Author: Shrestha Suvash
Date: June 2008
"I swear by Apollo Physician, by Askelpios, by Health, by panacea and by all the gods and goddesses, making them witnesses that I will carry out, according to my ability and judgment, this oath and this indenture. I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them." We all remember these lines as a part of Hippocrates oath the principles we vowed to follow in our medical practice. But now I feel its time we look back and ask ourselves, are we really following them? If yes, then every now and then, why do we get to hear: "Petition filed against doctor for negligence", "Dispute between doctors and patients", "Doctors going inhumane". So, the question here is "Are the doctors becoming inhumane?"
May be Yes
The present world is very materialistic and it has not spared medicine. The increased cost of patient care in some of the developing countries is evidence of the same. Have you ever bothered to calculate how much typhoid fever which is so common - costs to get treated? In Nepalese currency, add 200 rupees for investigations, 10 rupees a tablet of antibiotic twice daily at least for a week and 200 rupees service charge. In total, it makes 540 rupees. This makes around eight US dollars which is almost five times what an average person earns a day here. This calculation is just an estimate of the treatment charge in an average hospital. What is more disappointing is, there is no limit for the price a hospital can charge for its services. So, it is not hard to imagine the financial burden people have on their back.
Meanwhile, various malpractices are also making much news these days. Recently a disgraceful story of a kidney transplant racket in India smudged the image of the whole medical fraternity. This doctor had been secretly trading his patients kidneys for money. This is just one particular case which happened to come to the spotlight. There is no doubt there are many others which are going on under the dark shadows of white aprons. Unsafe abortions, recruiting human beings in research activities, illegal business of human blood are just few to name.
No one can deny the enormous influence of pharmaceutical companies on medical care. To ensure doctors' support, pharmaceuticals are created to fulfill each and every of their demands. They sponsor medical seminars, provide free lunches, provide gifts, and even pay for the travels. So, it's no surprise that doctors ought to show some courtesy in return. And how do they pay back? By prescribing their drugs without regard for quality. Unfortunately, through such habits, even many counterfeit and substandard drugs are entering the market.
It does not sound a good idea to inflict all the blame on the doctors. May be it's just the changes in medical practice. A renowned physician at Kathmandu Medical College in Nepal, a south Asian country shared his feelings, "In our days, a single doctor had to look after all the problems that one could ever have. But now, it has all changed. It seems we now have more specialized units than our body parts to look after." I feel, perhaps, this might just be doing some bad to our image. Because, I have seen it many times that a patient with a simple stomachache waits long hours in the medical OPD for his turn only to told by the medical officer that its not a medical case and he better see a doctor at the surgical OPD where he again has to wait equally long hours for his number. And he should feel lucky, if he does not get referred to yet another department. Yes, the doctors don't have any intention of adding extra trouble to the patients but the complicated system makes it seem so."
There used to be very little investigative equipment available and thus, the doctors had only their clinical skills to rely upon while concluding any diagnosis. But with the introduction of newer investigative, diagnostic, and therapeutic techniques, it is no surprise to see doctors prefer them more. But it can't also be ignored that these advanced gadgets have widened the gap between the doctor and his or her patient. In the present situation, a doctor would rather have an ultrasound done than palpate the abdomen and look for signs of cholelithiasis.
In contrast, I feel patients are also equally responsible for the tense relationship between patients and physicians. In the past few years, I have seen many incidents where patients - not satisfied with the service of the doctors and hospital - vandalized the hospitals and even beat up the doctors for no good reason. I clearly remember a 13 month old baby, who was brought into our hospital unconscious and totally blue. The doctor on duty put the baby in ventilation. But despite our sincere efforts, the baby succumbed after a day. No body got enough time to assess and see what exactly was wrong with the baby.
But soon after the baby expired, the baby's family accused the doctor for neglecting and killing him; they brought a large mass of people and started to break all the windows of our hospital. They only stopped after the hospital administration called for a talk, and surprisingly, they left with a good sum of money as compensation. One of our hospital administration staff explained, "Everybody knew it was not our fault, we had no other option. We could not fight and stop them from destroying our hospital. Neither could we stand there and watch them destroy everything. And we could not also keep the city police outside our hospital all the time. We were so helpless." Such incidences are not uncommon and I feel, some patients file petitions and drag doctors unnecessarily to court only to make money. So, for this reason, doctors are forced to be very cautious about what they say and do to their patients. Each and every statement they make has to be correct and they have to have consent forms filled up even for minor interventions so that they are on the safe side in case something unwanted happens. A senior doctor cautioned, "You just explain everything to the patient and his relatives. But don't do anything that the patient is not willing to. And never forget to get every detail in paper, so that you have the upper hand incase some legal complications come up. And its better not talk of the patient and his illness in front of the patient and his relatives unless you are asked." So, while working under such tense conditions, we can imagine the doctors would definitely sound little harsh and then they are said to go inhumane. But they have no other way out.
Patterns of disease may also have some role in straining the doctor/patient relationship. Diseases like diabetes, hypertension etc make up most cases these days. These are the diseases which require life long treatment and strict life style regulation which may not be comfortable. This might frustrate patients as they are always under medication and limitations. And this frustration is reflected as anger towards their physician.
Many times, it's the misunderstanding and ineffective communication that widens the gap between doctors and patients. Sometimes, the doctor might not provide proper instructions and other times the patient might not understand what the doctor means. This creates a whole lot of confusion. For example, it is a common problem of many patients that they have hard time reading the doctors' handwriting. which is barely legible. In such situation, how can the patients read his prescriptions and follow his instructions? Besides, the patient might also not strictly comply with the prescription and may not come for regular follow ups. In the end, overall effect falls on the health of the patient, the patient loses confidence in his doctor, and the doctor patient relation gets strained.
So, what's the solution?
What can we do to ensure that this sacred relationship between doctors and patients flourishes? Well, one very effective way could be to include communication skills teaching in the medical curriculum so that the young doctors learn good communication from a very early age.3 For example, holding the patient's hand while talking, maintaining proper eye contact, helping the patient sit up or walk around are some ways the doctor can get close to the patient. Doctors have to be taught how to be nice to the patients, how to inquire about the well being, how to explain to their disease. And of course, this teaching should focus on doctor-doctor communication as well and not only doctor-patient communication because many times it is the lack of communication or miscommunication between the health workers themselves that results in blunders. Like if a doctor on duty fails to provide proper handover to another doctor before leaving for home, the duty officer might not know which drug had to be stopped and which had to be started, how much fluid the patient had received and how much urine had the patient passed. So, there has to be a very good and effective working system. Similarly, doctors from different disciplines should have regular meetings and good discussion over the management of their patients so that the patient gets multidisciplinary care and treatment.
In conclusion, whether doctors are becoming inhumane or not is a debate in itself. But one thing is certain, the doctor patient relationship is turning more towards a salesman customer relationship, where each one tries to bargain and get the better deal. If anything goes wrong, patient, even without thinking for a single second, blames the doctor. And the doctor too, tries first to escape from his responsibility rather than to see what he can do to improve the condition. But, a person's health is such a sensitive and serious issue that it should never be seen from the perspective of salesman customer business. The emotions and sentiments of the patients should always be cared for while equal respect and gratefulness should be offered to the physicians. Only then can the doctor-patient relation can survive and flourish. Let's put all our differences and suspicions behind and lets create an environment of understanding and friendliness where a patient can feel his doctor by his side all the time and where a doctor can work without fearing of the consequences if something goes wrong.
1.Dulal H, Giri A. Kidney Kumar deported to India. The Himalayan times 2008 February 10;1.
2.Rahmann MM, Rahman S, Begum N et al. Client expectation from doctors: Expectation reality gap. Kathmandu University Medical Journal 2007;5(20):566-73.
3.Adhikari RK. Humanities in education of doctors. Kathmandu University Medical Journal 2007;5(20):443-4.
Written by Suvash Shrestha