The new medical villain on the block
© Dr. Rajas Deshpande
There are more than one options to choose from in the treatment of most medical conditions. Although doctors may differ on the exact diagnosis in some cases, they usually agree upon the “umbrella” or parent medical condition, and usually prescribe similar molecules as treatment.
It is extremely important for the patient to know that there are many medical problems for which individualised decisions have to be made, and the so called “standard” prescribed (correct) treatment may turn out hazardous (wrong) in some particular patient. For example, steroids may be lifesaving in some patients and fatal in some others with the same diagnosis (say meningitis: inflammation of the brain coverings, or brain swelling) depending upon whether they have other diseases like high BP, high sugars or low immunity. This is a very crucial factor while deciding treatments, and the experience and skill of a doctor trained in THAT particular disease is the most important factor deciding the outcome. Another simple example: one of the most commonly used medicine in the treatment of migraine and epilepsy, sodium valproate may cause significant weight gain and foetal risks, hence must be avoided especially in young women. There are thousands of such instances in medical practice, and the decision making is not as easy as it appears.
However, what with the interference / meddling from many sources, new “compromised” treatment patterns are now evolving, which may be extremely dangerous in long run.
1. The most dangerous of all is the legal trial fear. This is virtually eliminating any deviation from the “standard” protocols, even if life-saving, for the fear of having to answer non-medical luminaries in the court language. It has become safer for many to “Let whatever has to, happen to the patient” with standard protocols with book references rather than risk some medicines / surgeries as lifesaving measures based upon practical experience and knowledge. The moment some patient / relative talks in “legal” terms, all further decisions in that case become “compromised to suit legal justifications” rather than “to attempt best outcome for that patient”.
2. Insurance companies: These have been dictating the treatment protocols encouraging “invasive and intravenous” options. Insurance is mostly not sanctioned for any diagnosis if only oral medicines are used. So even if a patient of severe vertigo, high BP or transient stroke is admitted, treated with oral medicines and discharged after investigations, insurance is not usually sanctioned. This results in “Overstatement” of medical conditions, unwarranted use of IV fluids / antibiotics and sometimes even procedures. Specialists have to only practice what the insurance doctors can understand, for the fear of rejection of insurance claim (which causes huge financial burden upon the patient). It is also sad that patients, for saving money, encourage and pressurise doctors to write incorrect diagnosis and invasive treatments. Non-compliance with such requests does not get the doctor any more respect or medals, it just results in loss of whatever meager income that patient would have generated, if sanctioned by the insurance company.
3. Corporate policies: These are based upon the “Revenue generation” which, combined with “Number of patients” is the sole assessment criteria for the doctors performance in most corporate set-ups. Although some private nursing homes and some rare corporate set-ups encourage “Good Doctor” practice, they are becoming fast extinct due to the “Finance Culture” network cultivated by the corporates and insurance companies together.
4. “Patient ownership”: Some doctors are quite close to some families (which is welcome), but they may not always choose the correct specialists/ experts / hospitals for the patient. There are many factors here, right from “genuine trust” to “English ChaiPani”. If it is a qualified specialist and the relation is based upon trust, this works good. But if the relation is based upon the E.C., then the treatment decisions may not always be correct (costlier options are preferred in many cases), as the specialist has to mostly comply with the referring doctor’s demands (and the patient’s family insists upon it).
5. Nonmedical Doctors: These are the relatives who know the who’s who in medical profession, many doctors actually accompany them, and dictate changes in the treatment to “SHOW” their medical worth to the patient / family. They in fact end up doing harm to the patient by “Khichadifying” the treatment. They surprisingly disappear whenever the patient turns critical or in the terminal phase. Involving big names does not always benefit the patient as the treating doctor shifts into “Safety mode” immediately.
6. Politicos / Govt. Officials etc. They have their own doctors (who cannot diagnose or dare treat the patient by themselves, but) who Google and advise the treating doctor what to do, right from investigations to treatment, impressing upon the minister that they are “in charge” till things go wrong, at which point they somersault.
7. Google doctors: Our dear “Walk English, Talk English, Can Google at My Wish” class that interferes with everything, with a basic presumption that doctors are a class of criminal retards who need to be taught medical basics they learnt from Google. Some even tell the doctor “This is the X ray”, “This is diabetes medicine” etc.!
8. Our local Gundas: They are relatively tolerable, as they do not actually interfere with treatment and cannot mostly read. They only get troublesome when the doctor explains the criticality of a condition. After hour-long explanations of criticality in the sweetest terms to them, they just say “We don’t know anything else. Patient must survive. Do anything. Or else…”.
9. Some (not all) overseas Doctor Uncles / Cousins who presume everyone practicing medicine in India needs more lessons about internet knowledge, and they can actually suggest better management of a critical / complicated patient from any specialty whom they have not even seen!
It is very easy for people to interfere in medical treatment, without realising what damage they can cause to the patient. As the treating doctor is ultimately responsible for the outcome, he / she must record such interference on paper, and obtain signatures (or thumb impressions) if any of the above alters the course of management. It is acceptable in some cases to receive suggestions and if reasonable implement them, but this should entirely be the prerogative of the treating doctor. One can always request a second opinion from a specialist expert for that disease in complicated and critical cases, but opinions from “any other doctor just because we know them” is not advisable.
If any “meddler” suggests to add / remove a drug, it must be mandatory that he / she writes it on paper and shares responsibility in writing for the final outcome.
As for the threatening goons, involving a PRO / med social worker from the beginning is advisable, and also the daily reminder to them that they are welcome to take the case to anyone else / other hospital if they are not happy with current treatment or do not completely trust the doctor, and obtain written willingness to continue treatment under present doctor. We may need to devise a “Trust in my doctor” consent form, and also local language paperwork to be filled in daily by relatives about their objections/ concerns (as it is common to entirely change stance later in case of complication). There is no solution at present to the type of relatives, who, in spite of the best interaction and explanations by treating doc about patient’s conditions, bluntly deny that the doctor told them anything. When you show them the “condition informed” paper signed, they say “My cousin signed that, and he has left .. I was never told about this by anyone”.
We must also consider marking the OPD / IPD case papers with some sign indicating “Treatment advised under Duress / Threat / Meddling”.
The Hon’ble Judges don’t like suggestions from the relatives, other judges, lawyers, political people, threatening goons when they are hearing / judging the case and making decisions. If disturbed, they can freely slap “Contempt or Interference charges” and punish the meddlers too. Human life is more important than any court case, and meddling with the ongoing treatment directly or indirectly must be legally declared a serious offence.
© Dr. Rajas Deshpande