The Doctor Will See You Now [Non-Fiction]

Chapter 139: General Medicine

In the cardiology pre-assessment clinic, I see patients coming in to get their coro+/-PCI (coronary angiogram +/- primary coronary intervention; basically, get their heart vessels looked at for blockage and maybe a stent or three if it's blocked). It's quite straightforward. Most of these people have had heart attacks so they'll need a stent or we have scans that suspect near-blockage of their blood vessels (such as on a CT scan or a treadmill test) so we need to confirm it. The waiting time for this clinic -- the last hurdle before the procedure -- is usually six to nine months. We also get them to bring their family because it's a consent clinic so the patient needs to sign, and ideally the family is present to help understand and ask any questions.

The schedule is they spend the early morning attending talks by nurses about the procedure of a coro+/-PCI and the funding and then go get their x-rays, ECGs, and echos. Then they see me and sign consent forms.

However, a lot of the time I wonder if the patient lives on a different planet altogether.

Me: So do you know why you're here today?

Patient: Oh, for my checkup. (No.) My lower back pain. (No.) I don't know, I just got told to be here. (Oh dear.)

This makes consenting patients for an invasive and not-that-low-risk procedure difficult because they have to actually know what they are getting. That is just step one of the consent.

I tell them they're here for coro+/-PCI. Some remember. Others claim they were never told.

Even though they just sat through a 2-hour seminar on coro+/-PCI.

I explain the consent process. To consent, the patient has to understand what I'm saying, retain what I'm saying, and make a consistent decision. I tell them I'll need them to repeat maybe one or two risks (out of the at least ten I tell them) to show they understand.

Me: So can you tell me one or two of the risks I told you about?

Patient: Oh, no need, it's safe.

Me: No, that's not how the consent goes. I need you to repeat one or two risks to show you remember and understand. Should I tell you again?

Patient: No, it's safe. It's OK.

I can't actually proceed with the consent when the patient just reassures me. They need to show me understanding.

Sometimes, it gets even wilder.

Patient: No. I refuse. I don't recall anyone telling me about this! I know nothing about this!

Me: But you agreed to be referred to this clinic nine months ago. And you just spent two hours in a talk about this.

Patient: I need time to think about this!

They should have been doing the thinking prior to the referral to this clinic nine months back, not when every preparation and investigation has already been done and we are just needing a signature. Now, this could very well be a colleague having miscommunicated to the patient when they made the referral or the patient having misunderstood, which is why they're here today oblivious to what is happening, but either way it means the same thing: we can't proceed and this is an unfortunate waste of my clinic slot time and other resources.

Me: That's fine, but this isn't a clinic for you to consider whether you're doing it or not. This is a clinic for those who have decided to go with it and to do all the preparation to go through with the procedure. If you can't decide, I'll cancel your slot today and you can have another referral once you've decided to go ahead.

Patient: Can I get back to you next week?

No. Slot cancelled.