in Radiology towards patient care and communication. A review of the PubMed does not show a single publication that has addressed this issue among radiology residents.

The results of this exercise emphatically show that a large number of residents do exhibit high levels of sensitivity and empathy towards patient illness and suffering. Some of the responses also indicate that they do have sense of guilt and helplessness in not being able to help patients.

We believe that the overall subjective evaluation of the results clearly points to a fertile field for the teaching of MH in the post graduate course as an inherent part of the syllabus. If done appropriately and in small groups, it is likely to have a positive impact on patient care in diagnostic and interventional radiology.

This study was in no way is meant to assess changes in resident behaviour after a brief exposure to MH and as such no conclusions are being drawn about its long term impact.

To assess this, a formal course over three years of radiology residency should be instituted and results evaluated. The Indian College of Radiology could take the lead in setting the plan for such a curriculum.

Long-term Follow up

In 2018, 8 and 7 years after the 'poetry sessions' in 2010 and 2011, I evaluated the 'long-term' impact of this session on participant residents. This was done using an online survey form. The survey form was sent to all the 468 residents who had enrolled in the review course in 2010 and 2011. But, as indicated earlier, only about 420 residents were present during this exercise.

Amongst other things, ALL 24 who responded have said that such an exercise as carried out as above should be a part of radiology education. The detailed results of this survey are at this link.

Acknowledgements :

I am grateful to Dr. Bhavin Jankharia and the Radiology Education Foundation, Mumbai , India for giving me the opportunity to conduct these sessions during the Radiology Review Courses.

I am also grateful to the residents who participated in this exercise and for giving permission to reproduce their comments.

Dr. Radha Ramaswamy, founder of the Centre for Community Dialogue and Change Bangalore, gave me valuable suggestions in the preparation of this manuscript.