The Lancet Student

Truth in clinical practice - Mauricio Avila-Guerra

This blog was submitted by TLS editor on 24th November 2011.
Tagged with truth-telling, clinical practice

*My response to the recent Lancet editorial, Truth-telling in clinical practice.

Adam FowlerI am a fifth year medical student from Bogotá, Colombia. Colombia is categorized as a developing country, with a population of 44 million. Of this number, around 1.7 million can neither read nor write. In countries like Colombia, it is therefore important to consider you may often work with patients who fit both categories (illiterate and living in a developing country).

I had the opportunity to do an internal medicine clerkship, in my third year of medical school, in the National Cancer Institute in Bogotá; it was a shocking experience (both good and bad). Being in a cancer institute, of course as a patient you’d know you have cancer, but then the question, is how much time do you have left?... or even, will you survive?

Two experiences I had with “truth-telling” happened there. Both of my patients were from a rural area, and neither of them had come to the capital (Bogotá) before. The first patient , was an eight year old boy suffering from leukemia. I had to tell him the truth - that he had little time left to live. He said to me, “I know, I’m going to die. Do not sit with me, sit with my mom… she is very sad because I’m leaving”. I was perplexed; an eight year old boy was much more mature about death than I. It was the first time that little boyhad been told about cancer and death. In the short period of time since his diagnosis he had processed all that information and realized he was going to die. I wasn’t aware of death at that age; it took me much longer to figure out the meaning of dying.

The second clinical experience was with a 24 year old, young man suffering from colorectal cancer. He had a family history of cancer in young adults, and one of his brothers had colorectal cancer too. He had no formal education at all. I realized this when I gave him a patient brochure about cancer, and he did not read it. I had to tell him that he already had a metastatic disease, explaining his back pain and subsequent paralysis were due to a metastasis in one of his vertebrae. His answer was, “when am I leaving the hospital?” I explained again the truth - the severity of his disease, explaining why his disease could not be treated at home with “natural remedies” (mixes of herbs and parts of animals that were used in his town) and that he needed to be in the hospital, but  again, he told me “I just want to go home.” After that I went to speak with his sister, I told her the same about the metastatic disease and the need to be in a hospital, I even told her that she should run some tests because of her family history of cancer, again I got the same answer, “he just wants to go home.” I was confused; I didn’t understand why he wanted to go home and not to be in a hospital where he was being taken care of. That week my patient died, he was the first patient I was in charge of (as a student) who died.

I personally think truth-telling and dealing with the results of conveying certain information is all about negotiation and knowing your patient. You can’t treat all the patients the same way. Even if you are delivering the same information, it is not a script. Whatever the brackground, every consult is a new story you will write with every one of your patients.

A fifth year medical student in the Pontificia Universidad Javeriana in Bogotá Colombia, I am interested in neurosurgery, neurology (neurosciences in general) and education. I am part of the neurosciences group of the Hospital Universitario San Ignacio, and the Hippocampus group, a student-based neurosciences research group.