Tuesday, December 2, 2014

'I am the good doctor, rest are bad'




A good doctor has limits as to how much he/she can achieve in a lifetime but the rogues have no limit, they can go on wreaking havoc for as long as they practice and can jeopardize the health of, don't gasp, the entire world population.
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There is a spectrum with near-ideal doctors at one end and unconscionable rogues at the other, with majority near the midpoint. The more doctors we have near the ideal end, the better. Tragically, the trend in Nepal shows that the meticulous near-ideal doctors are being fast outnumbered by the rogues as medical education transforms itself as a conscience-free profit-seeking venture from a responsible enterprise to produce qualified doctors. 


As I wrote the first part of this series (When a hospital kills you with a bill), it was the first ever instance in which I pointed fingers at some individual doctors along with the system for the wrongdoing. I obviously expected outrage from the colleagues in the fraternity because I had dirtied my hands in showing the public the mound of dirt that our profession had become.

Many doctors were infuriated. But to my surprise, the fury—at least of the people who shared it with me—was not directed at me. Most of them argued strongly that the doctors in question should be sued for causing damage to the patient and should be exposed for bringing shame to the profession. Apparently, everyone with open eyes in the profession has been anxiously watching the proliferation of rogue doctors who pose a threat to the fellow doctors as much as the patients by bringing ill-repute to the profession.

This is what one desperate junior wrote to me:
           
As I observed during my duty in ICU, this is exactly the fate of many such fathers. Couldn't agree more when you wrote: the lives of the patients hinge on scrupulousness of the decision taken by a person rather than some meticulously prepared and enforced protocol based on evidence.

I was yet to see this sort of devastation before internship and used to think your analogy of butchers and doctors as an exaggeration. But now I realize even that is an understatement and our system is really rotten to the core. Now with the …. I have been painfully realizing that our entire health sector has been hijacked by the butchers.

Having reminded that, I am postponing the article outlining the solutions to the problem for some other time. Here I will elaborate the same theme from the first article now that people both in and out of the profession have been engaged to the issue with acute interest.

This brings us to the question: What makes a doctor good and what makes him/her rogue?

I am a good doctor and all others are bad; or at least, they are not as good as me.

Well, that is not my statement but a notion that an average doctor in Nepal is bound to have. 

That is because, in a country where the government lets private medical colleges fleece as much as twenty millions to make a doctor and pays twenty thousands a month as a salary after they graduate, one has to resort to private practice and for that you and only you have to be a 'good doctor'. There is no other recourse: however up-to-date and scientifically based your treatment, people will flock to the quack in the neighborhood who is simply known as the 'good doctor'.


What is a good doctor then? A doctor who

a)     views patients as human beings rather than as his subjects or clients and keeps their interest above everything else including hospital's as well his own interest, at least in the setting of health care delivery
b)     has integrity, is reasonably competent and is committed to constant improvement of his own knowledge and skills for the better management of the patient
c)     has the broad vision to see even the remote future of health care delivery system and avoids indulging in lapses that jeopardize health of the future generation (to be elaborated below)
d)     sees health profession as an opportunity to comprehensively alleviate people's suffering rather than a way to treat an illness and earn a buck.

Are we looking for an ideal doctor then? Is that a realistic possibility in a setting as awful as Nepal's health sector? Every patient wants an 'ideal doctor' to treat him and the privileged among us come to settle for presumably the best that is available. But who categorizes a doctor as bad, alright, good, best available and ideal? 

In theory, every doctor is supposed to have minimum competence and a degree of integrity before being awarded a degree and the license to practice. Those with same degree are supposed to have a remarkably similar proficiency and competency. 

But the reality is different. There are at least five independent authorities that award the degree of a doctor in the country and a council to give the license. An initiative to make medical education under the umbrella of a singe medical university has been meeting a stiff resistance from the politicians and their proxies in the profession. 

To know more about the real world where we live, let's go back to the setting about which I talked in the first article. 

If you think there cannot be anything worse than operating a terminally ill cancer patient and pushing her family to homelessness, you are mistaken. A good doctor has limits as to how much he/she can achieve in a lifetime but the rogues have no limit, they can go on wreaking havoc for as long as they practice and can jeopardize the health of, don't gasp, the entire world population.

Indeed the other problem was what caught my attention first and the prospects were terrifying. I had never seen so many antibiotics, all of them higher-end ones mostly reserved for complicated infections and sepsis in ICU setting being used in a general ward. Having not observed the treatment part for more than three years (I am more of a diagnostician now dealing with diagnosis of a disease rather than treating it, thanks to my specialty), I was not familiar with the latest protocols for preventing and treating infections in the patients. But the sight of those antibiotics in the bedside of every patient was alarming.

As I would see it later, my mother was given a single dose of a common antibiotic priced at around 100 rupees before undergoing a procedure to remove her gall bladder in a govt hospital in Kathmandu. Hundred rupees was all we paid as such for the antibiotic during her entire hospital stay.

For the same procedure in the index private hospital that we are talking about, they had been giving one of the newest combo antibiotic that cost nearly five thousand rupees for daily dose. That started with the prophylactic dose before the surgery and followed for as many days as they wished. On average, a patient undergoing the same procedure in this hospital would pay nearly thirty thousand rupees for antibiotics only. 

Add to that the other similarly costly and unnecessary drips containing amino acids etc. and the bill for medicines easily crosses fifty thousand rupees. Add to that the investigations, many of them dictated more by the hospital's policy to collect maximum revenue than by the need to the patient as judged by the clinician, and the bill easily approaches a lakh rupees.

Even some patients with working diagnosis of 'Acid peptic disease'—an ailment commonly known as gastritis or 'gastric' having nothing to do with ordinary systemic infections treated with such antibiotics—were being given the same costly antibiotic.


This will likely make you think that such private hospitals are to be avoided by the poor but the rich people will be alright there. You are once against mistaken.

You may be alarmed to hear that antibiotics, unlike any other medicine, are vulnerable species in medicine but that is the truth. After a certain span of time, they lose potency to fight against the microbes because like many other species in the earth, microbes too adapt to the presence of antibiotics (antimicrobials is the more appropriate term) rendering them ineffective against the infections that were once treatable by them. This phenomenon is called Antimicrobial Resistance (AMR) and is one of the intractable challenges to modern medicine.

Compared to other drugs, say anti-hypertensives and anti-diabetic drugs that never lose potency, the returns from a new class of antibiotics are thus likely to be limited for a certain time and the big drug companies, almost all of them profit-seeking private ones, are reluctant to invest billions of dollars to discover more new antibiotics.

As existing antibiotics become increasingly useless and new antibiotics fail to be invented, we are rapidly moving towards a nightmarish 'post-antibiotic era' in which we will once again succumb to ordinary infections like our grandparents did before discovery of penicillin. 

The only viable way forward is to preserve the potency of the existing antibiotics for as long as possible by curtailing their irrational and unnecessary use that gives microbes opportunities to develop resistance. If we do the opposite and help microbes develop resistance, that will become disastrous to not only our hospital and country but to the whole world because given the extent of globalization, a multi-resistant microbe can travel from one continent to another in a matter of hours. 

Let's once again come back to the doctors in our index hospital. They seemed to be as oblivious to this fact as the farmer ploughing his filed in the village who never went to a school. All they cared about was how to 'treat' their patients no matter what the cost for the whole fraternity and for the entire future. In other words, they were silently gobbling up a precious future resource that would help save millions of lives in the future if their potency is preserved carefully but could be useless any moment if the indiscriminate use is continued. 

After this, even the term rogue will have more ominous implications than usual once used to describe these doctors. When I explained this to Prof Govinda K C who has been fighting for the cause of quality medical education and health care, "That is the crime against humanity" was all he said. 

While it is unrealistic to portray an individual doctor into either good or rogue category, it is more prudent to view the profession as having people across the entire spectrum from near-ideal doctors at one end and unconscionable rogues at the other, with majority near the midpoint. The more doctors we have near the ideal end, the better. Tragically, the trend in Nepal shows that the meticulous near-ideal doctors are being fast outnumbered by the rogues as medical education transforms itself as a conscience-free profit-seeking venture from a responsible enterprise to produce qualified doctors. 


For more information on the issue of Antimicrobial Resistance, visit the official blog of Nepalese Initiative for Prevention of Antimicrobial Resistance which was, in turn, inspired by the very rogue doctors described here in the article. Read more about corruption in Nepal's health sector (in Nepali) here and here.

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I do not know why I often tend to view people rather grimly: they usually are not as benevolent, well-intentioned and capable or strong as they appear to be. This assumption is founded on my own self-assessment, though I don’t have a clue as to whether it is justifiable to generalize an observation made in one individual. This being the fact, my views of writers as ‘capable’ people are not that encouraging: I tend to see them as people who intend to create really great and world-changing writings but most of the times end up producing parochial pieces. Also, given the fact that the society where we grow and learn is full of dishonesty, treachery, deceit and above else, mundanity, it is rather unrealistic to expect an entirely reinvigorating work of writing from every other person who scribbles words in paper.


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Somebody has said: “I was born intelligent but education ruined me”. I was born a mere child, as everyone is, and grew up as an ordinary teenager eventually landing up in youth and then adulthood. The extent to which formal education helped me to learn about the world may be debatable but it definitely did not ruin me. There were, however, things that nearly ruined me. There came moments when I contemplated some difficult choices. And there came and passed periods when I underwent through an apparently everlasting spell of agony. There came bends in life from which it was very tempting to move straight ahead instead of following the zigzag course.


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