|Year : 2012 | Volume
| Issue : 1 | Page : 1-3
Counseling notes: A missing title in the medical records
Department of Surgery, J.N. Medical College, Belgaum, India
|Date of Web Publication||21-May-2012|
Department of Surgery, J.N. Medical College, Belgaum
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Godhi A. Counseling notes: A missing title in the medical records. J Sci Soc 2012;39:1-3
There is a conspicuous absence of counseling notes in our medical records. The medical students are not trained in the art of counseling techniques. One of the reasons for this may be the absence of this title in the standard protocol of case sheet writing. Many text books on clinical methods describe the format of case sheet writing under several titles, namely, chief complaints, history of present illness, past history, family history, personal history, general physical examination, local examination, systemic examination, diagnosis, investigations, plan of treatment, execution of the plan, follow-up, and outcome. An important title between the plan of treatment and the execution of the plan is the title of 'counseling notes' and this is missing in most of our medical records. The reason for this realization is the changing scenario in the medical profession in the recent times.
| Changing Scenario and the Need for Counseling|| |
In the past the patients accepted the treatment planned and executed by the doctors who practiced paternalistic medicine. In choosing the doctors, the patients had few options. Illiteracy was rampant and the patients were generally ignorant about the diseases. This scenario has progressively changed over the years. People have become more educated and the media has played its role in mass health education. The common man has some general knowledge about common diseases. Doctors, corporate hospitals, and the nursing homes have proliferated, and the patients can exercise their option more than ever before. Doctors have retracted from the paternalistic roles; patients have to participate in the decision-making process. The phenomenal growth of medical science, astonishing technological advances, increasing healthcare costs, improving awareness, rising expectations of the patients, and most importantly the consumer protection act have brought into sharp focus the missing title called 'counseling notes' in our medical records.
Counseling means, "exchange of opinions to reach a conclusion" (Webster's Dictionary). There is hardly any place for counseling, while eliciting a patient's medical history; a formal consent is required for a physical examination, especially internal examination. It is at the end of the physical examination that the counseling takes an increasingly important role in the dilemma of diagnosis, accuracy of investigations, treatment options, outcome, complications, and the costs.
| Dilemma of Diagnosis|| |
The patients often expect that every disease should be diagnosed on the first visit with cent percent accuracy; in simple diseases it is possible, but not in complicated ones, and if this is made known to them their mind is prepared to accept a subsequent change in the diagnosis. When the final diagnosis is less serious than the first, the patients are happy to accept it, but if it is more serious the patients experience effects such as unhappiness and loss of faith in the doctors. The intensity of these undesirable, but unavoidable effects of change in the diagnosis can be minimized by prior counseling. For example, a benign looking breast lump turning out to be malignant in the HPR.
| Accuracy of Investigations and their Complications|| |
Many patients believe that it is always possible to prove the diagnosis by laboratory tests and that more expensive the tests, the more accurate they are; counseling should remove this misconception. Laboratory tests are not always 100% sensitive and specific. Patients with simple curable disease do not pose much of a problem, but those with serious and life-threatening or incurable diseases often demand foolproof laboratory diagnosis, and such a proof is not always possible to secure. In the absence of such a proof and when the laboratory test reports are conflicting, counseling becomes increasingly difficult, for example, disagreement between pathologists about the presence or absence of cancer in a specimen. Counseling should also include a brief mention about the anticipated complications of the investigations, for example, allergic reaction to IV contrast.
| Plan of Treatment and the Complications|| |
That the patient has to participate in the planning and execution of the treatment is an accepted norm. The doctor has to offer treatment options, discuss the merits and demerits of each modality, and then decide to administer it. Possible complications and their approximate incidence should be discussed, for example, recurrent nerve palsy in thyroidectomy. In surgical treatment it has important implications; in the middle of the operation, when the patient is unconscious, the surgeon may be compelled by unexpected circumstances to alter the plan of treatment, for example, colostomy during an emergency exploration for intestinal obstruction.
| The Quality of Outcome|| |
It is a fond desire of many patients that every disease is completely curable. Many diseases, disabilities, and deaths are not totally preventable by the most modern medicine. Discussion about the outcome of treatment is especially important in surgical patients, because, the operation is an event unparalleled in non-surgical branches of medicine; and any adverse postoperative outcome is almost always attributed to surgery. In a search for a cure for incurable diseases, the patients keep changing doctors and hospitals, spending their resources, until they are told and convinced that cure is unachievable. Counsel the patient with an incurable disease to accept the disease and live with it and those with fatal disease to accept the ultimate and depart with dignity. The patients' ability to cope with the disease and accept the outcome of treatment improves if it is told to them before executing the treatment; whatever may be the anticipated outcome - whether palliation or cure.
| Methods of Counseling|| |
There is no single best method suitable for all patients on all occasions. Counseling is individualized and personalized. Verbal counseling is the most common method [Table 1]. Showing charts, diagrams is an easy and effective way of convincing. Showing other patients being treated for a similar disease is quite helpful. Giving the patient education material for reading or showing a video are other methods. Speaking the patient's language and having a good vocabulary and communication skills makes the job easier.
| Factors Influencing the Counseling|| |
Patients background, literacy, level of understanding and trust in the doctor are the most important patient factors. The suspicious and indecisive mind of the patient is an obstacle. Patients' perceptions about the doctor's honesty, trustworthiness, dependability, empathy, and intensions have their measure of impact on counseling. Nature of illness, whether simple, curable, simple to diagnose and treat with assured successful outcome, or a complex disease, difficult to diagnose and treat with a guarded prognosis, or a fatal incurable disease, have an important bearing on counseling.
| Characteristics of Good Counseling|| |
The patients are in a state of physical, psychosocial, familial, financial, functional, emotional, and spiritual distress. Counseling should more or less address all these issues. It should be careful, cautious, convincing, consoling, and reassuring, and not careless, confusing, misleading, indifferent, and intimidating. How much to tell, how and when to tell, how much is too much or too less, and how much is optimum, depends upon the factors influencing the counseling. There may be a paradoxical situation when the doctor is extremely happy after a successful treatment of a complicated disease, and the patient is extremely unhappy because of improper counseling and unrealistically high expectations. Beneficence (do good) and nonmaleficence (do no harm) should be the guiding principles.
| Truth and Counseling|| |
Telling the truth is the best policy in counseling. Bitter truth can be made more palatable; refrain from temptation to hide the truth. Lies need to be remembered. Truth need not be remembered because the truth is durable, constant, and consistent. When the whole truth is not known, tell what is known for sure.
| Counseling and the Percentage|| |
In medicine nothing is 100%. Use 'percentage' liberally in counseling. For example, 10% conversion rate in laparoscopic cholecystectomy, 50 - 60% five-year survival in cancer patients, 90 - 95% cure rate in hernia repair, 5 - 10% recurrence rate after fistulectomy, 50 - 60% chance of saving a diabetic foot, and so on.
| Consumer Protection Act and Patients Rights|| |
Patients rights are supreme and one should remember to respect them while counseling: right to refuse the plan of treatment suggested by the doctor, right to information, to have a second opinion, to change the doctor and the hospital in the middle of the treatment; the doctor need not feel embarrassed. The Consumer Protection Act (COPRA) has given another right, the right to file a suit in the consumer forum. Many of the consumer cases against the doctors are avoidable if every patient is counseled properly and more importantly the counseling notes are documented in the medical records and authenticated by the doctor, patient / relative, and a witness. Many unsavory instances of the public taking the law into their hands and manhandling the doctors and ransacking the hospitals are preventable by proper counseling.
A consent form is an important documentary evidence in the consumer court. A printed consent form, which is usually signed by the patient / relative at the time of admission, giving a blanket consent for all tests and treatment is weak evidence. Consent taken after the counseling notes are documented is strong evidence, which can save the doctors from many consumer cases. The communication and counseling skills are put to an acid test by the worst situations, wherein the treatment results in a severe adverse outcome due to the most unanticipated rare complication, for example, death due to drug reaction. Successful counseling will convince, console, and calm the agitated and aggrieved relatives, who understand the human limitations of the doctors and the uncertainties of medical science.
| Counseling Triangle|| |
When counseling, the doctor should be acutely aware of the presence of others (e.g., relatives) and should put himself in the place of the patient and others and look at and listen to the doctor (himself) [Figure 1].
| Conclusion|| |
Counseling is an art more than a science, more psychology and sociology, than medicine and surgery. As much a share of the success of the doctor in the practice of medicine goes to his communication and counseling skills as his medical knowledge and technical skills, which must be kept updated. Documenting, 'Good counseling notes' in the medical records is a positive step forward to preserve the dignity and nobility of our profession.