1. Background and history
My patient, Mr. V is a 65-years-old Indian man. He was an accountant 5 years ago, previously worked in one of the companies in Malaysia before he retired. Mr. V is 83kg and 171 cm tall. His BMI is 28.4 kg/m2. He is living in Cheras, Selangor. Mr. V is suffering from metabolic syndrome. He was first diagnosed with type 2 diabetes mellitus 8 years ago. His blood glucose level at time of diagnosis was 12.0 mmol/L. He found out about this after having a blood test due to knee pain. After 3 years, he also developed hypertension and hypercholesterolemia. He was told by doctor his medical condition was due to poor eating habits and sedentary lifestyle. He had a pilonidal sinus surgery at 1980s. He is currently under medication of Metformin and Gliclazide for diabetes, Simvastatin for hypercholesterolemia and Pindolol for hypertension. He is compliance with all his medications (takes every morning for Metformin, Gliclazide and Pindolol and night for Simvastatin). Hence, all his medical conditions are under control. His blood pressure is 122/79 mmHg and fasting blood glucose level is 6.2 mmol/L for the latest checkup. He is a non-smoker but he does take alcohol. He normally takes 3 cans of beer every weekend and sometimes go for social drinking with his friends. Apart from hypercholesterolemia and hypertension, he does not develop any other conditions like kidney problems, myocardial infarction, stroke and others. However, at one time, he was once tested with fasting blood glucose level of 2.1 mmol/L asymptomatically. In his family, only he and his elder brother, aged 73 diagnosed with type 2 diabetes. His mother was passed away because of cirrhosis at age of 56. He is married and has 2 sons. His spouse and his sons do not have develop any major medical conditions.
2. Biological Aspects
Metabolic syndrome is a medical condition of fasting hyperglycemia, along with abdominal fat accumulation, hypertension and hyperlipidemia and is accompanied by high risk of vascular disease. (Martin, 2015). Metabolic syndrome could be due to genetic or lifestyle factor. However, in Mr.V’s case, it is most likely to be due to poor eating habits and sedentary lifestyle. Since he had pilonidal sinus surgery before, this could be due to his long hour of sitting while working as an accountant, which proves his sedentary lifestyle.(Kazim Duman, 2016) Poor eating habits like consuming high calories and high fat content food frequently will cause the increase of adipocyte in our body. Progressively, human body unable to provide sufficient blood to the increased adipocytes, causes the adipocyte undergo hypoxia and necrosis and release adipocytokine. Release of adipocytokine will cause imbalance of adiponectin, which promote insulin function and resistin, which resist insulin function, and eventually, leads to insulin resistance (Maxine A. Papadakis, 2017). Furthermore, overweight, minimal physical exercise, high fat diet and visceral obesity will cause insulin resistance. Insulin resistance will cause β-cells of pancreatic islets of Langerhans to secrete more insulin, causes hyperinsulinemia to lower the increased blood glucose level. Hyperinsulinemia able to compensate the abnormalities temporarily only. Eventually, there will not be sufficient insulin secreted to compensate it, and type 2 diabetes mellitus developed. Insulin functions by binding to ligand-activated tyrosine kinase and causes phosphoinositide 3-kinase (PI3K) pathway and mitogen-activated protein (MAP) kinase pathway(Bokhari, 2018). However, insulin resistance will block the PI3K pathway. Consequently, inhibiting PI3K pathway will reduce nitric oxide production, and cease glucose uptake by skeletal muscle(Takashi Tanaka, 2003). Furthermore, insulin resistance will cause lipolysis to be carried out without regulation. Hence, this will increase free fatty acid in body. These free fatty acid will leads to increase in production of apolipoprotein B which eventually increase production of VLDL(Julius, 2003). Moreover, insulin resistance causes lipoprotein lipase unable to reduce concentration of VLDL. Consequently, this will lead to hypercholesterolemia as VLDL will transport cholesterol ester and deposit in endothelium wall and causes increased risk of atherosclerosis(Bokhari, 2018). Besides, according to studies, (Strazzullo et al., 2006) insulin-resistant patient seems to show higher level of fractional proximal sodium re-absorption (FPRNa) compared to normal people. This means that the renal tubule tends to reabsorb more sodium ion, and which contribute to hypertension. Insulin resistant will also leads to elevation of endothelin-1, a peptide which causes vasoconstriction, and directly causes increase in blood pressure.(Sarafidis and Bakris, 2007). Moreover, Mr. V will experience hypoglycemia because of pindolol, a β1 and β2 adrenergic blocker, will inhibit hepatic gluconeogenesis and diminish glucagon response(Maxine A. Papadakis, 2017, P. T. Sawicki, 2001). Besides, Mr. V experience hypoglycemia unawareness mainly because of pindolol. Pindolol diminish symptoms of hypoglycemia like increased heartbeat rate by dampening adrenergic neurotransmitter (epinephrine and norepinephrine) response that released during hypoglycemia.(Goldstein, 2009)
3. Ethical Aspects
Medical Paternalism
The definition of medical paternalism is the doctor will decide for the patient that the doctor thinks in the best interest from the patient’s perspectives. Then, the patient will stick to the advice that the doctor offers. This causes an imbalance in therapeutic relationship that place doctor at higher position than patient. Medical paternalism is preferred in certain circumstances, for instance when the patient is severely ill, vulnerable, less knowledgeable. However, normally even though when the patient agrees to be in this therapeutic relationship, the suitability have to be considered. If medical paternalism is practiced, a detailed discussion between doctor and patient will less likely to take place. Hence, the modern therapeutic patient relationship is to put patient and doctor at the same level, and to make a decision together. In order to increase patient’s participation in decision-making, doctor needs to have a conducive environment to patient to welcome their opinion, knowing their expectations from doctor, providing sufficient information, and getting patient’s informed preference(Jonathan Silverman, 2013). In Mr. V’s case, he does not feel that doctor pressure him in anyways. In fact, doctor did inform him about the root of metabolic syndrome is due to lack of exercise and unhealthy diet and advise him to make changes in order to control this disease. Mr. V agrees to it and after discussing with doctor, he decided to exercise in a gym and take care of his diet. Mr. V is able to comply to the changes until now. Hence, all his medical conditions are under control. Becker’s health belief model states that doctors have to educate patient about their conditions, explain the treatment and outcome, and importantly understand patient’s inhibiting factors from adhering to the suggestions(Becker, 1974). The “best” decision is influenced by patient’s perception to the treatment procedure and together with doctor, only able to make the best suited decision for the patient(Deber, 1994). Mr.V’s case is a strong evidence that benefits can be yielded in the absence of medical paternalism.
Informed consent *
Informed consent is an agreement from patient that requires prior medical treatment. It is mandatory from ethical perspective. In order for patient to give an informed consent, patient must be given enough information and understand all procedures, outcome, risk, potential discomfort and benefits, , given sufficient time to make decision and remind patient to be able to withdraw consent at any point of time of feeling discomfort (John Harris, 2018, Lawal, 2011). Doctors have to respect for patient’s autonomy. A doctor should not carry out any medical procedures without patient’s informed consent. A proper form of consent should consist patient’s data, procedures, name of doctors, signature under wittiness(2013). In the case of patient is unable to understand what is being explained by the doctor like under drug influence, anaesthetics , doctor would need to get consent from family or relatives. Moreover, if the procedure is to be carried out by different doctor, an informed consent should be obtained from patient as well. Informed consent is significant as this is to protect individual right. Patient possess the right to choose medical treatments and this is superior than doctor’s duty to treat patients (Lawal, 2011). Besides, taking informed consent is also an obligation for doctor , as this will give an impression to the patient that the doctor is competent to the proposed treatment or procedure, and sometimes might aid in finding out unexpected findings(2013). In Mr. V’s case, as mentioned by Mr. V, doctor did not officially ask for his consent before simple procedure like taking blood pressure and testing blood glucose level. However, when the doctor requests blood test or urine test, doctor will explain the purpose of the tests and get consent from him. Since Mr. V is able to understand what is being told by the doctor, Mr. V is able to give an informed consent to doctor prior any medical treatments.
Confidentiality
Confidentiality in medical field means prevent spreading of information that patient provides to third parties without patient’s knowledge(Saunders, 2016). Confidentiality is significant in protecting every patient’s right, impede exploitation of information, and respect patient’s decision. Ignoring confidentiality will lead to distrust in therapeutic relationship and became barrier for patient to seek medical help. (Julius Bourke, 2008). There should not be disclosure of information to even patient’s families without patient’s consent. Confidentiality need to maintained even after patient deceased(Saunders, 2016). There are some challenges sometimes to remain confidentiality. For instance, in Mr. V clinics, two patients will be in the consultation room, being interviewed by two doctors. It is possible where one patient might overheard another patient’s personal information, hence, confidentiality is breached. Furthermore, even though it is unavoidable for doctors to discuss patient’s condition sometimes, doctor should try to avoid discuss in crowded area to prevent unintentional disclosure of information(2011). For instance, during my medical visit, as previously mentioned, the two doctors in same consultation room sometimes will discuss about some patient’s condition, nevertheless they discuss only when there are no patients in consultation room and stop discussing before the next patient come in. During their discussion, they never mention about names, instead they keep the patient’s identities anonymous. This is the practice that it should be to prevent disclosure of patient’s information. Apart from that, the clinic is using computer to store patient’s medical record. The obligation of protecting the data falls under the doctor where doctor have to make sure that only appropriate user able to access to patient’s data and restrict unauthorized user from getting access to the data. As mentioned previously, metabolic syndrome can be caused by genetic factor. If Mr. V were to have to do genetic testing, all information regarding genetic can only be revealed upon patient’s consent. If patient refused to, provided this will not lead to significant threat to health of the relatives and families, doctor should kept the result confidential. (2011)
4. Legal Aspects
A valid consent is characterized by the consent is given voluntarily, well-informed and competent to make decision. Patient that aged 18 and above is considered majority and possess legal capacity to give a valid consent. In minority cases, parental or guardian’s consent is required. Patient need to have mental capacity where patient able to make understand, remember, reasoning using information being exposed and expresses decision(Matthew Hotopf, 2004). In Mr.V’s case, he is able to give a valid consent as he fulfilled the capacity to give an informed consent. If there is no valid consent being given, doctor can be sued with assault or battery. The only circumstance that informed consent is not required when it is an emergency where informed consent is impossible to get and due to time constrain, doctor should act in patient’s best interest to produce best therapeutic outcome provided the patient had not signed any refusal treatment documents(1995). Besides, under normal circumstances, patient’s information should be remained private and confidential and not to disclose to third parties. This is because according to Personal Data Protection Act 2010, data user ( hospital or doctor) should not be revealing patient’s data or else the data user will be fined maximum RM300,000 or imprisonment not more than 2 years or both.(Malaysia, 2010) . However, there are some circumstance where legitimate assumption of patient would wish to disclose information even lack of mental capacity for instance coma after accidents. It is best not to assume patient’s consent and respect patient’s autonomy. There are some circumstances where confidentiality can be breached. For instance when instructed by court, to protect public interest when reporting infectious disease, these are the incidences where patient’s consent is not required as public safety outweighs than individual right. Apart from these, under other incidences like disclosure for medical research, report victim of abuse, disclosure to families and others can only be done upon patient’s valid consent. Even though after obtaining patient’s consent, patient identities must be de-identified and only disclose the relevant information. (2011)
5. Sociological Aspects
In Mr. V’s case, from the perspective of political view, government policies do have an impact on his health. The clinic that Mr. V goes for routine medical checkup and medicine collection is fully subsidized by government and it is free of charge for citizen that aged 60 and above. As mentioned by Mr. V, this clearly reduce his much of his financial burden as without this, he would have to purchase all the medications out of pocket in long term and under the government policy, this will ensure the continuation availability of medication to him. As for social aspects, the nature of his job had benefitted him from getting more serious disease. Mr. V felt that the stress that he had when he was working was bearable, and he has sufficient quality sleep every night (7 hours) before and after retirement. He strongly believes that this is the reason that until now he only developed metabolic syndrome but not other serious diseases like cancer. This is because when he does not experienced stress, he is less likely to be engaged in smoking or taking drugs, which reduce his risk of developing cancer. Moreover, he expressed that education of metabolic syndrome would have benefited him. Mr. V wishes to know more about the consequence of his poor eating habits and sedentary lifestyle and would take preventive measures before being diagnosed with diabetes. Not only knowledge of disease, if he were to be informed to conduct annual medical body check up, he might notice the high risk of developing diabetes and could have taken some proactive measures before it actually arise. From the point of ethnicity, because majority of his friends are Indians and Chinese, which influences him to start drinking. This is undeniably true as there are 62.5% and 49.7% Indian and Chinese heavy drinker, ranked 1st and 3rd in alcohol consumption among different ethnic groups in Malaysia.(Abd Kadir Abu Bakar, 2015).
6. Self-Care and Lifestyle
Since Mr. V is retired, he is now living with relaxed lifestyle and minimal stress. He has no major financial crisis currently. He is living harmoniously and happily with his spouse. Even though their sons are not living with them but very often his sons will come back for dinner with them. His residential area is fairly relaxing, comforting and lesser car. He did not know anything much related to diabetes mellitus apart from being hyperglycemia prior diagnosis, and until now, he sees hypercholesterolemia and hypertension as separate disease and do not know these diseases are interrelated. Only as soon as he realized the root of the problem, he started to modify his lifestyle by controlling his diet and exercising. He and his wife each cook two dishes for lunch every day. They only eat vegetables for lunch. He tries to reduce intake of rice as well. Moreover, he stops drinking sugary drinks like carbonated drinks. For exercise, he started to go the gym near his housing area and runs at least 5 km on treadmill. He goes to the gym 4 times per week. He is a Hinduist but he does not believe any alternative medicines and only takes orthodox medicine. Regarding stress management, he believes that he did not experience much stress when he was working before. He mentioned that he did a stress test before he was retired and the result stated that his stress level was optimal at that time. He usually unwinds his stress by having drinks with his friends. Lastly, he had no issues to connect to family and friends, and he mentioned with the advancement of technologies even further foster his relationship with surrounding people.
7. Patient’s Perspective
At the time of being diagnosed, he recalled that he had a slight feeling of denial, worried and helplessness. Even though he was diagnosed in 2010, he initially refused to take medication. However, the feelings did not last long as he knew that this is very common. This is because the doctor explained to him about his medical conditions, medication and lifestyle modification. Hence, he did not feel helpless after that and started his medication since 2011. He mentioned that the conditions just arise naturally. Regarding to his medical checkup, he has been seeing the same doctor for several years and he is satisfied with the doctor and all medical staffs. All staffs are punctual to serve patients. However, the waiting time sometimes can be very long and he needed to take leave every time he came for medical checkups, hence he suggested that the service could be better if there is additional number of staff to handle vast number of patients every day. He chooses to visit this clinic because of the completeness of facilities compared to other government subsidized clinics like X-ray, blood test, urine test and others. This is the reason why he willing to travel 20 minutes from his house to the clinics by motorcycle every month. Regarding monthly collection of medication, he finds it is quite inconvenient but he understands that this is government policies to minimize wastage of medicine. Even though Mr. V is under medications for hypercholesterolemia and hypertension, he still thought he only had diabetes as his cholesterol and blood pressure reading is normal.
8. Own Perspective
In my own reflection, I think the interview went very smoothly and he was very willing to share and respond to all our questions, even all medication name. However, as previously mentioned, the patient actually did not realize he had hypercholesterolemia and hypertension as the reading seems to be normal. However, it could be due to the medications that he has been taking that controlling the medical conditions. He repeatedly mentioned that the disease arises naturally, which clearly, he is unable to understand thoroughly that his lifestyle is the major contributing factor. I believe he is not the only patient that will think this way. A lot of people will not realize the importance of having good eating habits and exercising until their health problem arise. Hence, in future, when I become a practitioner, I will try my best to educate people surrounding me and my patients about the importance of a healthy lifestyle and encourage them to adopt it to take it as early intervention or preventive measures before any medical conditions arise. In Mr. V case, now he has been taking care of his diet and exercising frequently. If he were to do this in earlier time, he might not need to take any medications by now and able to live a healthy life. Moreover, by educating them the importance of healthy lifestyle can reduce the risk of their child being diagnosed with metabolic syndrome as well. Their child genetically is already being at higher risk of developing metabolic syndrome compared with other people, if the child adopted the unhealthy lifestyle from parents, this is a chain effects that contribute to even more patients suffered from metabolic syndrome in future.