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The Elephant and the Blind Men

4 Jul

“It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it”
– Sir William Osle

That was quite a busy day for me. While working as a –fulltime senior consulting general surgeon , in a public charitable trust hospital, which happens to be a premier neurological institute in central part of my country, we have a daily outpatient department. In the morning I was busy operating on a emergency abdominal problem. Around 12 noon I came down rushing to OPD as I had another emergency to handle again. Quickly I called upon – Asharani 25 years old female who came from 300 kms distance. As soon as I saw her – a young, fair, sickly woman holding her neck stiff, I asked her to narrate what is wrong with her .She showed me a big 8cmX7cmX6cm size cystic swelling on her manubrium sternum. It was painless when it appeared 6 months back & now it has become painful for one month, it was fluctuant. I had in mind “ a cold abscess” diagnosis. When I asked her about stiff neck, she told me that she is sick for 6-8 months and the neck stiffness is there for about 40-45 days. I asked her to open her mouth and put torchlight there. Hey!! My expectation was correct. There was a big retropharangeal swelling on the right side protruding anteriorly in pharynx. Now my diagnosis got almost confirmed. When I touched her upper cervical spine she was uncomfortable. Stiffness of her neck with stretched stermomastoid on right side was an aftermath of Pott’s cervical spine I could guess. I had to confirm my diagnosis by some necessary investigations. I advised her for X-ray chest, X ray neck AP & Lateral views haemogram, IgG and IgM for TB Elisa, and ultimately CT Scan of cervical spine.

I was in a hurry to go back to OT for the next surgery. I told her to show me all the reports when I came back from the operation. And when I was back the diagnosis was confirmed beyond doubt.

When I asked her why she came so late? The following story was narrated by her relative as –
“Doctor, for last 6 months we have been consulting specialists in a big district place. We took all the medicines sincerely, but she continued to feel ill. We changed the doctors, specialists. She was given cervical traction and physiotherapy so many days, she had received a couple of injections, but there is no relief. We are disgusted with everybody there so came here. Tell us what is wrong with her? No doctor has told us what is wrong with her .

When I saw her previous papers I also got disgusted. She had been practically taken to six senior consultants of different specialities. Amongst them 2 were orthopedic surgeons, 2 general physicians and 2 general surgeons too. None of them had even tried to diagnose her ,instead she had received a list of variety of medicines, injections, traction and physiotherapy etc ,without a Diagnosis.

Her CT Scan was showing evidence of lysis in C2 body, base of odontoid &right lateral mass of C2& right foramen transversum with large paravertebral collection[abscess] with early A-A dislocation [A-A distance-4 mm.] Bilateral minimal epidural collection ,carotid vessels pushed laterally on right side. She was balancing her head on a very thin rim of cortex of her C2 spine; which could have easily given way and she could have became Quadriplegic !!!!,
Similar lytic area in Manubrium sternum with large extra thoracic &smaller intrathoracic collection[abscess] was also reported.
Her IgG for TB was 2600 serounits (strongly positive) .
A young woman with two small children from a country where no doctor can afford to forget about the diagnosis of Tuberculosis and can manage to use all the sophisticated investigations on earth, easily available and also affordable for this particular patient, has progressed to the hilt of quadriplegia. Thanks to her neck stiffness – a protective phenomenon of her body, her inability to swallow properly, else this thin rim could have given way. It would have caused collapse & quadriplegia . Is there any difference at all in a young woman without quadriplegia and a young woman with quadriplegia? I reffered the patient to our hospital’s Neurosurgeon, we got her admitted. Next day her cold abscess from both places was evacuated and posterior fixation of cervical spine was done. She was put on full 5 drug AKT [ Anti kochs Treatment ] regime and a Philadelfia Collar was given . Gradually she got completely alright. We told the relatives how narrowly she is escaped from quadriplegia. They were extremely grateful to us. She went home on 14th postoperative day walking.

But I am terribly disturbed from this incidence!! I presented this patient’s case along with my questions to our doctor colleagues:
1. Do we expect patients to choose their specialists? And tell their diagnosis to them so that they can start treatment ?
2. Do we expect our colleagues not to give medicines to anybody unless they make a diagnosis ?
3. Are these people to be called qualified & expert quacks, though they’re having masters degree in their specialty they don’t take strains for diagnosis and treat the patients? Don’t exert, as these patients are illiterate?
4. Can they justify – their behavior stating a saying – “eyes don’t see what the mind doesn’t know !”
5. Stating that when they saw the patient –
1. It was an early stage of the disease, so they could miss the diagnosis.
2. Or they have a very busy OPD and couldn’t devote much time to take proper history and examination. And when I saw and diagnosed it was a “fully blown”? Case, so very easy to diagnose.

Indeed it was very easy to diagnose for me because I always want to diagnose and then treat my patients. As 5 days before I saw, a physician MD medicine had seen the patient and had labeled her as some cyst??? And referred to me for a surgical opinion !!
6. To blame their tubular vision and forget or blame patient’s relatives.
7. Patient might not have followed a single doctor so how can the doctor know patient’s progress? When she is lost to follow-up. Indeed this patient has changed 6 specialists in 8 months but why?
8. Here I remember an old story of 6 blind men and an elephant. Each one tried to feel the elephant. Whatever part they felt they labeled it as they thought. One who touched the tail said it’s a rope, other feeling leg, said it as tree, one feeling & holding trunk mistook it as a- big tube, one felt Tusks as sword, other holding big ear thought it as leaf and the 6th felt the body , thought it’s a wall. Entire elephant cannot be felt easily and so inability to judge . But blind men had never seen an elephant so they cannot be blamed .

Here these are educated, supposed to have acquired knowledge & having all 5 special+1 common senses and a license to treat. They forgot important principle – that ‘THE PATIENTS ARE OURSELVES’. This one grave incidence tells so many things about the society. Very often we see many, undiagnosed or misdiagnosed but treated (How and for what) patients. Medical knowledge has reached the level of telemedicine and telesurgery is coming in. But there is so much disparity in availability of treatment. There are many social, political, educational and financial reasons.

The fundamental aim of medical art and science has always been to alleviate human pain and suffering. Have we really achieved it? So giving only symptomatic treatment often masks the internal disease & allows it to progress ,creates complications ,increases morbidity & may even kill the patient.

“If it is a question of doubt in diagnosis you may often observe that one man solves the doubt when the others could not, and the way in which one man happened to solve it is this: he applied to the diagnosis of the case some method of examination which the others had not applied” – (Lockwood)

General practice, speciality , subspeciality or superspeciality whatever any doctor may practice the crux of curing any patient lies in two most important aspects of treatment i.e. : 1.Timely diagnosis
2. Timely treatment
We don’t need hi tech machinery or big hospitals to at least suspect the Diagnosis & the cure follows .

As long as any doctor physician/surgeon knows the importance of these two utmost important things patients will not get justice by way of cure, they may become more morbid or die ultimately. I am not pointing towards terminally sick cancer patients or massive myocardial infraction patients whom we fail to save in spite of following the above two norms. I am bringing forth the patient who can surely be saved if and when they get timely diagnosis and timely treatment. In this era of modern sophisticated medical practice so many times we find that The Physician may play the part of a pathogen; it may be by commission or omission . The possibilities & dangers of commission in short can be listed as —–
A- Iatrogenic Diseases….assaults of Modern therapy, injuditious use of therapeutic agents ,thoughtlessly , needlessly & indescriminately given blood transfusions ,exposure to diagnostic & therapeutic ionising radiation. Antibiotics are regarded as the cure for all for the most minor infections & steroid therapy is the refuge of the destitute, it is small wonder that the old maladies are replaced by new manmade ones, multitude of allergens exceeds pathogenic microorganisms in number. The degree of benefit to the patient is not by any means directly proportional to the number of procedures, tests & drugs used.

B—The threat of omission is represented by failure of the doctor to understand patients as people rather than as cases of abnormal physiology & biochemistry. Doctor has to learn to see & treat the person , not the disease .
I compare this tendency of doctors (not to let go any patient without writing a prescription ) with the priests of a temple , where no devotee goes without taking the holy water (teertha). Do they feel scared of refering to other proper specialist ,so that they lose monetorily . Medicine claims the patient even when the etiology is uncertain , prognosis unfavourable , & the therapy of an experimental nature . Under these circumstances the attempt at a medical miracle can be a hedge against failure, since miracles amy only be hoped for & cannot by definition be expected . The radical monopoly over health care that the contemporary physician claims now forces him to reassume priestly & royal functions that his ancestors gave up when they became specialized as technical healers .
The ritualization of crisis , a general trait of a morbid society ,does three things for the doctor. It provides him With a license that usually only the military can claim . The professional who is believed to be in command can easily presume immunity from the ordinary rules of justice & decency. So many doctors are so busy in practice that they have very little time to ‘listen’ to a patient’s complaint ,no time to thorougly make a good physical examination , so a short cut is adapted . Only chief complaints are heard (not listened) & an array of investigations are written for the patient .So many want their pathologists & radiologists to give them a diagnosis . We were taught in the Medical collages to give prime importance to patient’s history , & good physical examination , corelating these to come to a provisional diagnosis & differential diagnosis. To confirm the diagnosis help of investigations is taken & a Final diagnosis is made , before starting the treatment. To follow 7 stages of ‘diagnostic crescendo’.
Tubular vision –every specialist seeing his or her system or part of the system , forgetting that human body is not a machine of assembled spare parts. Man is more than the sum total of his organs & parts.

 
Ivan Illich has already concluded Doctor’s effectiveness in patients’ cure as an illusion . But in all cases it’s not true. Efforts are needed to educate our population so that they can help in their own diagnosis , can know that only high technology & lot’s of money can not save them in critical problems . They must demand their diagnosis from their doctors, should ask questions to their physician & then only take treatment. This Medicine’s Forgotten Man should make his presence felt in every stage of his diagnosis & treatment .

 

About the Author

Author: Dr. Sanjeevanee Kelkar

About: A general surgeon & for last 16 yrs working as a full time General Surgeon in a Charitable Trust Hospital in Nagpur.She is also a Senior Consultant & Medical Superintendent also for last 5 years.

Contact: http://www.drsanjeevanee.com
sanjeevanee@yahoo.com

Allow Doctors to make Mistakes

25 Apr

1. Sangam Yadav, 35, a taxi-driver had severe abdominal pain, he was treated in casualty department but did not get relief and wanted admission. But the lady doctor did not feel he was serious enough to need admission. A scuffle and doctor-bashing. Indeed – patient was not serious.

2. Ramdas Patil, 33, an auto-driver attended V.N. Desai Hospital in Santa-Cruz(E), in early morning hours. He was given an injection but died within 10 minutes. Doctors were blamed for “delay” and for “wrong” injection. Mob-Fury, Hospital property damage, Dharana, doctors’ strike. Finally, diagnosis haemorrhagic pancreatitis – nothing could have been done. The injection was innocuous.

3. End stage renal disease, patient admitted repeatedly-died. Yet Dr. Dahake assaulted and injured in K.E.M. Hospital.

4. A patient delivers in private nursing home, but starts bleeding profusely. The doctor transfers the patient urgently, even accompanies the patient – inspite of transfusions and efforts, patient dies. The relatives go back to the Nursing Home and destroy furniture and equipment. Postpartum haemorrhage is a rare but known dreaded complication of even a normal delivery.

Incidences are galore, but the reaction of the Press and general public is same. ‘Doctors/hospitals are negligent, and sympathy for the mob’. Even if their violent acts are mildly condemned, they were ‘Angry’, ‘Upset’ ‘Agitated’- Never ‘Roudy’ ‘Hooligans’. There is hardly any word supporting the claims of the doctors/hospitals that the violent incidences were totally unjustified. It is left to the Association of the medical professionals to defend themselves. Naturally, ‘Bandh’ and Strikes are becoming part of their professional life.

But is that all? No. The escalating costs of health services and over crowding of the tertiary hospitals are directly related to these strained relationships. Generally, the doctors are highly sensitive about-even scared of – complications or deaths at their hands; these cause disrepute and adversely affect their practice. Therefore, by nature, doctors advise more investigations and more precautions than really necessary-to be on the safer side. But two generations back, they took into account the patient’s economic and social condition and often took upon themselves the burden of deciding not to overburden him with heavy expenses, by avoiding costly modes of investigation and treatment. Now no more! With the dangers of law suits and even more – of assaults and damage to property– Darwin’s law of ‘Preservation of self and preservation of species’ overrides all other considerations.

Doctors ask for every investigation, prescribe the most-modern costliest of medicines and on the patients’ raising slightest doubts, seek self-protection by calling higher specialists, cardiologist for chest-pain, diabetologist for diabetes, and nephrologist for urine trouble. Too many cooks easily spoil your (health care) broth. (Crooks? No. I really meant cooks). Normally, faith heals; but when suspicion and antogornism grow, faith cannot heal. Every symptom has to be proved objectively to be inconsequential. Therefore, your headache is cured by the same aspirin but only after MRI of the brain, and fundoscopy by an ophthalmologist. Your pricking pain in the chest calls for Angio-graphy, after ECG, Stress-test and 2-D Echo, to be declared as due to indigestion and gases.
But this is not all! if you get admitted to a nursing home or a small hospital, you will certainly be treated well as long as your condition is relatively stable or you need a relatively straight forward operation. But, if the patient becomes even a bit serious and/or relatives start asking too many questions, most of the average doctors play safe and advise the patient to go to a major hospital –even when he has enough knowledge and skill to treat the condition – ‘No Assault, No Destruction, No Law–suit, please’, they seem to say. Thus, many I.C.U. patients are transferred to 5-star hospitals. This explains the strange paradoxical phenomenon that there is no bed available in a 40-50 bedded I.C.U. of 5-Star Hospitals despite exorbitant costs while I.C.U.s in small hospitals are virtually vacant.

The situation in public hospitals is even worse. At one time, peripheral hospitals were bristling with activity. Lecturers and post-graduate student residents were posted and fresh young honorary specialists were keen to gain experience. Learning Experience was a great motivational force. No more so now. Now it is drab routine working. With fixed (low) salary or honorarium, money-incentive is zero. Job satisfaction would have been a good motivational force if, indeed, there was any job satisfaction. Are the patients grateful? Instead, there are mostly complaints and grievances and the ‘elected’ ‘rulers’ come shouting and cursing the doctors who are only ‘Paid’ ‘Servants’. Why should they risk assaults and damages at all? It is better to pack off every risky patient, be he a medically risky patient or a socially risky person. Everyone is advised to go to major teaching Hospital-Sion, KEM etc.. The simplest excuse is lack of staff and/or lack of equipment. A clamour for more staff and modern equipment is strongly supported by people, the Press and the Media. This explains another strange phenomenon that teaching hospitals are over-over-crowded while peripheral hospitals work with ‘Susegad’ style upto 2pm or so and then virtually go to sleep. When someone like Ramdas Patil suddenly disturbs this sleepy atmosphere in early morning hours, at V.N. Desai hospital in Santa-Cruz, it is no wonder that things go wrong. The ‘Susegad’ style of working can not suddenly change into Jet’ style, anywhere in the world. Some scape-goats are massacred and everything continues as usual.

Much more attention is required in various other directions. Medical Education has to be re-oriented to become compatible with social needs. System of working must be changed, proper motivation ought to be created for doctors to work – and performance based emoluments has to be one of them. But at the same time, ‘Riots, Assaults and Destructions’ ought to be condemned outright – whether the doctor/hospital is right or wrong. It can not help – It certainly worsens the situation – and people will suffer more. People will have to develope a little more faith in doctors – at least those who talk and explain – and allow them to make errors of judgment; often not even that – the death or the complication could be inevitable, unavoidable. Please allow Doctors to make mistakes – so they will be willing to treat you at reasonable costs and available facilities.

About: Dr. Sadanand Nadkarni
General Surgeon, Former Dean, L.T.Med.College, Sion.

Contact: sadanadkarni@gmail.com, 9320044525

Website: www.healthandsociety.in

Disclaimer: All the contents of this Article is provided “As Is”. That means there is no warranty of any kind. Indianhealthjournal makes no claim that the Article’s information is appropriate in any jurisdiction or that the products described in the Article will be available for purchase in all jurisdiction.

Putting Patients First Conference – 20th Oct, Mumbai

16 Oct

PUTTING PATIENTS FIRST CONFERENCE
NEHRU CENTRE 20TH OCTOBER 2010: 

9.30AM – 1.30PM

In order to improve healthcare, we must be sick and tired of being sick and tired.

Engaging patients is not easy; yet, it is fundamental to achieving better outcomes in consumers’ healthcare.

Patients and doctors need to trust and respect each other. The better the doctor-patient relationship, the better will be the amount and quality of information about the patient’s disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient’s knowledge about the disease.

Doctors need to work in partnership with patients by providing Information Therapy – which is something we seek to incorporate in the process of delivering the best medical care to patients.

A well- informed patient is a satisfied patient.

The conference is open to everyone. Participation is free. We would like to listen to your inputs.

The conference will be broadcast on the Web, to ensure higher visibility !

Conference Partners:

help logoplus91 logoPEAS logo

Informed Consent: How technology can help both doctor and patient !

6 Aug

Date: 4th July 2010

Author: Parag Vora

About: CEO, Infoseek India Private Limited (Patient Education Awareness Series)

Contact: parag@infoseekindia.com

Getting Informed consent from the patient remains a very tricky area in medical practice today . Failure to obtain valid consent is one the commonest reasons patients go to court when they are unhappy with their doctor.Unfortunately, no standardized guidelines have ever been published by the Medical Council of India, Indian Medical Association, or any other ‘reputed’ medical body. This is a huge lacuna, and the importance of taking consent has never been taught to most doctors properly, even though there has been a huge rise in medico-legal and malpractice claims in the past decade or so.

All over India there is a lot of diversity in the way consent is taken and interpreted. There have been instances where consents have been highly inadequate; and in some cases, the doctor has completely forgotten to take a consent altogether ! What makes a consent an ideal consent is still a grey area in India. The ambiguity in the consent document leads to variable interpretations that have resulted in damages to medical fraternity in the form of malpractice claims and litigations.

The Supreme Court of India has laid down certain guidelines in its various judgments for what makes a consent valid; and how it should be taken. Consent and its adequacy has been the most common issue that crops up in medico-legal situation. This is especially true in certain specialties such as obstetrics.

Initially, the concept of Informed consent was developed in order to protect the health of participants in clinical trials and healthcare research. However, in view of the importance of patient autonomy, and the need to protect doctors against medical lawsuits, it is now considered to be an important component of all aspects of health care. Though a very commonly used term, , the fact remains that it is very difficult to prove that the patient did in fact provide true “Informed consent” in a court of law in a medico-legal case.

There are many reasons for this. The limited amount of time available to counsel patients in a busy practice may make this impractical. Also, “How much to reveal” and “How to inform the patient about the risk of complications without scaring the patient away ” is another practical issue , thus making it difficult for doctors to fulfill the legal criterion of informed consent. The inadequate level of education and the language barrier poses another important and genuine problem in our country.

We all know that mere signing on the consent form is not considered to be enough in a court of in law. Similarly , doctors feel very vulnerable when a patient, inspite of being genuinely adequately informed about the risks of the procedure, conveniently claims that no explanation was given to him by the doctor, when he is on the witness stand !

All good doctors want to have a truthful, genuine, transparent doctor- patient relationship where the interests of both the parties are recognised and respected. There is adequate data to prove that giving proper information to patients has improved patient satisfaction and decreased litigation in medical practices.

As a step in streamlining the consent taking process and helping it to make it truly informed consent, to protect both doctors and patients , we are launching P.E.A.S™ Patient Consent software, which has been developed with the help of one of India’s leading medicolegal experts, Dr Nikhil Datar. This software helps manage medicolegal risk with innovative tools which enhance doctor-patient communication at the same time ! The software provides a multilingual, audio visual patient information – cum – consent taking solution for the first time in India . This allows doctors to achieve detailed, provable documentation of the consent process , without wasting his precious time .

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