Responses to Reflection Questions by Dr. Abdul Nadir, Treating Physician Author

1. What barriers do you encounter in your own clinical practice/training that could promote delayed diagnosis and care?

In my practice in Islamabad, one of the barriers can be monetary. If I must perform an endoscopic procedure, I am cognizant of the fact that a patient may or may not be able to afford it. Typically, I try to perform only non-invasive and inexpensive tests to make an accurate diagnosis. As an example, I don’t do an endoscopy, which is frequently done to look for esophageal varices in US, and rather look at a combination of liver function tests and platelet count to determine Aspartate aminotransferase (AST) to platelet ratio to ascertain whether varices are present or absent.

2. What clinical reasoning practices do you (or could you) intentionally engage in to avoid cognitive biases in diagnosing patients?

I try to get first-hand information directly from the patient rather than relying on the second-hand information scribbled on prescriptions that a patient has brought to me for their clinic visit in Islamabad. Typically, a prescription may or may not have prior medical history, vital signs and chief complaint of a patient, which I try to review with my best ability.

I particularly check the medications a patient is on or has been on in the past before making a treatment plan. Typically a generic medicine with different trade names is manufactured by hundreds of pharmaceutical companies throughout Pakistan, and if I could not figure out what a trade name’s generic equivalent is, I ask patients to bring their medications or get someone to send the picture of the label so I can read the generic name of the medicine. Almost all patients come with an attendant in Islamabad, and frequently it will be the husband bringing his wife along and want to give a history on behalf of his wife. I try my utmost to listen to the wife and get her narration in the proper context, along with the caregivers input and review the paperwork available before making a strategy to combat the illness. As many say, a proper historical data contributes 90% in making an accurate diagnosis, while physical examination, review of records and investigations make the rest.

3. What intentional approaches do you take to better listen and communicate with patients, so they feel heard, respected and validated?

After introducing myself to my patient and their attendant, I listen to their story and do not interrupt them. Typically, they would stop within five minutes and then I clarify any part of the story that needs further elaboration. Even if patients take longer to give their history, I do not interrupt them and only occasionally, if they wander too much, lead them to what I am interested in knowing. Some patients take a bit longer, but many others want in and out of the doctor’s office and compensate for the time that another patient needs to get their point across. I try my best that my patients don’t feel that I am hurrying through their appointment.