TO ERR IS HUMAN

A mistake can be labeled as a situation that could have been prevented. Everybody makes some mistake or the other at some point of time, and doctors are no exceptions. But they find it very hard to acknowledge the error. There are many reasons for this.

Doctors try their best to not to make any mistake, and therefore, just like everybody, their first response is to always try to justify or explain it away by blaming someone else. Common justifications are, “It wasn't my fault that a mistake was made, it was made by the nurse or the assistant.” We all need to live with our self-esteems intact, and doctors have egos which need protection, which is why it's hard for them to acknowledge that they are human and can err.

Doctors think of themselves as being in a helping profession and want their patients to get better. When they realize (often to their horror) that they have committed a mistake which has ended up harming their patient, it becomes hard for them to live with this bitter truth. In order to prevent cognitive conflict, it’s perfectly natural for them to refuse to accept the truth, and even hide the fact from themselves.

Doctors will often try to cover up errors because they are scared that if they acknowledge that they have goofed, their colleagues will think poorly of them, with their juniors and staff members no longer respecting them.  They are also understandably worried that that if their patients find out that an error was made, they will want to punish them by taking legal action against them in a court of law.

Also, doctors have been brainwashed by their professional liability, insurance companies, hospital management professionals, risk management companies and lawyers to never confess to having made an error. They are told to shut up, rather than apologize to the patient. This is because lawyers are worried that if doctors are truthful and acknowledge that they have made a mistake, this will be used against them in a court.

Doctors are also scared that if they tell the patient they made a mistake, the patient will no longer trust them, and this will damage the doctor-patient relationship. This is why the reflex action for most doctors is to cover up mistakes, much like a child does, rather than face up to them, like a mature adult should.

The first response is often one of denial, to hide the mistake, not just from the patient or from the rest of the medical team, but even from themselves. It is hard for all to acknowledge the fact that we have made an error, and not just for doctors.

All doctors agree that mistakes can be made in medical practice. But all of them will also claim in the same breath that they have not made any, leaving one wondering that who is making all these mistakes.

Doctors need to learn to be honest and open, not just with patients, but with themselves also, so that even if a mistake occurs, they can do something constructive about it. Not only will this minimize the harm caused by the error, they can also take action to prevent the mistake from happening again. This is extremely important, not just for the patient and the healthcare system in general, but for the doctor himself. Trying to cover up mistakes ends up in creating a major burden of guilt and shame, which can progressively worsen as time goes by.

Doctors need to remember that patients can be quite forgiving, and many will accept the fact that honest errors were made. They can forgive their doctor for these, but they will never forgive a doctor for trying to cover these up by lying to them.

BACK TO THE FUTURE

A person had been studying a lot all his life, always trying to be amongst the toppers. He had to become a doctor, after all. All of his friends had started with their jobs / business, while he still took money from his home. Five years of graduation, then post graduation, which might be followed by super specialization. He had to become a doctor, after all.

In spite of all this, neither did his study ever ceased, nor his learning. After all, he wishes to become not just a doctor, but an excellent one. And that too in a country like India, where for the last 65 years, the policy of our government has failed to achieve in the field of healthcare. The government spends thousands of crores of rupees in the name of healthcare. But what a common man gets of it is no secret, and can be appreciated in almost every government hospital of the country.

On the other hand, private healthcare providers have always invested in the latest technologies, acquired new skills, all at their own expense, raising the standard of medical and healthcare facilities. Today people residing in small towns can have a sigh of relief that they do not have to go to big cities and metros for basic medical facilities.

But why is all this being discussed here? It is because all of a doctor’s hard work is going to be undone by some policy-makers, back to the era of the British Raj, through what they call “CLINICAL ESTABLISHMENT ACT”.

It is a long act, which everyone should read, to know that the bureaucrats, without giving much thought, without taking the doctors along, without realizing its long-term effects, are keen to implement as a law.

It is imperative to know the effects of the act on the doctors as well as the common man. As soon as the act is implemented, medical practitioners would have to get themselves registered with the state and district councils, paying the heaviest fee in the country. As if the hefty amount spent in education was not enough. These councils would be headed by bureaucrats and politicians, or people nominated by them. The key word here is “nominated”, and not “elected”.

These councils would also inspect medical practitioners on a regular basis to check for their competency and standards being maintained. The government is trying to regulate something which is already regulated by the state medical council, the medical council of India and 41 other acts. Now an official would be instructing a doctor how to run a clinic and which medicines to prescribe, with the powers to even seal the establishment if he does not like something. Now a doctor would have to either do as was prevalent in the “License Raj”, keeping the babus happy, year after year, or shut down his practice. There would be no further hearing once the establishment is sealed. A doctor would not even be allowed to appeal in the court as these councils would be the ultimate authority in this matter. It also opens the door to abuse of power, as authorities can penalize or shut down the clinic of a good doctor for reasons not connected with his medical expertise.

Besides, the records of the patients would no longer remain confidential. The records would have to be shared “electronically” with the government. The government wants to know everything, who is suffering from what disease, is prescribed what medication or has undergone what surgery.

Moreover, the consultation fees of a medical practitioner would also be governed by the government. It is of no concern whether the doctor is a general practitioner, specialist or a super specialist. The consultation fee for all would be the same. This would result in a lack of interest within the medical fraternity to go for post graduation or super specialization, leading to a loss for the entire community. Similarly, the rates of surgeries would be the same for both old and modern techniques. This does not seem to be a very sensible idea as the expenses involved in attaining a higher qualification or establishing latest equipments for surgery are immense.

Medical insurance has never been implemented by the government. Instead, the throats of doctors are being sliced. On one hand there are talks of deregulating the prices of petrol and diesel to make the market economics work, and on the other, medical practitioners are about to be made scapegoats.

The state council also has been formed very precariously. There would be only one representative from modern medicine and allopathy, which is being practiced by more than 95% of the doctors. Other systems, being practiced by less than 5%, would be having three representatives. If passed, this act would open the doors for unqualified persons to get registered as doctors in the guise of Yoga, Unani, Siddha, Nursing and Pharmacy branches. This is like taking a step backward to check the misuse of allopathic and ayurvedic medicine by unqualified persons. What is really happening? In which era are we living?

There is even more to this. No separate registration would be required to run a laboratory along with an establishment. No emphasis has been given to whether the laboratory technician is suitably qualified or not.

Furthermore, a doctor would be required to “stabilize” a patient before sending him across to the nearest referral hospital, failing which he could face a non-bailable warrant. The definition of “stabilize” is unclear. Besides, it is not realistic to expect a regular general practitioner to be equipped with ventilators and so on. The equipment is expensive, and if individual doctors were to invest in such equipment, who would be sharing their costs? To expect all clinics to be at least 500 square feet is practically impossible in bigger cities, where the cost of real estate is exorbitant. If a doctor had that kind of money, there would not be any need for him to practice.

Having invested in a large room, expensive equipments and so on, a doctor would be under pressure to recover the costs and the most likely victims would be the patients. The act’s stiff requirements and penalties would encourage corporatization of healthcare. The small, neighborhood doctor would eventually be forced to shut down. Such “draconian” measures would also keep young people away from becoming doctors.

Someone would indeed be benefitted from this act. But that someone would not be the common man or the doctor.

WHY IS YOUR DOCTOR AN EMOTIONLESS BRUTE??

A patient’s body is a mystery to be solved. A doctor’s emotional state and their way of dealing with his own emotions play a critical role in solving this mystery. Emotions continuously express difficulties in revealing sensitive information to their patients, affecting decision making and ultimately affecting the whole outcome of the treatment.

If a doctor attaches himself emotionally with the patient, his feelings for the patient suffer from the resulting lack of judgment. If every medical professional gets emotional with the patients then there would just be doctors blabbering and walking around, not being able to make clear, conscious decisions. Doctors have to separate themselves emotionally from their patients in order to do their job. This is what keeps them sane. Besides, if they took on every emotional task with every patient that came to them for treatment, especially if the patient is dying, the doctor would not be able to maintain his sanity after some time. He would end up taking it home, messing up his personal life as well.

Feelings seem to add an important dimension of complexity to doctors. It has been seen that when doctors get emotionally attached while attending patients, they become more vulnerable to feelings of loss when these patients are not cured, or the worst case scenario being, they die.

Studies have shown that junior doctors may be more strongly affected by patient’s death than senior doctors and female doctors report more psychological distress than male doctors indicating that female doctors and interns may require more emotional support after patient’s death. This does not mean that doctors and other medical professionals should be cold and heartless, but they have to maintain a certain distance from their patients in order to keep going on a daily basis.

The medical profession is definitely not a walk in the park, even though it is really gratifying. But in addition to the miracles, doctors also see a lot of tragedy. When a patient is sick, the doctor should not be over emotional and panicky. He should be able to think instantly in order to give the best care possible, and also should put on a brave face for their patient. He must learn to control their emotions in order to do their job.

Doctors should be more serious about performing their work and saving the patient than being nice and emotional. It is very hard for anyone to make critical, time-sensitive decisions when he lets emotions get involved. Doctors must make an effort to keep from ever getting emotionally attached in order to make life-saving, split-second decisions.

A hospital is a gloomy place. If every doctor starts getting upset and starts crying over every distressing case, there would be no more doctors. If a patient is in his terminal stages and a doctor comes in to notify and instead starts crying, wouldn’t that seem a bit wide of the mark? Doctors are human beings just like everybody else. It would be deplorable if they do not learn to train themselves not to shed tears over every patient. It would seem quite awkward if a doctor studies a patient’s chart and starts crying himself.

Caring for ailing people is a part of every doctor’s clinical experience, both during training and in subsequent practice. In every case, benefit of the patient should be the highest priority, not the feelings of one’s own. To deliver the best care, doctors should not let emotions interfere with their decisions. They must be level-headed, detached and tough, but all the while caring. The best care comes from a doctor who regards a patient as a mathematician looking at a complicated equation.

ETHICAL MEDICAL PRACTICE: THE MISSING LINK

People are meant to be loved and things are meant to be used. Unfortunately, in the present commercial world, it is the other way round, with people being used and things being loved. Thanks to the “market economy”, there is more emphasis on amassing wealth by hook or crook, ignoring the ethics, dodging the rules and regulations, and bypassing the government policies. Today is an era of enterprise society, where profit at any cost has become the ultimate goal. This is leading to a dangerous precedent, taking a heavy toll on human values, virtues and principles.

Man is a social animal. Biological needs like eating and sleeping constitute the innate nature of human beings. In a civilized and modern society, a person’s stature is set by his conduct, ethical standards and moral values. Money and materialism take second place. Among all living organisms, only humans have the discriminatory power, who can judge what is good and what is bad. Society acts as a mould to shape a person’s behavior. It is generally said that a corrupt society breeds corrupt individuals, with honest and dedicated people being an endangered species facing extinction. Such societies need to be overhauled, with radical changes being the need of the hour so that the right individuals have a right place to thrive.

According to the words of Mahatma Gandhi, there is no wrong in earning money, but one must stick to moral and ethical code. Both of these are not contradictory, but, in fact, are complimentary. Even the medical profession is not free from the growing commercialism, pushing the selfless service to the back seat. Doctors were considered next to God, giving the utmost importance to medical profession. But considering the current conditions, the perception seems to be changing. Widespread superstitions, appalling low level of medical awareness, rising medical expenditure, poor functioning of government hospitals and inaccessibility to medical care are driving people especially in rural areas to consult quacks, which are bent on bringing disrepute to the medical profession. Urban areas are no exception. A large number of corporate hospitals, diagnostic centers and pharmaceutical companies are duping susceptible people by ordering unnecessary diagnostic and pathological tests and mounting medical bills, turning the holy profession into an unholy commercial venture.

Doctors getting kickbacks for prescriptions from pharmaceutical companies are a common practice. Institutional changes, transparent policies and greater accountability are the need of the hour to address the current crisis.

Root causes for unethical practice is a social pressure. Parents have a deep sense of urge to get their children educated and, in turn, build a better life than their peers. There is this perception in the society that education is meant just for earning a decent livelihood, and not to make responsible and law abiding citizens. As a result, education has turned into a profitable venture and parents are ready to invest huge amounts and force their wards to study “elite subjects”, like medicine, engineering or charted accountancy in order to get handsome returns. In this process, the opinions of children are often ignored.

With their parents having invested huge amounts on their education, the young graduates are eager to get back the returns, and prepare to disregard and circumvent any rule or regulation that comes in their way. This urge for commercialization breaks the backbone of patients belonging to lower and middle classes. There seems to be more emphasis on mere collection of facts or data in education, ignoring the basic concept that knowledge is obtained only when meaningful data and information is properly organized. It is application of this knowledge that leads to wisdom and clarity of perception. In spite of an increased expenditure on education, quality seems to be appalling. And expecting ethical practice filled with love, passion and compassion from the products of such a system is nothing short of imprudence.

For the past several decades, there have been various governments formulating several policies towards welfare of the state, with their main aim being to address pertinent issues such as poverty, illiteracy, inequality and so on. However, even after several decades of independence, there is a hold-up on various fronts owing to negligence and lack of commitment of bureaucrats and politicians. Many factors play a role while recruiting for government posts, including abuse of money as well as power. Moreover, poor infrastructural facilities and lack of availability of medicines at government setups denies committed individuals an opportunity to serve the public. One cannot expect ethical practice with dedication to profession and service to public from the individuals selected for jobs like such.

There are three key societal members who can make a difference if a country is to be corruption free and become a nation of beautiful minds, the father, the mother and the teacher. All of them play a key role in making ethical practice feasible in the present commercial world.

Not all medical practitioners engage in immoral and unethical practices. There are many selfless doctors who serve with utmost care and responsibility, providing untiring services to the needy, downtrodden and marginalized sections of the society. Ethical practice is feasible in the present commercial world only when high levels of ethical standards and moral values are incorporated in the society, the system is made more transparent and fool proof with greater accountability, provisions are made to implement already existing ethical codes and guidelines, making general population more aware, and inculcating a sense of responsibility and spirit of selfless service, care and compassion among medical graduates. Only then can the medical practitioners hope and dream of getting the appropriate reverence they deserve.

HOW GOOD IS YOUR DOCTOR??

Time has been ever-changing. And it’s time it changes again. In the past, medical care was more sporadic than it is now, diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications, there were no blockbuster drugs for many diseases, and doctors did not manage nearly as many patients on multiple medications as they do now.

In those times, there wasn’t much doctor-patient interaction between visits. Today, doctors manage more chronic conditions; use more medications and laboratory monitoring, more patient education, and more administrative work for the patients than before.

What makes a good doctor, and how to measure it? Should doctors be judged on the basis of the outcome of treatment? Real outcomes of treatment are not values of blood pressure or blood sugar; they are the number of deaths due to negligence, strokes, heart attacks, hospital-acquired infections and the like.

In today’s scenario, such events are seen as preventable and punishable. Ironically, even the insurance industry has no trouble recognizing “Acts of God” as events beyond human control in all spheres other than healthcare.

There is too little discussion about responsibility of the patient. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well. If a diabetic patient doesn’t follow his doctor’s advice, then the concerned doctor must not have tried hard enough. And as the logic goes, the doctor should be penalized with a smaller paycheck or huge penalties.

A few comparisons illustrate the dilemma of judging the outcomes. Are firefighters ever penalized if the house they’re dousing to the best of their ability still burns down? Do the police investigating a murder case not get a paycheck if the crime remains unsolved? Is the military shamed in full public view if it loses a war? Even if we were to accept and embrace outcomes-based judgments in health care, the main question remains how to and who would we measure outcomes? We already know that an episode of hospitalization for a given life threatening disease can seem successful, but any readmission due to the same disease can cast doubt on that. First, of course, not all of that “outcome” is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more.

There can be a mediocre doctor, but with a good team and excellent support staff, he might be able to work wonders. On the other hand, even the smartest doctor who knows the science perfectly might not be able to deliver consistently reliable care if there a lack of proper system built around him to do so.

In measuring doctor quality, skills like empathy towards patients should be also taken into account, which can be measure through patient experience surveys. Likewise, focus must also be on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, ability to collaborate and effectively lead teams. People don’t really bring these things into consideration, erroneously assuming that all doctors have them.  For measuring good systems, the current metrics are prevalent such as whether the doctor is able to achieve good blood pressure and diabetes control.

In addition to the qualities of humility and empathy, a doctor also needs to be technically proficient. For example, a surgeon’s empathy and kindness matter, but it may not be as critical to his being an effective surgeon as his technical and team management skills. For physicians, their effectiveness is much more dependent on their ability to listen, be empathic, and take the patient’s values into consideration.

Also, much of what happens in sickness and in health is not dependent at all on the doctor. For example, a miserable weather pattern can make the rate of relapse of common cold and flu higher for one month than the next. What kind of bureaucracy would it take to create a judgmental scale that factored in such things?

Other than short term outcomes for specific diseases like some surgery, hospitalizations and such discrete episodes of care, how can the outcome be measured in primary care and disease prevention? When patients switch doctors, who gets the credit or blame for future outcomes?

Defining outcomes is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all the patients. For example, the elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher (due to a higher incidence of attacks of low blood sugar).

In almost every area of medicine, every case is a different one, and that must be considered if doctors are to best serve each of their patients. It is ironic and very sad that those who used to consider the doctors next to God are the ones who look for crude, universally applicable target outcomes. Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

The central question for who should judge the outcome of the treatment hinges on the priorities of whoever holds the purse strings. Health insurance companies, if the profit motives are overlooked, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications or procedures are not covered. Politicians also favor the population view of health care. If a patient is paying the doctor directly, he expects the doctor to deliver the care that works for them. If the government or an insurance company is paying, they expect doctors to deliver care that meets their standards, because they don’t trust the patients to know what is best for them, with their main focus being to have the doctor do what helps most of the patients, even if some are not helped or are not happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current scenario, patients and the relatives need to be given every option about the ways how their health can be taken care of. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care.

In order to maintain what partnership is left today between doctors and patients, there needs to be a sense of trust, shared by patients and providers. And there must be, after all, some ways to achieve this.

IS ALL REALLY WELL?? (PART II)

It is alleged that doctors are writing unnecessary and costly medications. Doctors are no ones to decide the price of a drug. They do not manufacture or give license to drug manufacturers. Controlling the price of essential drugs is a government job, a matter in which doctors are helpless. A large amount of rural population should have access to cheap generic drugs, but also, the pharmacy companies that charge more for the drugs are the ones that spend millions of rupees for research and development of new drugs. Had there not been drug trials, no new drugs would have been invented and the mortality rates would have been comparable to Stone Age. Many reputed pharmaceutical giants who have invested much money into research and development naturally keep the prices of their products a little high. This is understandably inevitable and the fact has to be accepted that quality comes only at a cost. Also, many local companies manufacture generic products (which is a copy of the original molecule discovered by the expensive company which can be used for unaffordable patients). But many of these generic drugs are of substandard quality and are the reason of many uncalled deaths due to drug reactions. If this seems like an exaggeration, let’s recall the regular incidents in our country of spurious and sub-standard drugs and even vaccines killing the people who happen to receive them. The drugs dispensed by the government hospitals fail to bring down the high fever and other ailments of patients who go there, while the same drug prescribed by the same government doctor, dispensed by a private chemist across the road, quickly puts the patient back on his feet. And the responsibility for the quality of drugs also comes to lie on the doctors.

Doctors do not sleep for numerous nights. Their life is just books and tests because they have to save lives in future. No light has ever been thrown on the entrance examinations and the hard work, dedication and sacrifices a doctor needs. A day spent in the emergency department and OPD of a hospital would make many realize that the work timings, working conditions, lunch breaks, doctor to patient ratio, hours of sleep per week, living conditions in the hostel and the stipend is worse than a class 4 laborer. Doctors are always exposed to infections as they are always around the sick. Their job is not from 9 to 5 but it is 24 hours a day, 7 days a week, till they die. Their family life is a mess because they don’t spend time with them.

Government hospitals should multiply several folds, with an increase in the number of doctors in each department, improving the doctor to patient ratio. Doctor's salaries and living conditions should be looked after and should be comparable to other professionals. Government hospitals should be upgraded to the standard of private hospitals, which is the job of the government. The general population too bears the responsibility to maintain the govt. property like hospitals. Corruption should be stopped at the topmost level that eats the major chunk of hospital funds. Doctors should be given proper social security. The primary school education must include more and more health related topics so that the general public is made aware about common diseases and the 'acceptable' qualifications of the doctors. None of our film stars ever gets him treated at a government hospitals, preferring foreign doctors and corporate hospitals. If quality treatment (at lower cost) is available at government hospitals, no one would want to go to empty their pockets at corporate hospitals. Also, the pharmaceutical companies should be regulated. They are the real money makers, with doctors being just the apparent culprits. Regulatory authorities should also keep a check on the quality of drugs being manufactured and at the same time, sold at the local chemist.

People are misled by watching such T.V. shows. They must use their brains as it is a sensitive issue. After watching such a show, people might also start suspecting the doctor of fleecing even in cases of “real” emergencies. If there are panel discussions to find solutions in a healthy way in such shows, a lot more viable solutions would have come up. Calling all the doctors as “TRADERS OF DEATH” is as serious allegation as calling all actors 'Rapists' (after one incident in the film industry) or all persons of a particular community 'Terrorists'. Knowing that many facts had been twisted to strike a chord with the audience, little faith is left in the stories that would be projected in the upcoming shows. A large segment of the 'classes' as well as 'masses' feels betrayed. The myth of an unbiased actor who strives for nothing but the truth and the betterment of the society has been busted.

It is very easy to point fingers. All might not be well. But all is not well anywhere. It is a different thing creating awareness about dowry or female feticide. But it is an entirely different matter to comment on such a technical and complicated issue without getting into the details of it. The entire medical fraternity is being maligned. For every 10 doctors who are doing wrong, there are more than 1000 healers. Someone somewhere does owe the doctors an apology. This issue is not as simple as is thought it is. Justice cannot be done to such an issue, especially after charging a whooping amount for creating awareness. Only a few doctors may be doing just a little bit of social service, but at least they do not charge for it!!!