Saturday, June 21, 2008

The Ugly Physician, once again perhaps, a time to ponder…

"Our lives begin to end the day we become silent about things that matter." ~Martin Luther King, Jr.

“Health care professionals, lawyers, regulators and patients must rise above the long tradition of blame and denial and uncover together the systematic flaws in the U.S. health care system that lead to repeated errors. Rather than attempting to assuage guilt or outrage about errors by punishing, discounting, or self-flagellation, physicians need to look to preventing recurrence of errors.” ~ Lucian L. Leape, Author of To Err is Human: Building a Safer Health System, Institute of Medicine 1999 report.

It is saddening to read yet another scathing and cynical attack on the medical profession in a letter to the editor (NST 17 April, 2001).

The manifestly biased and unjustified allegations by the writer will undoubtedly raise the ire and requisite disgust of many a medical doctor.

It obviously begs the question that the writer must have been horribly aggrieved to feel so negatively and petulantly as he does toward the medical profession, and he deserves our sympathy.

It is truly sad because this implies that the writer has lost his trust of doctors. He views the medical profession with such suspicion and skepticism that he thoroughly confuses the issues of appropriate remuneration with his own values of what is construed in his own mind, as greed.

Just because a physician or surgeon earns more than a certain amount does not make him a criminal! Neither does this imply that he has to carry out surreptitiously illegal and unnecessary procedures to do so. Such allegations smack of envy, and envy does not become of anyone in this day and age of modern-day economics.

While one may have socialist aspirations and value systems, these should not be used to pontificate on one’s own version of righteousness, as to what is deemed appropriate and what is not. More importantly, this disparaging attitude is quite untenable and mischievously speculative.

Unsubstantiated remarks such as fee splitting, commissioning, performing unwarranted surgeries for financial gains, paints a rather contemptuous picture of the medical profession, particularly those in the private sector.

While some of these despicable practices might indeed be occurring, statements such as these should not be airily vented without adequate substantiation.

Just because one can imagine such terrible things happening does not mean that it is indeed taking place, especially when one is already quite noticeably paranoid.

If one has the proof and the evidence, I would strongly urge taking the most robust and appropriate legal action against the practitioner to help eradicate such practices, with haste.

However, one must remember that anyone accused of any wrongdoing deserves to be given due process of the law. Trial by media or mob lynching cannot be the approach to tackle these unspeakably unethical breaches of the medical profession.

Shouldn’t we be fair, or should we let our anger blindside our judgment so much that we adopt the slippery slope trampling of the rights of the accused, because we are so, so angry, so aggrieved?

Vengeance at all cost constitutes vigilantism and can be punishable when wrongly applied, despite the most righteously perceived justification. One simply cannot take the law into one’s hands, or failing that, character-assassinate another through libelous means.

Perhaps other avenues of grievance address and redress could be explored. Perhaps the medical profession could also make this easier for public scrutiny and audit of our records, without resorting to the adversarial medico-legal challenges, which is the approach available these days.

The public on the other hand should be more accommodating and less intimidating with their demands for blood and vengeance for their perceived suffering due to alleged medical negligence or errors.

Talking and working out with doctors, without naive expectations could form the basis of a better more trustworthy relationship, so that less anger and untoward grievances can be better avoided.

Patients should also learn to be less demanding and understand that health and medical care is not an exact science. It is at best a carefully constructed art of healing where the patient has to play a dependent yet rightful role, and the physician too his trained expertise. He must remember that sometimes errors or less than the best outcomes of medical treatment or procedures can and will occur through no fault caused by anyone.

Nevertheless, all these recurring themes attacking the medical profession angers and saddens me. Something is not quite right out there. There is too much misunderstanding, too much anger, too much hate. I cannot help but think that perhaps, there is just too much smoke to simply wish it all away, as if there was no underlying fire, to stoke it.

Could it be that we doctors have ourselves to blame for some of this malaise in our public’s perception of us?

As doctors it is a timely reminder for us to take up this recurring challenge to ensure that we are not repeatedly placed in such compromising positions where our actions can be called to question by either our patients or the press.

We should as best as possible remain above the fray of such actions and activities, which might be misconstrued as unethical or even downright illegal or criminal.

We must rise above ourselves in our professional services while earning our legitimate wages or fees. All dubious endeavours toward moneymaking concern or actions, which could insidiously breach the tenuous lines of propriety such as unjustified personal gain or enrichment at the expense of their patients or clients, should be scrupulously avoided.

Doctors’ connections or involvement with business-like concerns should be seen to be above board and not smack of conflicts of interest. The latter refers particularly to physician-owned or shared medical facilities or equipment such as pathological laboratories, MRIs, lithotriptors, catheterization laboratories, renal centres, nursing homes, etc.

Another tradition of medical education and option, which is surprisingly unpopular amongst the highly competitive atmosphere of secondary or tertiary care, involves specialists and sub-specialists.

This is the lost art of sharing resources and decision-making choices with fellow-colleagues through medical conferences and discussions. This is now almost nonexistent in most private healthcare facilities, where the interdisciplinary or departmental approach is frowned upon, and where solo practitioners reign supreme, often practicing at their wits’ end, within their narrowly circumscribed field or expertise.

While this might not be altogether bad—because there are some brilliant, highly skilled and most up-to-date specialists—case-sharing and information exchanges can always help hone one’s better development as a physician or surgeon. Bringing back the grand ward rounds might be for the better if we can be persuaded to welcome this enterprise into all private medical centres.

Because of fear of losing patients, there is now a tendency to precipitate actions and decisions. Part of the problem is the impatience or even contemptuous arrogance of our newly informed clients who hanker for quick instant results and treatment.

When such patients feel deprived of adequate or less-than-convincing explanations or are fearful from their limited knowledge of the pronounced diagnosis, they frequently panic and hunt around for immediate answers or possible clutches of redeeming straws.

Unfortunately they are then most gullible and vulnerable to the grandiloquent practitioner who can then promise them the world, often without due consideration as to the patient’s overall well being.

Nowadays, many a physician or surgeon would be only too happy (perhaps too human?) to oblige the demanding client for a quick perhaps less-than-correct surgery, or a less-than-optimum balance of therapeutic choice which might not stand the wisdom of time and longer term prognosis.

I have lost my fair share of patients whom I could not persuade that their conditions warrant more major surgeries, than the much preferred less invasive ones, sometimes to great disastrous consequence.

I can vividly recall one glaring example. A year ago, an otherwise fit 72-year old diabetic and hypertensive patient was referred to me for recurrent bouts of acute pulmonary edema.

He was subsequently discovered to have had diffuse triple-vessel coronary artery disease, and of course a poor left ventricular function. After a few months of stabilization, I referred him for coronary bypass surgery as this was in my considered opinion the best option for his long-term prognosis.

Naturally he and his family were disturbed that he should undergo such a major operation at such an age, and instead of seeing the cardiac surgeon, they self-referred him to another cardiologist, who promptly considered him a possible angioplasty candidate based on the patient’s desire for a lesser procedure.

He underwent multiple angioplasties and unfortunately for the patient, during the complex procedure, which crashed, he suffered a massive heart attack, hypotension and also a stroke.
The rueful son called me to relate what had happened and that his father was now on a ventilator, and the doctor had told them that there was not much else they could do. The son wondered if there was still some miraculous thing that I could offer by transferring him to the hospital where I practice!

Sadly I had to reiterate the bad news, which was that there was nothing else we could do, and he died at home a few days later.

Of course, most of us would hanker after a less invasive procedure, because we all want to recover more quickly without too much inconvenience or pain, but sometimes this is not the best-tried or evidence-based option.

Of course as well-trained and experienced practitioners, we might become too enthralled with our own superlative skills that we begin to imagine that we are god-like and that we can tackle all medical problems that are presented to us.

Doing all we technically are capable of doing, including heroic salvage procedures might sometimes be justifiable, but they must be well thought of, by weighing all aspects of our therapeutic decision.

We sometimes have a great difficulty in saying no, even when our lurking conscience tells us otherwise. We believe too much in our own talents and our expertise to pause and reflect on the right thing to do. We let our ego get the better of us, and our patient’s interest is not served the better for it.

I remembered one conversation I had with the late Professor TJ Danaraj. He had said that you could train a monkey to do anything including the most delicate surgery, but that that is not the point. It is making the right decision to do or not to do, to make a well-reasoned diagnosis, to choose a wiser therapeutic option that makes a better physician.

Rash fear-instilling opinions, which provoke the patient to make an ill-informed and ill-considered decision regarding their treatment options, should be avoided where necessary.

Re-consider the patient’s right to a second opinion or even a third, without the need to be fearful of losing face or the patient.

On the other hand, the referred patient for another opinion should also not be promptly hijacked from the poor first physician, by clever manipulation, implied connivance, one-upmanship or unethical self-promoting salesmanship.

But I believe the medical profession and doctors are made of sterner and better stuff—I believe too that there is that karma of life, which will come round, one way or the other. Surely as doctors we can do better for ourselves, and let the public judge us more kindly than they are wont to nowadays.

Let us give them reasons not to doubt us, and to trust us once again, and accord to us our rightful place in the health care paradigm as the respected provider and confidante. Are we so sure that we haven’t contributed to some of these ugly characterizations of our profession these days?

Let us listen once again to our hearts, to our soul within, which makes us choose to be the healer within, for as long as any medical doctor can remember.

Because, if we have forgotten how that feels, that wondrous feeling of being a healer, a doctor first, and that our patients are there because we have an obligation and a necessary connection to serve them with the best of our abilities (including helping them make the wisest and best medical and health choices), then it is perhaps time to quit being a doctor—to acknowledge that we have lost our vocation, and choose something else to profit by, lest we demean the profession by hanging in there with our growing warts and all…

(MMA News Editorial, July 2002)

No comments: