Why custodian of patient is in line of fire

Dr J Maheshwari

Medical treatment has ad- vanced a lot with a battery of diagnostic tests, role of specialists and a range of options to choose from. What hasn’t ad- vanced though is the trust be- tween a doctor and patient. It has in fact regressed over the years with the entire system chipping away at this trust and making doctor the fall guy.

There was a time when doc- tors would just feel your pulse and give medicines (often some home- made pills and mixture) from their personal dispensary, and the patient would take those med- icines without a doubt or ques- tions. The doctor’s assurance that “you will be get well” often led to the patients actually getting back on their feet. If things did not im- prove, the patient would be sent to a hospital, usually a government- run facility. And, yes, the doctor would never ask for his fee; it was given very respectfully to ‘com- pounder sahib’.

The treatment was based on trust between the doctor and the family. Those were family doc- tors, and they were like family members. One can see them in Bollywood films like “Hum Aapke Hain Kaun’ where ‘doc- tor uncle’ was very much a part of the family, attending wedding functions, singing and dancing.

Being asked to go to a hospi- tal meant the problem was seri- ous in nature and the patient would be mentally prepared for any eventuality. Never would the patient question the intent behind being referred to a hospi- tal. The hospital doctor and the family would accept the out- come of the treatment as their destiny. It was all clinical medi- cine – no x-rays, no blood tests.

Investigative medicine changed all that. All clinical problems had to be backed by tests – starting with simple tests like x-rays and blood tests to more complicated scans. Now the patient wanted to know what was happening. Often, the test reports were rather confusing and the doctor appeared to be in- decisive. This genuine dilemma often elicited the response: “The doctor is not able to understand the problem.” This set off a chain of second opinions, often different, if not contradictory. In the end, one of the doctors had to be ‘wrong’. With this came erosion of faith in doctors. New tests meant more expansive medical treatments and new di- agnoses. What used to be a sim- ple ‘seasonal fever’ became the dreaded ‘viral’ and more recent- ly ‘dengue fever’.

Internet only compounded the problem. Patients googled their ailment or condition and reports. With extensive and of- ten irrelevant information available on the net, the patient would get more and more con- fused and anxious. This had a far-reaching impact on the diag- nosis-making ability of the most intelligent doctor.

The doctors also ended up ‘fine-tuning’ the treatment ac- cording to affordability and, sometimes, understanding and demands of the patient. The pa- tients would like tests done for the most minor ailment. With this came a whole bazaar of in- vestigative medicine, making medical treatment much more expensive. Doctors often had to take a decision whether or not to subject the patient to expensive tests – in case of a negative re- sult, the patient would consider them to be ‘unnecessary’ and if

not carried out, the question would be – ‘why not?’

With the shift from a clinical- based to a heavily investigative- based approach came a new problem of over-diagnosis and varied interpretations of the tests. This led to utter chaos. Ill- ness now meant a horrendous experience for the patient!

Now the doctor had to explain what was going on (half the time the doctor himself won’t know what was happening). For exam-

cine but also have the ability to ex- plain everything to the patient in a language she understands.

But it doesn’t stop at explana- tion. You also have to document your interactions and ask the family of the patient to sign it. Signing a consent form, for exam- ple, always conveyed to the pa- tient that doctors are doing this to ‘cover’ themselves. Most patients anyway sign it without reading. This led to a breach in the doctor- patient relationship whenever

patients would still go to over- crowded government hospitals as trust and facilities were much better there. With the advent of ‘five-star’ hospitals, business or- ganisations saw profit opportu- nities. They set up fancy build- ings, hired best of government doctors and became an attrac- tive option for patients who could afford. Since the overall service experience was better, even those who could not afford it ventured to these hospitals.

Enter health insurance. The educated and rich bought insur- ance. Since they were not paying from their pocket they didn’t bother about the charges, which spiralled. The victim in all this was the not-so-educated and poor who did not have insur- ance. For them falling ill meant selling their life-time posses- sions. The anxiety associated with falling ill peaked, and a lit- tle aberration in treatment cre- ated a crisis in the doctor-pa- tient relationship.

Big private hospitals with their big marketing budgets have controlled the patient pop- ulation. The doctors working with them have to fall in line as the management controls the ‘business’, and often things oth- er than treatment becomes im- portant. Doctors understand that they can’t raise their voice because either they are bound by the revenue they themselves draw or fear the possibility of being asked to go…but where?

In this scenario, ultimately when things go wrong, it’s the custodian of the patient, the doctor, like a soldier in battle- field, is on the firing line. The buck stops there!

(Dr J Maheshwari is Senior Director, Orthopaedics, at Max Hospital, Saket)

    

In the movie ‘Hum Aapke Hain Kaun’, ‘doctor uncle’ — played by Satish Shah— was very much a part of the family, attending wedding functions



ple, every fever on day 2 or 3 will be considered as viral fever, on day 7 or 8 typhoid fever, on day 20 or 30 tuberculosis, and after that whatever. Explaining to the pa- tient in a language that he or she could understand was always a daunting task. The additional burden of what to say and what not to say spooked the doctors. If they said the real thing, it was tak- en as “doctor frightened us”, and if not, “he never told us”. How could a doctor tell an already tense patient, due to undergo sur- gery, that in any operation there is a risk of death! Today’s doctor is expected to not only know medi-

things went wrong – “You were explained,” patients were often told. Documentation has be- come the most important facet of practising medicine. That, and flicking through reports, takes up a lot of time. It cuts into conversation and counselling time. The most important aspect of being empathetic to the patient is getting neglected.

Private healthcare has brought its own complexity. Ini- tially, there were a few private, often charitable, hospitals where the sole purpose was to deliver medical care at an affor- dable price. A large number of