RMAGUDA’s MAR [15-10]:My Most Difficult Patient

Indexing Title: RMAGUDA’s MAR [15-10]
MAR Title: My Most Difficult Patient
Date of Medical Observation: November 2015
Tag: Realizations in training brought about my management of a difficult patient
Category: Professional/Ethical-Reinforcement
I am already nearing the end of my surgical residency when I encountered my most difficult patient. He is difficult in more ways than I can describe. At first, I was glad when he was introduced by my batchmate for me to operate on since I am still lacking a case on major esophagogastric cases. I immediately reviewed his history and performed a physical examination on the patient. I also brushed up on my anatomy, the pathophysiology of the disease, the different treatment modalities offered for treatment. I was excited to handle a not-so-common major operative case. My thrill on performing the procedure soon began to wane as troubles arise-first on the improvement of the patient’s nutritional status, next is the consultant on board, followed by additional tests required in order to determine the pulmonary status of the patient because of the possibility of involvement of the chest for his operation. With a deep intake of breath, I all tackled it persistently and without a falter in my mood during my encounters with the patient and his family one-by-one. Eventually, I, with the guidance of my consultant and my supportive team, was able to finally operate on the patient. The patient’s postoperative stay was still not without worries, as we meticulously followed his vitals signs, drainage output, and daily performed a physical examination on him in order to ensure that we are not missing the beginnings of a dreadful anastomotic leak. Right when we were beginning to get confident that the patient will be finally sent home, when we were again beleaguered by a “complaint” regarding his management. A meeting was held with the Hospital Director and the Consultant to the Mayor regarding several points on his management. We defended ourselves with full confidence because all our requested examinations, needed medications, and needed operative materials were all within good judgement. On further investigation during the meeting, we were cleared of any allegations. That meeting was somehow disheartening since it showed all of us residents that no matter what good you show to your patients, there will always be other people, who would think otherwise. Being surgeon in a government hospital sure has its ups and downs. But in the end, I knew that I should not let it color my handling of this particular patient’s case or the other succeeding “care of” patients, which will fall under my care. Thankfully with the maturity brought about my seniority in the department a harmonious relationship is still created between me, the patient, and their relatives. And in a few days time, my most difficult patient will finally be sent home “Improved”.
INSIGHT: (Physical, Professional/Ethical, Psychosocial) (Stimulus, Discovery, Reinforcement)
Ever since I started my surgery training here in our beloved department, I have already accepted the intensity of general surgery residency in Ospital ng Maynila. As I went climb the ladder of residency, I have noted that it was both exhilarating and exhausting. Slowly, from my seniors and from my consultants, I have been developing my competency to handle wide variety of surgical cases. Slowly, I learned how to head off problems and arrive at solutions immediately and with more assurance. I have come to know most of the serious complications that could arise, and know the solutions to handle them. I have gained confidence in my surgical skills and ability to handle a wide range of situations.
Enduring the years in our hospital, other than competency in surgical procedures, I learned the value of resourcefulness. Being in our institution, we were behind the ideal and current surgical patient management. There were technological and surgical advances still not available within our reach. However, those limitations did not stop me and my fellow residents from learning. With our consultants who always supported us and pushed us, we always strive to give the best of care to patients by developing or improvising to near ideal set-up or facilities.
The grueling years of training in the department were made bearable by the strong bond of love and respect that revolves between each resident. Although, we still follow the rules of hierarchy, this training department has become more of a family. We treated our consultants and seniors before us with high regard because of their greater experience and knowledge. In turn, as a senior resident, I pass on my learnings to my junior residents so they too can benefit in honing their skills and aptitude in surgery.
In regards to dealing with difficult patients, paramedical personnel and difficult colleagues, I managed to make each encounter to be a challenge and not a personal attack on me. This approach I do has led to civilized discussion on contentious issues and resolution of problems.
Patients place their lives on our hands, a surgeon’s hand, mostly for life-altering operations. Therefore, we must always strive to better ourselves in order not to be left behind on the continually expanding and advancing surgical knowledge, techniques and technology. I then realized that a surgeon must dedicate their lives to continuous studying and learning so that patients get the best possible care.
I may be nearing this five-year journey but I know that I still have a long way to go. As this year comes to its end, realizations kept pouring in starting from the day that I decided to become a surgeon and applying here as a surgery resident. I know that this end is only the beginning. I am eternally grateful to my mentors for nurturing me and assisting me to reach this goal. I may not be the perfect apprentice but I know that I did my best. If I may go my separate way, I will always bring what I learned from them and will always look back from where it all began.
ROJoson’s Notes (15nov30):
There  will be more difficult patients to come, and indefinitely for that matter, as long as one continues to practice medicine and surgery.  There will be patients with more difficult health problems to solve.  There will be patients with more difficult mindset and personality to handle.  That’s the inherent challenge in the practice of medicine and surgery.  One has just to be perseverant if one wants to continue to practice medicine and surgery.
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