May , 2017
The failing doctor-patient relationship! Why?
14:26 pm

Dr. Sarfaraz Baig

In India, doctors are crying foul over the allegations of victimisation. To understand this, it is probably time to introspect the doctor-patient relationship. It is necessary more than ever now as a recent survey shows that a large section of the Indian population perceives doctors as one of the most corrupt communities of society. There have been certain developments over the last few decades that may have led to such perceptions. 

The major cause of conflict seems to be the cost. There are several reasons why the cost has spiralled. The local nursing home and the unimpressively clad doctor on the street have been slowly replaced by the cravat-wearing, polished, and gadget friendly doctor inside a suave and expensive multi-speciality hospital. It’s no wonder that the cost inputs in these establishments have translated into increasing the cost of treatment. It’s important to note that the fees of the doctors in a majority of circumstances
have not gone high commensurate to the hospital’s establishment costs.

Governments worldwide, except for the Scandinavian countries, have failed in providing reasonable healthcare to the masses. They have realised how expensive and complicated it is to dispense mass medical care. Private healthcare wasn’t supposed to fill in this gap but unfortunately that’s what is happening. The majority of the lower and middle classes chooses private over state health institutions for the want of better care but are not prepared to afford the bills of these hospitals.

There has been considerable progress in the technology and drugs used in medical science in the last few decades. CT scan, MRI, PET scan, angiography, laparoscopic technology, stents, staplers, mesh, joint prosthesis, high-end antibiotics, anti-cancer drugs, robotic measures- the list is endless. As a result, costs have increased manifold.  Given a choice, the insurance companies are not willing to shell more money on these gadgets.

Statistics indicate that healthcare has become safer over the years. Complications from treatments have come down, surgeries have become safer, more accurate diagnosis and precision treatment is the order of the day. A large part of this success can be attributed to the improvement in imaging, lab tests, better understanding of the disease, multi-disciplinary approach and better drugs and procedures. For instance, a patient with gallstones three decades back would need a surgery with large wounds that entailed risk of wound infection, hernias and a 7-10 day stay in the hospital. Laparoscopy has changed this. For this to happen, one needs the hospital to buy instruments and also require the doctors to undergo a rigorous training in laparoscopic surgery and anaesthesia. Ultimately, this means more expenditure.

The pharmaceutical and medical instruments industry has participated in a competitive race (sometimes unhealthy) to boost their sales. The accusations against doctors regarding unethical practices perpetrated by the industry - sponsored vacations, paid conferences, unnecessary tests and procedures- have long been piling. It is acceptable to believe that where there is profit, there is corruption! However, nobody knows the extent of this corruption. Although the critiques claim it is rampant, it’s probably blown out of proportion! In fact, the Medical Council of India has also laid down guidelines for ethical practice .

Medical science is poorly understood by the external world. Let me explain. There are three kinds of problems- simple, complicated and complex. Adding two plus two is a simple problem.

Complicated problem is like launching a rocket- difficult but possible by solving the issue in a step by step manner. Rearing a child on the other hand is a complex problem. It’s not a linear issue. There are many factors that will influence the final outcome which ultimately will be unpredictable. Medical treatment is a complex issue. Biology is not linear, hence neither is treatment of diseases. It’s for this reason  that it is difficult to lay down a single approach for a medical problem. Frequently, in the treatment of diseases, the course may not be predictable. There may be complications, surprises, aberrations. It is for the same reason that the definition of negligence cannot be clear-cut. It is the absence of “reasonable care” that defines negligence. Since reasonable could be many approaches, it is fairly difficult to corner a doctor for a negligent act.

The reaction and tolerance levels of the patient and their family are changing, probably reflecting the general trend in society. There is an increasingly intolerant reaction to complications arising out of medical care. This was unheard of earlier. People would accept death as an act of God. Not anymore! One hears of acts of vandalism after a death or after media reports negligent medical practices. 

Frequently, there is lack of adequate counselling before the commencement of treatment regarding the potential risks and complications. The communication part is left to the doctor only, who may be good in his craft but may not be proficient in this art. Nobody teaches communication skills in medical colleges.

Complications imply more cost. And the costs may be manifold. An ICU care may cost anywhere between `30000 and `100000 per day in a corporate hospital, depending on the requirements of a patient. The bill payer of the unfortunate patient is torn between hope and frustration due to the unpredictability of the situation. Some go bankrupt or sell property to pay these bills whereas some get angry and violent and some plead for stopping the treatment, unable to bear the financial burden. Some doctors let go of their fees in these cases but such acts are drop in the ocean.

Death arising out of a complication is an unfortunate incident that scars both the doctor and the family of the patient. Sometimes, the patient's family accuse the doctors and hospital for negligence and refuse to pay the bills. The bills are usually settled after negotiations and sometimes with letters from the political class.

The reality is that complications are inevitable in few cases. The risks are taken by the patient and the family prior to initiating treatment. In a climate of trust, it’s accepted graciously albeit with a heavy heart. However, in a climate of mistrust, as seen in recent times, any negative outcome is equated as negligence and frequently leads to disgruntlement and even violent protests.

A large part of image building of any individual, organisation, product or service lies with the media. In the last decade, the media has reported adverse outcomes, negligence and deaths from medical and surgical treatment. It's probable that the success stories and the prolonged training needed to be a doctor have largely gone under-reported leading to a biased, negative and unsympathetic perception by the general public.The areas like trauma and emergencies are the bane of modern healthcare. The infrastructure and logistics needed to deliver this type of care is expensive and needs a lot of human resource management. It explains why most governments, especially the less affording nations, are unable to provide a decent facility for accidents and emergencies. Private healthcare on the other hand, invests a lot in this area because of the demand and the scope of earning profits from it, too.

However medical ethics forbids not dispensing emergency care for lack of payment. And this is where there most of the recent conflicts between healthcare providers and patients have originated. Some patients get the A&E care for days and then are unable to pay the hospital bills leading to a deadlock situation. In the Indian context, politicians have often entered to solve this deadlock mostly with a bias to rein in the hospitals. This has led to ugly situations and represented the entire flock of medical professionals and institutions in a poor light.

The repercussions of a failed doctor- patient relationship can be extremely detrimental to society. The effects can be numerous. Many bright students may shy away from taking this profession, doctors may not want their children to enter their profession, there could be migration to other regions, and there may be increase of litigation, complaints and even acts of vandalism.

Therefore, we need to examine the reasons for this phenomenon and rectify them. Much of it is due to the lack of understanding of the complexity and the evolution of medical science which in recent times, like other scientific disciplines, is moving at a rapid pace. Treatment has definitely become safer but unfortunately, at the expense of increased cost. Education and awareness has to increase among the general public regarding the same.

However, there are many specific areas in the medical profession that needs to be addressed more objectively and immediately - cost, ethics, advertising, communication, corporatisation of health sector, infrastructure of the government hospitals, legislation to curb negligence, etc. Whereas some decisions are executive/ legislative, some are related to ethics. And ethics cannot be legislated or enforced. Doctors will have to look inside them and their community and prevent malpractices. Expelling a few rotten apples can be exemplary and will be a confidence building measure for society.

The government and the media can take a responsible role in this area to repair the burnt bridges. Planting the seeds of mistrust in the minds of the patient will be detrimental to entire society. The media has to refrain from passing verdicts on doctors and hospitals before a fair investigation.



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