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Wednesday, October 19, 2011

Can you trust your Doctor anymore?

I was reading over some blogs while I came across this one about the writer having a bad (well, really very bad) experience with her Doctor! She's written her heart out and I'm assuming she channeled most of her anger into the blog. However, she made one mistake! She forgot to look at the other side of the coin. I am trying to show a glimpse of that other side if possible in this post. Do both of us a favour and read her side of the story first to understand this post better. She writes at A-Musing.

Can you trust your Doctor anymore? I would think you don't have a choice. It's like politics. You have to vote for someone, so you do but you may not like the person you've voted for. Let me explain. If you can't trust your Doctor, you have but 2 options left. The Internet and God! Here's why the Doctor is a better bet.

The internet, although a vast whorehouse (yes this is intentional and not a typo for storehouse) of information, will only allow you to read what you want. Try it sometimes. If you have something, and are looking for the symptoms, you would tend to read more into what symptoms you have rather than analyse the whole situation. For eg, A fever can be almost anything, but it is most likely to be nothing. Start searching the internet for fever related diseases and the average hypochondriac (all of us are at some level) would probably end up thinking he/she has malaria, dengue, or Mediterranean Tick Fever!!

God, because, you would probably not realise God's helping you, until you're on your death bed and receive a miracle. Get real, no one attributes a cold going away to God being great! At that point, it's just something that would have happened anyway!

Coming back to the Doctor. There are some points I agree about. Specialities and Super Specialities are branching into areas as small as the pituitary gland (a couple of cms at best). How much would I need to study to know all I can about something as large as a pea! To this question, I have one standard answer! As much as you can! Medicine is not a static knowledge base where x and y always have definite values. There is no constant in medicine and no textbook that can highlight what each patient would go through during a particular illness. It's impossible. That's why its called a practice. The more we see, the more we know and I'll let you into a huge secret here....80% of our work is pure INSTINCT! We just know sometimes, that this fever is more than it appears, that this headache would be the last one of your life, that this little black spot on your toe is going to lead to an amputation of your foot, if you don't listen to the advise we give.

The grand old family physician works almost entirely on instinct because he know's your family, your background, what you are prone to getting and what you aren't. I agree with Purba, that this is a dying art, but it's more alive than you think. You're the one's that are killing it. Who runs to a pediatrician when your child has a cold. You think the G.P. can't handle that? What about when you have vertigo. This one's my favourite. Straight to the neurologist we go, when all it most likely is, is ear wax! Even then, we must see an ENT right? Hardly necessary. These super specialists are booming because you are feeding their fire. Post operative dressings can be done by any family physician, but patient's prefer going to the surgeon. He's a surgeon, for God's sakes. He can either operate or devote his time to simple dressings (of course complicated one's go to the surgeon, that's a given) . If you want him to remove time from his operating schedule and dress your wound, he is going to charge you for it. Then, don't wince about the costs!

Coming to the monetary aspect. We charge, overcharge and extort at times. Sure we do. We have homes to run, same as you. Are you telling me that the delicious bar of chocolate that you so relish, actually costs Rs. 30. I know for a fact, that the manufacturing costs, including wrapping, do not exceed Rs. 10 at best! You gladly pay for that don't you. Look at the fuel prices! Do you  think our government is losing money on petrol. Now, look at it this way. Out of the 10 years which we study to become specialists, we earn Rs. 0. However, during this time, we treat almost > 10000 patients (and this is a conservative average of 1000 patients a year, almost just 3 a day. I know OPD's that see 45 patients everyday) all for Rs. 0. When we finally get our degrees, after all the fees (of course there are free seats - these just cost Rs. 80,000 in a private college, a paid seat is about 200000), the exam fees (approx 50000 counting exams every year), the registration fees (about 10000), the travelling (because there are not enough medical colleges near home), we're almost 30 by now (assuming you finish school at 16, junior college at 18, MBBS at 23, Internship at 24, Post Grad by 28 and struggle for 2 years to get a hospital job / clinic if you have rich parents). After this, if I charge you Rs. 500 for a consultation (which is how much you would pay for a movie if it was a couple going) is that too much??

Let's take insurance. Most Doctor's hate insurance and insurance providers. You want to know why? Most patients claiming insurance request us to present inflated bills, hide previous illnesses, lie about the duration of the disease and more things I can't write about. They also expect the Doctor to help them out in whatever way possible to process their claim. When did we become insurance agents! The OPD insurance registration that Purba talks about is mostly in the big hospitals. You want to know why it's necessary. Some patients calmly walk away without paying many times. Who's the clinic/hospital supposed to catch then?

Investigations! This one can go on for another 200 pages. We prescribe them most often because we need them. Other times, it's because patients are ignorant regarding their health and don't maintain a yearly check on themselves. You want to prevent diseases but don't want to take the steps to prevent them. Studies in the US clearly state that half the number of colon cancers can be cured if detected early. The way to do this is yearly colonoscopies after a particular age. Would you do it? What would your reaction be if you were told you have a tumour? I'll tell you. You would say, but I feel perfectly fine! That's why we order tests! Sometimes, you feel nothing while a disease grows inside. On the other hand, I do agree, that most tests ordered today are over the top and unnecessary! This is a small group though.

Medications. I would love to send of some of my patients with just a simple Crocin. Maybe some warm salt water gargling. Would you be satisfied with that? I can guarantee that this is the correct modality of treatment for certain symptoms, but would you pay me for hearing this. Most patients are dissatisfied with the medication they receive as they expect more. I have actually had people walking into the clinic and demanding injections even when they are not required. What do I say to them? If I don't give it, someone else will and I lose my patient to another specialist!

It's a delicate balance between under doing and overdoing. Neither Purba nor I can decide which is right. It's up to you, the patients. Just leave with this thought though. Blood Pressure can change in minutes. If you have a high reading at a Doctor's clinic, most will tell you to get it checked again. Don't ignore them. At the same time, don't ask them whether they're sure you don't need an ECG / Echo. They will advise you for it if you do! Remember, we get sued for medical negligence if this happens. No one can sue the patient for not following instructions!

6 comments:

  1. Very well written. Very moderatist, though. We do not see 10,000 patients for Rs. 0. We actually pay, and those in pvt colleges may have to cough up upto Rs. 20 lacs to do it.

    "These super specialists are booming because you are feeding their fire." Very true. Since I have just finished my MBBS, no one is in a better position than me to vouch for this fact.

    Here's one for overmedication: young man comes in to see me with what is an obvious viral fever with mild upper respi infection. I prescribe lots of fluids, paracetamol and rest. And patience for a week. I send for some routine blood work which comes back absolutely clean supporting my provisional. Now after 2 days he rages in complaining I am a quack and he still feels sick. He goes to the older MD, DM guy next door and gets a script for Coamoxiclav for 8 days, TDS. And by the 5th day of that he is fit and fine. Not only do I lose him as a patient but also he bad mouths me around. What do I do now? Do the math...

    A decade worth of education to just be marked as a Pharma shill or quack - do we really deserve it?

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  2. I happen to agree with what you have expressed. As individuals we have have unique perspectives based on our experiences. And strangely there are no rights and wrongs :)

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  3. @Pranab I'm trying to keep it on an average what with people skipping their rural postings and all. Horrid read about your patient, but that's just it. Sometimes, you have to give in to the patient's wishes more than clinical judgement. That's where Instinct comes in!
    @Purba An experience is all it takes to make someone bad, but to earn a good reputation takes many many satisfied patients!

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  4. Very well written Doc...I agree with you on everything:)

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  5. Thanks Anjum. Did you read the linked blog though? What are your views on that?

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  6. thank you very much for the sharing this wonderful thought.

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