© Dr. Rajas Deshpande
What is the Guarantee, Doctor?
Best of the Doctors internally react like metal on sandpaper to this question by the patient or relatives. While surgeons are the most common victims of this question, physicians also often succumb to these innocent words. It’s not that the doctor wants to hide or lie, it’s just that the real answer is too complicated to explain to everyone in these days of word by word legal scrutiny and over-interpretation of colloquial reassurances. This question was earlier asked only in context of surgical outcome, but now is asked with reference to outpatient treatment, hospital admissions and any planned / emergency treatment.
A simple example. A patient developing a heart attack, in the OPD is advised to get admitted and start treatment in the casualty / ICU. Patient is very anxious, so is his family.
The panicked wife asks in front of the patient with tears flowing down.
“Is it very serious, Doctor?.. He will be OK na?”
“Yes, please go to the casualty immediately” Doctor, meaning to reassure.
“Guaranteed he will be ok na, Doctor?” Asked patient’s son.
“I cannot guarantee, but we need to start treatment immediately”. Doctor, on guard now.
“What are the percentage chances of his recovery, Doc?” Asks the suspicious son.
What should the doctor answer? A few years ago, a confident and reassuring “Don’t worry, he will be all right, just admit him and start treatment quickly” would be sufficient. But today, one can’t use these words in presence of a family recording your conversation, or having no prior exposure to basics in healthcare and heart attack as “The doctor said he will be alright and misguided us, otherwise we would have gone to another hospital” is the hanging legal sword. Also, the truth “The patient is having a heart attack and is in a potentially critical state” told with any amount of compassion, concern and love, is going to worsen the patient’s anxiety, blood pressure and thereby risk his health further. If one tells the truth about possible complications of a heart attack including death, there are also the allegations of “overinflating the risk to get him admitted and get the investigations and earn from this and the treatment / angioplasty / bypass surgery which may have been unnecessary”!
Most diseases have standard manuals and treatment protocols, which most doctors follow. But if it everything medical was this mechanical, patients could choose their own medicines by researching google and also hire robotic machines to get their own surgeries done (and I am sure robots will not mind being beaten up for failure).. When one expects human skills, one must also accept human limitation and mistakes.
© Dr. Rajas Deshpande
The best team of doctors anywhere in the world will never be able to guarantee the life of any human being for any period of time. With all investigations and check-ups, the best guarantee one can receive is that “At the present moment you do not have any apparent condition that threatens your life or health, and with a reasonable confidence we think that you should be able to tolerate x amount of stress for y type of procedure. We can not exclude the possibility of your developing any reactions or complications to a procedure / single medicine or combination of more medicines”.
Is that sufficient?
Many patients are understandably afraid of admission and surgery. Most physicians / surgeons are equally concerned about the outcomes. Mostly the patient has chosen a doctor who he / she can trust. So where does it all go wrong with the “Guarantee” word?
All doctors / scientists in the world taken together also cannot explain everything that happens in human body, or even why and when exactly things go wrong in some diseases or in a particular case. Most of our current medical knowledge is based upon centuries of research, but what we don’t know far exceeds what we know. In spite of the best drugs used, patient’s body may not respond the same way in all cases. Patients may develop fatal reactions to simplest of the common medicines used in wards / hospitals / operation theatres. (“Wrong medicine given by doctor claims life”: Media).
Medical literature quotes many instances of sudden cardiac arrest (stopping of heart), sudden severe drops in blood pressure, respiratory arrest, convulsions etc. during simplest of the surgeries / procedures like even dental surgeries. Although every procedure with risk must be planned in a set-up prepared for resuscitation, no one can guarantee a good outcome of resuscitation. Apparently healthy, improving patients may develop sudden complications and then the suspicion and blame game begins.
Given this, any doctor who predicts a guaranteed good outcome / percentage of recovery is actually stating the statistical possibilities based upon his / her experience for that combination of disease / age / sex / and treatment or procedure. These are never hard-and-fast assurances of definite outcomes. Most consent letters signed by the patients / relatives mention most of the risks involved with procedures / surgeries, including death. However, for the non-surgical cases, there are no consent forms for treatments and accepting the risks of their failure / adverse effects. Therein results the “over-expectation” that any non-surgical case, especially young, must only get better.
© Dr. Rajas Deshpande
While every doctor must explain all possible risks, minor and major, and encourage the patient to read standard websites about the risks and outcome statistics of the planned procedures, this is highly impractical in a country with majority illiterate and superstitious population. The mention of true risk / death risk, however minor, may end up in the patient deciding against surgery / medical treatment. Not every patient/ relative is a stable minded intelligent philosopher who can analyse and accept the situation, and a negative reaction about the doctor telling them the truth is quite a common scenario. Hence the “sweet, lying and/or cheaper” doctor is preferable to many patients, and there begins the whole imbroglio.
“In this advanced age, why cannot you guarantee a good outcome of a surgery and so many diseases, doctor?” ask the innocent worshipers of Discovery and Science channels and HollyMedical TV serials.
Well. Spaceships fall or fail even today. US President’s or security agency’s web accounts are hacked. Hundreds of earthquakes happen without any prediction in spite of thousands of satellites. Richest of the people treated in best of the hospitals in the world still die. Hundreds of rapes and murders happen every day. Traffic accidents kill thousands daily. Pilots still dive their planes in mountains with hundreds aboard. Does advanced technology prevent all these? Does anyone guarantee a definite punishment of a murderer or rapist who committed the crime with multiple witnesses? Can we guarantee proper electricity, rains, weather, food for all with all the advances in technology we have?
Why quote these examples?
Just to show that unless the risk directly affects oneself or family, the limitations of technological advances are comfortably accepted and / or neglected.
I sincerely think the greatest “Advance” in technology is only that people have started thinking they know everything because they can google, email and whatsapp. No one has become a better human being with any modern technology.
Like everything else controlled by nature, human body is mostly unpredictable. Mood, sleep, behavior, digestion are all unpredictable even without external influence. Add one external factor, say stale food, and all the above change unpredictably.
What is dangerous about this uncertainty?
Although these examples below are rare in the general population, they are quite common in the medical establishments:
Otherwise healthy people of any age may have a tendency of abnormal rhythms developing in the heart. They may already have “stenosed” or constricted blood vessels in the heart or brain, which may shut down during procedures / because of high or low blood pressures. They may develop blood clots spontaneously or in response to infection, immobility or dehydration. The heart may stop suddenly in response to some common / uncommon medicine, it may also dilate and fail to pump in severe stress.There may be ballooning of blood vessels in the brain (aneurysms), which may rupture either without apparent cause or with even minor stress / high blood pressure. There may be a tendency of convulsions (even when the patient never had them in earlier life) and with regular medicines / antibiotics / anaesthetic drugs/ contrast media used in some CT scans etc, patients may suddenly develop a flurry of seizures. Hospital admission and surgery are both stressful states for the mind, and patients may develop higher blood pressures in hospital or around the surgical day.
Some people may have kidney / liver / nerve / spine / brain damage just on the verge of failure, some may have increased chances of developing an infection due to low immunity, and the chances of catching dangerous infections in hospital environment are always higher. Before any minor / major surgery, the doctors’ team usually thoroughly does the standard check-ups required to minimise risk for that procedure, the budget given to the patient includes these tests too. However, if anymore risks are found after admission or further tests are advised by the experts (like MRI brain in a patient admitted for knee replacement, who has earlier had a stroke / paralysis), the budget exceeds and most of the patients end up thinking that the hospital is doing unnecessary tests. It is not possible to correctly predict the risk of a future stroke during surgery without doing some test for the blood circulation in the brain, and MRI is the only non-invasive test for assessment of such patients. However, the reluctance to add this to the budget for surgery causes dual problem: one may not be able to prevent an otherwise preventable stroke, and the new complication extends hospital stay and disability, far more costlier than the MRI would have been. Also, once the joint replacement surgery is done, MRI cannot be done for a certain time after that, and one has to prefer CT scan, which causes very high exposure to xrays. The tendency to minimise healthcare expenses thus costs dearly to many.
© Dr. Rajas Deshpande
One must overcome the mentality of extracting a Rolls Royce (USA / Europe healthcare technology and infrastructure) in the price of a Tata Nano (Indian technology and infrastructure). When the govt.’s expenditures on health sector are skimpy, the basic lifesaving medicines and instruments are not available even in many district level govt. hospitals, one must not expect just the medical doctors to apply “the most recent and best technological and research advances” to non paying, concessional, free patients without being funded for the drugs / instrumentation / skill and time involved.
To express in simple terms for the highly software savvy younger generations: If at all we make a software for eliminating all risks and do all the tests to ensure good health and outcome prior to surgery or for the treatment of any medical condition, even then, the risk will never be shown as “Zero”, although the cost of completing this for even a minor surgery would cross 5 lacs and take two weeks minimum. Also the software will automatically up the risks with delay in starting the treatment, smoking and alcoholism, diabetes and hypertension, genetic factors, and many other facts, it will be far more than the 10-30 percent risk that the skilled doctors usually predict for life, and will also reduce the 80-90 percent guarantee they assure for a good outcome of many major surgeries.
Without such software, the Doctor’s brains, experience and skills will have to be trusted for risk assessment and prediction based upon their training. These, to state honestly, are not always the best when cheapest.
If the hospitals ask for this simple consent : “ I want a complete workup by all specialists concerned with my illness and all necessary tests be done to ensure best outcomes and also if anything goes wrong all the best treatment must be done for saving my life and safeguarding best health, AT ALL COSTS, getting the best foreign medical technology for me”, how many will be willing to sign that? To state bluntly and begging forgiveness, the current informal deal is “Doctor, do the best you can in minimum expenditure with a guarantee of life and good outcome”.
One cannot even guarantee if one will reach home today, what with traffic and terror. We accept that anyone can die anytime due to a natural disaster. Similarly, our society must also be educated that just reaching the hospital is not a guarantee of life or cure. While most doctors take utmost care for a good outcome, things may still go wrong, more frequently in a hospital.
There is no justification of negligence. Every mishap must be questioned, investigated and explained, but the presumption that all mishaps in hospital are the doctor’s fault has to go. And the investigation of any such complication must also include : health information hidden by the relatives / patient, delays in investigations and treatment advised by doctors earlier, addictions and adherence to prescribed medicines, interference in treatment by seeking multiple opinions, treatments from various pathies simultaneously, and involving non specialist doctors. It must also involve the delays by insurance companies in sanctioning the funds for which relatives keep on postponing the tests and even treatment.
If truth is palatable, legally speaking there are no guarantees in Medicine. Only good and bad chances may be predicted by experienced doctors in that specialty, that too approximately. As long as legal fears interfere with medical treatments, patients will continue to suffer.
The more you love someone and are available for them, the more you are taken for granted. The more you give, the more the receiver expects. Hope this nightmare does not apply to the Medical profession.
By the way, what do we guarantee a good doctor in India?
Ask the thousands of burnt souls practicing Medicine in India.
© Dr. Rajas Deshpande
I sincerely wish this article goes to atleast Indian medical journals.