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.