Painful Injection 

© Dr. Rajas Deshpande

“Anyone Treat Anything” and the “Add-On complaints”.

“Doc I have come to you for this severe headache since last five months”.
Examined, investigated, prescription given.
5 days later:
“Doc there is no relief. This back pain is killing me”.
“What about the headache you had?”
“Oh that went away the next day, but this backache has been there for years now. I forgot to tell you last time. I also want you to review and advise about my Sugar and BP medicines”.
……………..
Specialty practice in India is considered to be just like family practice. The concept of “problem-based” consultation is yet to arrive. Once seen by a specialist, all the subsequent health issues are thought to be automatically the responsibility of that doctor, and he / she is supposed to solve them at a “Follow-Up” charge for years. The concept of “New health issue, New consult” is yet to dawn.

Unfair to compare, but this is like visiting a hotel once to eat an unlimited Rice Plate, and then keeping on visiting repeatedly later to reap the “unlimited” benefit from the bill paid on the first day.

There are two sides. Some specialists also encourage this “treating everything” once the patient comes to them, and often transgress their field of expertise to keep on treating everything till the time something goes wrong, when alone a cross-reference is made. Once someone starts practice in some specialty, they should ideally only stick to that branch, unless it is an emergency.

Even at the cost of patient “misunderstanding and blaming”, some specialists follow this correct practice of referring to another specialist where indicated.

“You only give the treatment, doc for everything.. we have faith in you” is very rewarding and beautiful to hear, but at the same time a doctor who thinks he/she can should think twice.
© Dr. Rajas Deshpande

The second issue is that of “Going on adding” the complaints even after the doctor has finished examination and has already issued a prescription.

The whole process is logical, and disciplined: recording the complaints and other medical details, then performing a physical examination, reviewing old test reports and advising new, writing a prescription, and explaining the condition and management to the patient. There are limitations in the time spent for one patient, and a single significant complaint added later after the prescription is written can change the diagnostic possibilities (“I just remembered, I had episodes of unconsciousness / tuberculosis / head injury in the past”). It then becomes imperative that the doctor rewrites the case history, and changes tests advised and even treatment sometimes.

There are simple solutions, but these become difficult in India.
1. The doc must spend extra time with every patient to give them sufficient time to remember. This is feasible only when the charges are time based, as some patients are not done talking even after 30 minutes. The experienced docs then learn the skills and tricks to save time and to “steer” the patient.
2. Patient can fill up / record forms while in the waiting room, where almost all important questions are already mentioned, so one cannot miss. This is difficult in two ways: most of our population is illiterate, and even the literates do not fill up these forms properly. Also, most of the working class come “flying” in a hurry to “get over with this quickly and fly to another meeting/ chore”, so they keep busy with their cellphones in the waiting area (sometimes even in the doctor’s chamber). Secondly, such mention of “all earlier health issues” also invites unwanted exaggeration of otherwise minor complaints especially in the depressed / suppressed / anxious and overenthusiastic patients, often diverting from the main health issue.
3. Doctor’s assistants / junior doctors “filtering” the information for each case: this may be the best option, but again the specialist must take responsibility for their mistakes. Also, one must remember that patients often do not take the “assistant doctors” seriously and may omit crucial information while talking to them. Also, a patient who pays for a specialist’s service deserves interview and examination by that specialist, not only a quick overview of an assistant’s opinion.
4. Patient must make and retain a notebook / digital diary common to all his / her medical issues, consults, details of all prior treatment and tests and carry it for every consult, minor or major. While the doctors / hospitals are supposed to keep their own records, they are blind to what happens outside their medical jurisdiction, so it becomes almost useless. A unified national healthcare software is at least 10 years away.

The IMA / MCI must devise large scale patient education programmes that will help curb the misunderstandings, hate, violence which society harbors towards medical professionals. Encouraging correct referrals, specifying doctor’s fees based upon the equation of “Time + Skill + Experience + Complications in a case” at different levels from family practitioners to super specialists may also help. A basic model of “Primary General Practitioner” who attends simple health issues with referral to a specialist based upon patient’s choice / proximity / GP’s honest opinion and suggesting at least two specialist names will help control this “Anyone Treat Anything” practice so rampant today.

There always will be allegations of “cut practice” whenever there is referral, as average human nature finds pleasure in blaming others especially successful and presuming everyone else a sinner while imagining oneself a moral-ethical icon.

To imagine that everyone in the medical profession is a sinner and guilty, and everyone in the society is innocent is a sign of immaturity of intellect. This is our working diagnosis right now.
© Dr. Rajas Deshpande

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