"Shopping" for healthcare

It is very  common for patients to go from one hospital to another and from one doctor to another to seek guidance regarding illness. As it happens in any field, medicine, law or management, opinions are bound to vary. This leads to more confusion and sometimes panic, leading to even more consultations and even more confusion!! Of course when ones health and life are concerned, this confusion leads to untold misery.

The basic reason for taking several opinions is the lack of trust in the system. Is the doctor recommending an unnecessary test? an unnecessary operation? Is he trying to make money for himself? is he trying to 'feed' the hospital for its laboratory to make more money? While this train of thoughts is understandable, it is at the same time, causing harm to the patient.

The confusion of differing opinions is bad in itself. In addition it encourages several unhealthy practices. It gives an opportunity for the person giving a second opinion

• to create a doubt in the mind of the patient about the first opinion
• to ask for more tests and add costs

One may say that professionals should not do this. But after all, they are a part of society they come from and their behaviour reflects the behaviour of our society.

Instead, one could consider the following:

• Find a family practitioner. Go to him for all your health issues. It is not a good idea to go to a specialist directly unless it is an emergency.
• Go to a specialist directly only in an emergency - e.g., severe headache, chest pain, abdominal pain, collapse, loss of consciousness etc.
• The specialist must be identified when you are healthy and fine; you should not look for a specialist at the time of an emergency!
• How do you find a specialist? Your family doctor may suggest one; your family and friends might have been looked after well - ethically, conscientiously with reasonable charges - by a specialist. Have such a person in mind and keep his contact details.
• For any specialist help call him - if the problem does not pertain to his specialty, he will suggest a like minded specialist in the specialty you need.
• Let him choose the institution; such specialists know where patients get a fair deal and choose the hospital that he/she suggests.
• Another important attribute of an ethical specialist is to seek a second opinion himself, with the consent of the patient,  when the progress of treatment is not on expected lines.

Training in private practice

Here is my editorial in IJS about training in private practice.

I believe that each one of us is a student and a teacher at the same time.

We have to share what we know with others; Doctors and patients owe it to the next generation to train quality professionals; it will serve us well when we need medical help!!

Please see the link below:

https://dl.dropbox.com/u/54985496/editorial-ijs-1304a.pdf

The difference between Complications and negligence

There is an urgent need to 'educate' people about the difference between complications and negligence. I have used the word 'educate' in inverted commas to reiterate the fact that i do not intend to be supercilious. Everyone of us has to try and make people aware of certain basic facts of medical care; when this awareness is clear, all parties concerned -  patients,  hospitals and doctors - will approach 'problems' and conflicts in the right spirit.

The facts are as follows:

1. Medicine is an inexact science - I spite of all big advances in our understanding of the disease process, the excellent diagnostics that are available and the modern technology that goes into our tools, there is always a 'grey' area when doctors treat patients. Unlike in mathematics and computers, 2+2 is not always 4 in medicine!!
2. Working diagnosis - When a patient is seen first, the doctor takes a history, does a clinical examination and based on these orders some tests. Putting findings from these three aspects of a workup, the doctor makes a diagnosis. This is a provisional diagnosis, also called a working diagnosis; this is subject to change!! When such a change is made later, the doctor is accused of 'misdiagnosing' the condition.
3. Vagaries of investigations - Test results are dependant on many factors - collection of samples, standardization in laboratories, observer dependence of the personnel in laboratories and diagnostic centres and most importantly, the limitations of the test itself!! The clinician has the unenviable task of interpreting these results, making sense of conflicting results and integrate them with the clinical impression. These steps are taken not because the doctor 'does not know what he is doing' but because the nature his work is such.
4. There is more than one way of doing things correctly - the goal is to get the patient right. Many times this is achieved in different ways by different doctors. When patients approach other doctors for an opinion, the method he recommends may be different. That does not mean that the first opinion was a wrong opinion.
5. Complications are a part of health care delivery - the human body is a very complex 'machine'.Outcomes of the same treatment  for the same disease seen in two different patients can be very different.One may be completely cured and the other may end up in complications. The endeavour of the doctor is to keep the failures and complications to a minimum level - this level can never be zero.

If these basic facts are understood, all 'failures', 'misdiagnosis' and 'negligence' can be addressed in an objective and a scientific manner. We tend to approach all issues in healthcare in an emotional manner. The inevitable anxiety aroused by a near or dear one going through a complications, makes people see through 'coloured' glasses. Society must educate itself to try and get over this limitation and 'see' things in the right light.

Plexus

Some years ago, we set up a programme called Plexus under the auspices of the BMC Alumni Association. We felt that the students of BMC, who are the cream of the state, must be exposed to ideas and concepts that are not a routine part of the curriculum. By doing so, their horizons broaden and they will be better equipped to face life as doctors. It would also increase their 'competitiveness' in this fiercely competitive world!! Well, that is the theory. This programme has been floundering - very few students attend these activities!! Most students feel that this programme is not relevant to their needs. Is this perception correct? Are we wrong in thinking that the students need something more than what is formally taught in the medical colleges?

It is worthwhile analysing this situation. In 2005, the Canadian Medical Association brought out a document called 'Canmeds' that spells out the role of a doctor in society. Apart from being a knowledgeable doctor who is professionally good, the doctor has several other roles; he is a collaborator, a scientist, a teacher, a leader, an administrator and a communicator!! I would recommend that all of us - teachers, students, doctors and other healthcare providers read this important document available at http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf.  Are we training our students to take up all these roles?

Presently our students do not even know that society expects them to be all these. Their focus is on mugging up answers to some standard questions and regurgitating them in examinations to get good marks. this enables them to repeat the process and get into a postgraduate course, only to carry on the same rote learning. What after this? Are they equipped to discharge the responsibility that will be theirs as consultants? We have seen trainees after their post-graduation being woefully inadequate both in their knowledge and skill sets.

Can they blame the 'system' for this. Decidedly the system does influence training to a large extent. Our teaching and evaluation does not permit independent thinking and doing things 'out of the box'. I agree that 'conformity' and 'obedience' is rewarded and innovation is frowned upon. But what prevents students from 'conforming' on one side and thinking for themselves and learning additional knowledge and skills that is on offer outside the system? That too when this activity clearly gives them a competitive edge?

Have they ever thought of the training as a process that enables them to function efficiently in the job that they have chosen? So many good opportunities are allowed to go waste, only  because students do not know what it takes to be a good doctor. Programmes like  'Plexus', designed to educate them about this are shunned!! Sadly, they will realise their shortcomings once they come out of college and into the 'real' world.

Cost of Equipment

This is related to the fee structure of training courses that I wrote about recently. We had done a market survey of the mannequins available; without compromising on the quality, we got the 'best' mannequins. They were imported; we were aware of the 'running' costs. We were told that the central vein mannequin would take about a 100 punctures before the 'bladder' had to be replaced at a cost of Rs. 8500=00. Each puncture would cost Rs. 80=00 - pricey but acceptable. The bladder actually conked out after 20 punctures - costing each puncture a whopping Rs. 400=00!! The sales people contest the figure of 100 puncture now!!

This brings us to two larger issues.

Generally equipment is sold aggressively; many times with information that varies from a complete untruth to half truths to omission of important information. Every single thing cannot be taken in writing; even if we do, redressal of a grievance in the legal system is untenable in this country with the costs in time and money that is involved.  And, when it comes to servicing, all sorts of problems come up - not picking up phones, not keeping appointments, not committing to deadlines etc. We have seen this pattern in various fields ranging from mobile phone  to laparoscopic equipment sale!!How do we change this culture?

The second issue is one of manufacturing these equipment locally. Costs can be contained by doing this. There is a singular lack of enthusiasm from industrialists  in this regard. They cite lack of demand as a reason. Huge economies have been built by Japan, Korea and China by reverse engineering. Why can we not do this? Why can we not at least manufacture the consumables? Why do we have to look for big profits in every endeavour? I believe that rubber / plastic manufacturers can easily make the consumables in the mannequins. While the demand for this may not be great, they will at least sell enough to break even.

We really need to think about this in this country.

Fees for training

At the clinical skills centre we have set up at BMC, we have fixed some nominal charges for the courses. It is Rs. 1500=00 for a one day undergraduate course and Rs. 5000=00 for a 3 day postgraduate course. How did we fix this amount? We actually did a costing exercise before fixing this fee. We included the cost of consumables like sutures, suturing pads, the animal tissues that we buy, the honorarium we pay the mentors and the fixed cost of salaries to the 3 employees at the centre. We did not include capital costs as we have no loan to service - all the infrastructure came through donations and the space, electricity and water come gratis from BMC. As a gesture to BMC we reduced the cost to BMC students by 40% of the above mentioned amount for PGs and made the course free for UGs.
With this approach, the actual expenditure is about 2500=00 per day; but we kept it low because of assurances that the sutures and some props would be donated by the industry. With this fee structure we are self sufficient. Mind you, it still does not cover attrition; if any equipment conks out, we have raise donations again to replace it.
This long preamble is just to air the fact that practically everyone seems to think that the fee is too high and that we are trying to make a profit with this activity!! The university team objected; the college objected; I had one to one meetings, explaining the logic of costing and produced documentary evidence for the same. The fee was, in fact, fixed after getting clearances from these authorities.

Now the candidates are complaining!! They like the course very much, but say that the costs are high!!

How do I explain the following?

• The cost of  similar courses abroad runs into hundreds of pounds and dollars? Perhaps 10-15 times more expensive than the costs here.
• Somebody has to pay for the actuals - there are no free lunches in this world!!
• Unless we are self sufficient, we may not be able to survive and continue the training; depending on donations for everything is incorrect.
• knowledge and skill learning is an investment which fetches huge returns.

I would love your inputs on this issue.

kl-first-blog

It is  a bit surprising that this is my first blog!!
I have been using computers for the last 30 years!! I have always been very active in propagating its use in medicine. I have conducted workshops, given lectures about computers and have been an 'activist' in pushing computers among doctors.
But then, why did I not take to blogging?
The reason is simple - I did not believe that I had something very important to say to the world at large; what I needed to say was to the immediate world around me - my family, my students and mt colleagues - and for this I did not need to blog!
Does that mean that I have something very important to say to the world now?? Certainly not!!
But then the pulls and pushes of social networking are so strong that it is probably prudent to have a blog to say what you have to say; perhaps link this to a social networking site so that your 'network' at large gets information that you might want to convey.
There is another important reason; several of our activities from the alumni association of BMC have to reach a larger audience; very few people log on to our website; perhaps we can reach them better through networking.
let us see how this works; so long for now.