11

THE DOCTOR’S NAME THE DOCTOR’S NAME IN OUR BEAUTIFUL ARABIC IN OUR BEAUTIFUL ARABIC

LANGUAGELANGUAGE

HAKIM ( THE WISE PERSON)HAKIM ( THE WISE PERSON)

حكيمحكيمSO DOCTORS ARE WISE PERSONSSO DOCTORS ARE WISE PERSONS

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How ARE YOU GOING TO USE How ARE YOU GOING TO USE YOUR WISDOM ? YOUR WISDOM ?

If you are called to see a case in E.RIf you are called to see a case in E.R

And you haven't seen a similar case in your And you haven't seen a similar case in your carriercarrier

Do not panic. Do not get nervous. Do not start Do not panic. Do not get nervous. Do not start thinking who to call.thinking who to call.

A very good history may lead you to solve the A very good history may lead you to solve the problem.problem.

Think rational and analyze every symptom and Think rational and analyze every symptom and sign. sign.

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SO WE MUST USE OUR WISDOMSO WE MUST USE OUR WISDOMRelax & be your self when you see the Relax & be your self when you see the patient for the first time.patient for the first time.Think rationale & do not panic.Think rationale & do not panic.Do not let the patient lead you especially if Do not let the patient lead you especially if the patient is bad historian.the patient is bad historian.Remember that you need to take action Remember that you need to take action according to the case in front of you.according to the case in front of you.Do not let the thoughts of Do not let the thoughts of medico legalmedico legal consequences direct you in ordering too consequences direct you in ordering too many lab & x-ray investigations. many lab & x-ray investigations.

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Before ordering any investigation ask Before ordering any investigation ask your self the following questionsyour self the following questions

Is this investigation necessary?Is this investigation necessary?Will this investigation help the patient?Will this investigation help the patient?Will the result of this investigation help me Will the result of this investigation help me to reach a diagnosis?.to reach a diagnosis?.Are we suspecting a treatable condition?Are we suspecting a treatable condition?Will the result of this investigation change Will the result of this investigation change the line of management ?the line of management ?If the result is positive am I going to If the result is positive am I going to prescribe medication? Or send the patient prescribe medication? Or send the patient to O.R ?to O.R ?

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Instead of asking the Specialist or the Instead of asking the Specialist or the Radiologist to come at midnight , why Radiologist to come at midnight , why don’t you spare them for a possible RTA don’t you spare them for a possible RTA after some time?after some time?

66

Medicine is common senseMedicine is common senseWhat is this?What is this?SHORTNESS OF BREATH SHORTNESS OF BREATH AND DILATED VEINS ON ANT AND DILATED VEINS ON ANT CHEST WALL.CHEST WALL.Are u going to waste time by Are u going to waste time by doing CT scan in the middle of doing CT scan in the middle of the night?the night?Are u going to bring the ENT Are u going to bring the ENT consultant for urgent consultant for urgent tracheostomy?tracheostomy?OK take a second look at the OK take a second look at the patient and think RATIONAL.patient and think RATIONAL.Ask your self why this guy is Ask your self why this guy is having dilated veins on the having dilated veins on the anterior chest area?anterior chest area?Why he is having shortness of Why he is having shortness of breath?breath?

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??Then what is this? Then what is this? Dilated anterior chest Dilated anterior chest veins, and whole neck veins, and whole neck swelling. swelling. Why the DyspneaWhy the DyspneaDoes he have any thing Does he have any thing obstructing that blood obstructing that blood vessel which drains this vessel which drains this area? area? So their must be some So their must be some thing wrong in side his thing wrong in side his thoraxthoraxI Will do a simple, I Will do a simple, cheap quick CXR cheap quick CXR

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That is it,That is it,So it is a SVCOSo it is a SVCO

Are u going to call the CTS Are u going to call the CTS consultant for tissue consultant for tissue diagnosis? Which will not diagnosis? Which will not help the patient now and help the patient now and will keep him in agony for a will keep him in agony for a week?week?

Or say let us comfort the pt Or say let us comfort the pt and give him some thing to and give him some thing to relieve this condition? relieve this condition?

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So u have chosen to give a very high dose of So u have chosen to give a very high dose of Dexamethasone 24 mg stat and then 8 mg q 6 Dexamethasone 24 mg stat and then 8 mg q 6 hourly.+ Mannitol + Ohourly.+ Mannitol + O22

On the Next day in the morning u will feel how On the Next day in the morning u will feel how satisfied u r .satisfied u r .

Ask the CTS consultant to provide histology very Ask the CTS consultant to provide histology very quickly. Ask your Oncologist to come and see quickly. Ask your Oncologist to come and see patient. patient.

If this is due to Lymphoma then He might be able to If this is due to Lymphoma then He might be able to give him the first course of chemotherapy before give him the first course of chemotherapy before his referral to KFSH.his referral to KFSH.

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Think always wiselyThink always wiselyWhat is this ?What is this ?

What is this huge mass What is this huge mass under the chin? under the chin?

And why she is having And why she is having difficulty of breath?difficulty of breath?

What are we going to do?What are we going to do?

Send her for CT scan in Send her for CT scan in the middle of the night?the middle of the night?

The CT will show u the The CT will show u the mass. but will not solve mass. but will not solve the problem. the problem.

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Are u going to Take a biopsy and Are u going to Take a biopsy and wait for one week for the result while wait for one week for the result while she is in agony? she is in agony? Then start asking your self what Then start asking your self what conditions can give a similar conditions can give a similar picture? But u r still wasting picture? But u r still wasting precious time.precious time.Instead PHONE the ENT on duty to Instead PHONE the ENT on duty to come for urgent tracheostomy and come for urgent tracheostomy and ask him to take a piece of tissue for ask him to take a piece of tissue for histology during his work .histology during his work .Relive the pt’s agony and give her Relive the pt’s agony and give her high dose of steroids. high dose of steroids. Next morning discuss her with your Next morning discuss her with your colleagues . They will agree on one colleagues . They will agree on one diagnosis :Anaplastic carcinoma of diagnosis :Anaplastic carcinoma of thyroid. thyroid.

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Consult your Oncologist and he will advice you Consult your Oncologist and he will advice you to write an urgent fax to KFSH for quick to write an urgent fax to KFSH for quick course of palliative radiotherapy course of palliative radiotherapy

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A young pt comes with severe A young pt comes with severe Haemoptysis Haemoptysis

He is loosing a lot of blood and coughing blood He is loosing a lot of blood and coughing blood all the time.all the time.

Suddenly he starts complaining of symptoms of Suddenly he starts complaining of symptoms of pulmonary embolism.pulmonary embolism.

Are u going to request an urgent lung scan?Are u going to request an urgent lung scan?

If there is P.E are u going to give him If there is P.E are u going to give him anticoagulants?anticoagulants?

The answer is NO . Then why request L.S in The answer is NO . Then why request L.S in the first place?the first place?

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If your colleague is presenting a If your colleague is presenting a case during the morning reportcase during the morning report

Do not ask questions you already know Do not ask questions you already know their answer .their answer .

Try your best not to interrupt him/herTry your best not to interrupt him/her

Do not try to irritate your colleague: He is Do not try to irritate your colleague: He is having enough stress so don’t increase it.having enough stress so don’t increase it.

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If the patient’s case being presented was If the patient’s case being presented was hospitalised elsewhere :hospitalised elsewhere :

And the colleague presenting the case And the colleague presenting the case says: the xxxx investigation was not done says: the xxxx investigation was not done for this patient at that hospital .for this patient at that hospital .

Then do not ask him why this was not Then do not ask him why this was not done at that hospital……………..done at that hospital……………..

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Because :Because :

That question implies two possible That question implies two possible answers and a sarcastic insinuation The answers and a sarcastic insinuation The two possible answers will be:two possible answers will be:

How can I know how that hospital’s How can I know how that hospital’s doctors thinkdoctors think

Or : I do not knowOr : I do not know

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““why they did not do it at the xxxx why they did not do it at the xxxx hospital” ?hospital” ?

If your colleague presenting the case thinks If your colleague presenting the case thinks that your question was that your question was a sarcastic a sarcastic insinuation:insinuation:

Then this question means from in between Then this question means from in between the lines: “the lines: “Are you better than that hospital Are you better than that hospital doctors”? doctors”?

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If your colleague is presenting an If your colleague is presenting an advanced lung cancer case with advanced lung cancer case with

metastases metastases

Do not incest in which lung lobe the Do not incest in which lung lobe the primary is. what difference does it make to primary is. what difference does it make to you or to the stage IV patient. you or to the stage IV patient.

Unless if you are going to prescribe now a Unless if you are going to prescribe now a palliative radiotherapy course palliative radiotherapy course

2020

COMMUNICATION SKILLS – DOCTOR-PATIENT RELATIONSHIP

A Letter to all residents and junior specialists preparing for exam

By

(Dr. Mohammed Zakaria,)

Snr. Consultant - Clinical Oncologist)

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what kind of person ????(patient you are dealing with.)???

Before you reach a diagnosis and opt:

For

A treatment modality, you will have known by then what kind of person: The (patient you are dealing with.)

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What type of pt you are dealing What type of pt you are dealing with ????with ????

In a 5 year study I conducted about patient delay in presentation in Jordan:

Among the other results discovered we also noticed that :

There are only 3 types of patients

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What type of pt you are dealing What type of pt you are dealing with ????with ????

The strong patient:The strong patient: Asks about his/her Asks about his/her disease and wants to know everything disease and wants to know everything about his/her sickness. about his/her sickness.

He/She goes to the public library to He/She goes to the public library to search and read about his/her disease. search and read about his/her disease. Now they are using the Now they are using the internet internet which which will give more than enough details. will give more than enough details.

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The strong patientThe strong patient

The good thing about these patients is The good thing about these patients is he/she brings to you the latest news about he/she brings to you the latest news about his/her illness. his/her illness.

Do not refuse to take these papers from Do not refuse to take these papers from him/her and read them or you can do the him/her and read them or you can do the following:following:

Look at the article and say Oh Yes, I have Look at the article and say Oh Yes, I have read this article and I will read it again.read this article and I will read it again.

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The weak patient

The weak patient always asks about his illness like

1-“is it fatal, is there any treatment for it, 2-when I am going to die” In this case, use your diplomacy in answering

these questions.You can fight this disease only with courage &

co-operating with us.FOR ALLAH’s sake do not tell the Pt. about the

prognosis or life span.

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The indifferent patientThe indifferent patient

The indifferent patient – she/he The indifferent patient – she/he does not does not want to askwant to ask you you

nor wants to be toldnor wants to be told. .

He/she will do anything you tell, but deep He/she will do anything you tell, but deep inside them they know what is going on.inside them they know what is going on.

Be always serious but with a smile. Be always serious but with a smile.

Don’t joke with patient..Don’t joke with patient..

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Talking to patients at different times for Talking to patients at different times for different purposesdifferent purposes::First meeting - Give a smile and introduce First meeting - Give a smile and introduce yourself to the patient by saying your name and yourself to the patient by saying your name and post . (Resident, Specialist , Consultant)post . (Resident, Specialist , Consultant)Show the patient that you are very much Show the patient that you are very much concerned about him/her.concerned about him/her.Read the referral letter carefully and write a note Read the referral letter carefully and write a note on the new patient’s file. on the new patient’s file. Don’t undermine the referring doctorDon’t undermine the referring doctor..

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TAKING HISTORYTAKING HISTORY

OK, I read your referral letter but I want to OK, I read your referral letter but I want to hear from you. What brings you here ?hear from you. What brings you here ?

Do not ask the patient using medical Do not ask the patient using medical terms. Let’s start from head to feet.terms. Let’s start from head to feet.

Do not say – Do you have migraine, but Do not say – Do you have migraine, but say instead is your Headache on one sidesay instead is your Headache on one side

Do not say – Is it regular or irregular, but Do not say – Is it regular or irregular, but say instead how often it comes to You.say instead how often it comes to You.

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TAKING HISTORYTAKING HISTORY

a. Very gently tell the patient that you are going a. Very gently tell the patient that you are going to ask some questionsto ask some questions

b. Do not start with personal questions – as b. Do not start with personal questions – as period in female, sleeping habits or period in female, sleeping habits or

Night performance, Night performance,

c. Don’t ask direct questions (Are u Alcoholic? c. Don’t ask direct questions (Are u Alcoholic? Are you a heavy smoker) etc.Are you a heavy smoker) etc.

d. Ask about the age in very delicate way as d. Ask about the age in very delicate way as when you were you born etc.when you were you born etc.

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Do not say – Nostril, but you can say nose Do not say – Nostril, but you can say nose openingopening

Do not say – Haemoptysis, instead ask “did you Do not say – Haemoptysis, instead ask “did you notice red streaks in your saliva after coughing.notice red streaks in your saliva after coughing.

Do not say – I am going to examine your cervical Do not say – I am going to examine your cervical regions and supra clavicular areas, instead say regions and supra clavicular areas, instead say “may I have a look and feel your neck and the “may I have a look and feel your neck and the area above and below your collar bones.area above and below your collar bones.

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Examination:According to the case, i.e. if the patient is referred to you for a lump in the breast and you have asked her all the relative questions in simple plain words,

(do not say – Can I have a look at your breasts?. The examiner will tell you – come to see us back again next year…….caution).

Say, “now can I have a look at that lump”

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Do not say – When did you start having shortness Do not say – When did you start having shortness of breath or (SOB). of breath or (SOB).

How on earth the patient will know our How on earth the patient will know our abbreviations, but you can say “when did you abbreviations, but you can say “when did you start feeling difficulty of breathing”.start feeling difficulty of breathing”.

Do not say – Trachea – but say your wind pipe.Do not say – Trachea – but say your wind pipe.

Do not say – Oesophagus but say gallot Do not say – Oesophagus but say gallot

(or food pipe)(or food pipe)

Do not say – Dysphagia, but say difficulty in Do not say – Dysphagia, but say difficulty in passing foods through your Gallot. passing foods through your Gallot.

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TIP…..1TIP…..1

I cannot list all words, but my dear I cannot list all words, but my dear colleagues, remember colleagues, remember NOT to talk to patient in medical names or NOT to talk to patient in medical names or terms terms Especially if you are being examined Especially if you are being examined and the examiner is witnessing your and the examiner is witnessing your history taking and patient examinationhistory taking and patient examination..The examiner will get irritated and may tell The examiner will get irritated and may tell u come & see him again next year…….u come & see him again next year…….

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TIP …..2TIP …..2

For example, if the examiner shows you a For example, if the examiner shows you a short case of Ca lip short case of Ca lip

Do not hesitate to ask the patient if he is a Do not hesitate to ask the patient if he is a pipe-smoker pipe-smoker

(so the examiner will take a good (so the examiner will take a good impression about you). impression about you).

This is only an example. Always ask the Pt. This is only an example. Always ask the Pt. relevant questions. relevant questions.

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EXAMPLEEXAMPLE

If you encounter a basal cell carcinoma on If you encounter a basal cell carcinoma on the inner canthus or else where the inner canthus or else where

ask the patient if during his career or in ask the patient if during his career or in holidays was continuously exposed to sun holidays was continuously exposed to sun light.light.

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Now you have examined the patient and Now you have examined the patient and you are thinking of a specific disease. you are thinking of a specific disease. Explain to the patient that you want to Explain to the patient that you want to make some TESTS confirming results. make some TESTS confirming results. “ “I will ask for an x-ray of both breasts to I will ask for an x-ray of both breasts to compare and this x-ray is called compare and this x-ray is called Mammogram. Mammogram. This will tell us a lot about that lump we This will tell us a lot about that lump we felt”.felt”.

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THINK VERY CAREFULLY OF WHAT THINK VERY CAREFULLY OF WHAT U SAY: THE Pt. will memorize every U SAY: THE Pt. will memorize every

wordwordYou reached a diagnosis and you want to tell the You reached a diagnosis and you want to tell the patient what are you thinking of:patient what are you thinking of:““Look, you have cancer, we are going to take Look, you have cancer, we are going to take your breast away – then you will receive your breast away – then you will receive chemotherapy which will cause you vomiting, chemotherapy which will cause you vomiting, tiredness, loss of appetite, hairloss and you tiredness, loss of appetite, hairloss and you may be prone to infections which might be very may be prone to infections which might be very serious”!!! serious”!!! All the above statements are brutal, inhuman and All the above statements are brutal, inhuman and barbaric.barbaric.Oh, my God, you have just killed that patient.Oh, my God, you have just killed that patient.

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BREAKING BAD NEWSBREAKING BAD NEWS

(Break bad news in nice words, so the patient (Break bad news in nice words, so the patient will accept them and will have more confidence will accept them and will have more confidence in you.) in you.) In stead say: Both breasts x-ray showed a lump In stead say: Both breasts x-ray showed a lump in your breast, then as you remember, we took a in your breast, then as you remember, we took a sample from that lump, sample from that lump, The cell report is back and talking about having The cell report is back and talking about having some abnormal cells which do not follow your some abnormal cells which do not follow your body’s rules and act on their own - by increasing body’s rules and act on their own - by increasing size, or going to……….. size, or going to………..

3939

other organs. The best treatment will be other organs. The best treatment will be removing that breast followed by removing that breast followed by

chemicals + radiotherapy.chemicals + radiotherapy.

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Breaking bad news:Breaking bad news:

Suppose that your patient is 19 years old girl. Suppose that your patient is 19 years old girl.

She has osteosarcoma of lower femur. She has osteosarcoma of lower femur.

You have requested all work-up investigations You have requested all work-up investigations and she does not have metastatic cancer and she does not have metastatic cancer elsewhere. elsewhere.

Your team chaired by a Consultant and other Your team chaired by a Consultant and other specialists have decided that the best way of specialists have decided that the best way of management will be management will be amputation.amputation.

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The verdict.The verdict.

Now the patient with her mum and dad Now the patient with her mum and dad are sitting in front of you waiting for the are sitting in front of you waiting for the

verdict.verdict.

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Your can break the news in two ways and Your can break the news in two ways and you tell me which one is better, if you were you tell me which one is better, if you were the patient.the patient.

““Look, you have nasty cancer in your Rt. Look, you have nasty cancer in your Rt. Femur and needs above knee amputation Femur and needs above knee amputation (cut your leg) ….(cut your leg) ….

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Or you can sayOr you can say “I have bad news and “I have bad news and good news for you (with a smile on your good news for you (with a smile on your face)….. face)…..

You remember when we took a piece of You remember when we took a piece of your lump which was examined under the your lump which was examined under the microscope and after that we all had a microscope and after that we all had a meeting together to decide about what is meeting together to decide about what is best for you.. best for you..

4444

You have in your Rt. Leg bone: a group of You have in your Rt. Leg bone: a group of abnormal cells that do not follow your abnormal cells that do not follow your body’s regulations and behave on their body’s regulations and behave on their own. own. These cells together made that lump These cells together made that lump which affected part of your leg bone and which affected part of your leg bone and the best treatment will be removing that the best treatment will be removing that bulk of bad cells before they start to bulk of bad cells before they start to spread elsewhere in your body……..spread elsewhere in your body……..

4545

So there is an operation and after that So there is an operation and after that your problem will be solved completely by your problem will be solved completely by

our colleagues who are our colleagues who are very expert very expert in doing prosthesis!”in doing prosthesis!”

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By now you have toldBy now you have told her what is her what is necessary and she and her parents got necessary and she and her parents got the idea of amputation (from in between the idea of amputation (from in between the lines)….the lines)….then proceed in talking with a smile too. then proceed in talking with a smile too. “So, my dear miss …. (surname only – “So, my dear miss …. (surname only – don’t you ever break the doctor-patient don’t you ever break the doctor-patient barrier by calling her by her given name - barrier by calling her by her given name - Mary, Sue or whatever)Mary, Sue or whatever)

4747

this operation is called amputation this operation is called amputation followed by injections offollowed by injections ofchemical materials which hopefully will kill chemical materials which hopefully will kill all the bad cells in your body and in the all the bad cells in your body and in the meantime you will be doing meantime you will be doing physiotherapy and have physiotherapy and have measurement for a similar leg prosthesis measurement for a similar leg prosthesis and you will be able to walk again and and you will be able to walk again and nobody will notice it.nobody will notice it.

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The patient is a human being and she will ask you The patient is a human being and she will ask you ““Is there any otherIs there any other operation to save my leg” operation to save my leg” What will you say, What will you say, ““yes, there are many but in your case the good news yes, there are many but in your case the good news is that al your tests have shown that this nasty lump is that al your tests have shown that this nasty lump (you can call it cancer if you want) has not gone to (you can call it cancer if you want) has not gone to any other part of your body”, and she asks any other part of your body”, and she asks “ “ what about chemical treatment, is it what they call what about chemical treatment, is it what they call chemotherapy with hair-fall, vomiting, being tired chemotherapy with hair-fall, vomiting, being tired and feeling bad?” and feeling bad?” ““Yes, it is but now we have solutions for every Yes, it is but now we have solutions for every problemproblem

4949

, so you will get an injection of anti-, so you will get an injection of anti-vomiting before each course, vomiting before each course,

you will be monitored during the treatment you will be monitored during the treatment and if you have drop in the blood cells and if you have drop in the blood cells which are responsible for defense against which are responsible for defense against infection. infection.

There is another injection to raise them up. There is another injection to raise them up.

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Your hair will gradually start to fall so why Your hair will gradually start to fall so why don’t you go to the beauty parlor and have don’t you go to the beauty parlor and have a marines hair-cut so you don’t feel bad a marines hair-cut so you don’t feel bad when you see smaller hair coming out and when you see smaller hair coming out and …… 3-4 months after stopping this …… 3-4 months after stopping this chemo, your hair will grow again, chemo, your hair will grow again,

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mind you, you can wear a nice wig and nobody mind you, you can wear a nice wig and nobody will notice that. Believe me, your gain by all will notice that. Believe me, your gain by all these treatment options will be less than loss”these treatment options will be less than loss”The girl – Can I think about it and take another The girl – Can I think about it and take another opinion, doctoropinion, doctorThe doctor – yes, sure by all means, your The doctor – yes, sure by all means, your disease’s name in medical term is “Osteogenic disease’s name in medical term is “Osteogenic sarcoma”. You can even visit some web pages sarcoma”. You can even visit some web pages in the internet and know even more about it.in the internet and know even more about it.By now, the girl and her parents will think By now, the girl and her parents will think that you are the saviorthat you are the savior

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Guidelines for effective communication:Guidelines for effective communication:– Ask what the patient has already been told Ask what the patient has already been told

and establish the level of understanding for and establish the level of understanding for further discussion.further discussion.

– Avoid Jargon (e.g. prognosis, adjuvant)Avoid Jargon (e.g. prognosis, adjuvant)– Avoid euphemisms (misbehaving cells) after Avoid euphemisms (misbehaving cells) after

you are 100% sure of the diagnosis – say this you are 100% sure of the diagnosis – say this lump also is called cancer.lump also is called cancer.

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•Avoid closed questions (i.e. those which Avoid closed questions (i.e. those which are answered with are answered with yes or noyes or no, open ended , open ended questions)questions)•Involve the patient in decision making.Involve the patient in decision making.•Don’t tell the patient (“do you Don’t tell the patient (“do you understand”).understand”).• but (e.g. “tell me what you can but (e.g. “tell me what you can remember of the things, I have said”)remember of the things, I have said”)

•The next of kin person may ask you to The next of kin person may ask you to withhold information (please do not tell withhold information (please do not tell him).him).

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Tell them:Tell them:

– All information about test results is primarily the All information about test results is primarily the property of the patient.property of the patient.

– I will respond to the patient’s questions with honest I will respond to the patient’s questions with honest answers.answers.

– I will not force unrequested information on the patient.I will not force unrequested information on the patient.– If the patient does not ask, I ill not tell.If the patient does not ask, I ill not tell.– Give the relatives to understand that most patients Give the relatives to understand that most patients

realize the gravity of this situation from in between the realize the gravity of this situation from in between the lines and withholding information will lead the patient lines and withholding information will lead the patient to sense of isolation.to sense of isolation.

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The angry relativeThe angry relative may be having anxiety may be having anxiety or fear or as a method for gaining or fear or as a method for gaining attention.attention.– Do not respond to anger with angerDo not respond to anger with anger– Calm the situation down by being pleasant an Calm the situation down by being pleasant an

express a desire to help.express a desire to help.– Point out that you want the best for the patientPoint out that you want the best for the patient

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Tips for the examTips for the examWarm the stethoscope before using it over the Warm the stethoscope before using it over the patient’s skin. patient’s skin.

The examiner will not like you if he notices that The examiner will not like you if he notices that the patient says “your stethoscope is cold” !!!the patient says “your stethoscope is cold” !!!

Always talk to the patient about your next step Always talk to the patient about your next step during the examination.during the examination.

Do not joke with patient or with the nurse during Do not joke with patient or with the nurse during and after and throughout the whole visit.and after and throughout the whole visit.

Listen to the patient carefully and let him/her Listen to the patient carefully and let him/her understand that all your attention is in the patient understand that all your attention is in the patient himself/herself.himself/herself.

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Tips for the examTips for the examDo not do any extra move during examination.Do not do any extra move during examination.

Always Always use the 3 Golden Rules of (never)use the 3 Golden Rules of (never) during during examination of a lady.examination of a lady.– Never examine a lady in the presence of her husband if Never examine a lady in the presence of her husband if

there is no female nurse at that moment.there is no female nurse at that moment.– Never examine a lady in the presence of male assistant.Never examine a lady in the presence of male assistant.– Never examine a lady alone, always have a female nurse Never examine a lady alone, always have a female nurse

with you.with you.

Good Luck.Good Luck.

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GOOD LUCK

THANK YOU

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