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About myself..

 

Prasad Mallipudi

Hi, welcome to my blog. Here are some of my thoughts about Healthcare in India and also links to my social media sites. Please feel free to go through and let me know of your views. The actual website is having a revamp and will be ready soon. Check again after a few days..

Thank you.

Prasad Mallipudi (aka: Dr MBV Prasad)

email: bmallipudi@hotmail.com

 

Blame Culture

Our individual and collective psyche has become such that we tend to find fault with others and blame someone or something for any unwanted issue. Same is happening in healthcare sector too. As mentioned in the previous post, complications, untoward incidents, and bad outcomes are part of any healthcare delivery system. These happen in the best of the healthcare facilities too.

Whenever and unwanted incident happens, people are quick to point fingers at doctors and hospitals. In the present-day complex healthcare delivery systems, doctors do not have everything in their control, despite the will to control everything and deliver the best possible. In this blame culture, doctors are the easy and soft targets; for public, media, government and regulatory bodies.

This is leading to doctors being defensive and evasive in their interaction with the patients and relatives, leading to more suspicion. It is rather difficult to explain what is happening and why in a critically ill patient to lay people. Sometimes the doctors themselves do not know fully what is happening. They try to do their best and innovate based on their experience.

If the patients are mature enough to discuss the issues and uncertainties involved, the dialogue will be meaningful, and a proper “informed consent” can be taken. Most of the time the consenting process is a farce. Doctors do not have the time or inclination to take a proper informed consent or the patients are not willing to listen to the list of possible complications. When an untoward incident happens, all the hell breaks loose.

There is no transparency in the system, and it is the general tendency of the doctors and hospitals denying any responsibility. Due to this, small proportion of patients who get complications due to shortcomings in service provision are having to fend for themselves. Most of the times, the mishaps are minor and all that needs is an honest approach and an apology. Most people do understand that mistakes can happen and accept.

Some doctor colleagues tend to make loose comments without knowing the full picture. This may be out of simple ignorance or a deliberate smear campaign. Either way, it does not help anyone concerned. Due to the fear of being held accountable and further repercussions, doctors and hospitals are always in denial mode. Patients who have a genuine grievance are having to go through a prolonged legal battle. Most of them do not have the means or inclination to take the doctors to task.

Many countries have taken the concept of “no blame culture” from the airline industry. Due to the nature of civil aviation, it is especially important to investigate any mishaps, so that the aircraft and passenger safety is not compromised. They have a system of reporting any incident without the fear of being made a scapegoat. All the reported incidents are investigated, and appropriate action taken to prevent similar thing happening again. Many hospitals do have this system, but it is not always thorough and transparent.

It is high time it is adopted in our healthcare system too. All untoward incidents must be reported, investigated, and appropriate action taken. Patients must be informed and offered compensation where necessary. If they are not satisfied, they should have access to a quick and fair grievance redressal system. Till such time, we keep blaming each other and our “world-class healthcare” remains a slogan only.

Mixopathy

It is amazing to see the amount of ignorance people, especially those in power, have these days, despite the number of scientific advancements and knowledge base we have. Recent decision of the government to allow Ayurvedic doctors to perform several surgeries is beyond comprehension. Or it is perhaps the cunningness of the bigwigs to mislead the ignorant public. Or may be a bit of both.

Ayurveda is an excellent system of holistic healthcare. We have deviated considerably from the original thoughts and processes expounded by Sages Charaka and Sushruta. Majority of the Ayurvedic care we have these days is modified to present day situation. If you wish to know more about Ayurveda in its pristine form, please read “Ayurveda Lifestyle Wisdom” by Acharya Shunya, available on Amazon Kindle. https://read.amazon.in/kp/embed?asin=B01N2JWPOM&preview=newtab&linkCode=kpe&ref_=cm_sw_r_kb_dp_65eZFbAS2X3JN

Ayurveda can be followed by anyone who has the inclination. Ideally everyone should be encouraged to follow it, as it is an excellent way to maintain the body and prevent disease. It requires considerable amount of discipline and restraint. It involves following a rigorous daily routine and certain simple practices. It emphasises a lot on what to eat, when to eat and how to eat. The results are not immediately apparent. It takes some time for the body to readjust and manifest the good effects.

Our present-day psyche wants quick results. Both doctors and public alike have gotten into the mindset that some external manipulation in the form of a medicine (tablet or injection) or procedure/surgery is required to restore health. We made ourselves oblivious to the enormous repair and regenerative capacity our body is endowed with naturally.

This natural healing capacity is indeed the reason for some of the alternative therapies to become popular. They are cheap compared to Allopathy and are considered to be “safe”. Whoever uses these alternative therapies have faith in them. It is the mostly the “placebo” effect and the natural healing that is the reason for improvement. As mentioned in the previous posts, majority of the ailments are due to our lifestyle choices and can be corrected by simple lifestyle changes.

Majority of the countries have discarded Homeopathy as it has not been proven to be of use in scientific studies. A 2015 comprehensive assessment of evidence by the Australian government’s National Health and Medical Research Council concluded that there is no reliable evidence that homeopathy is effective for any health condition. Please see the views of National Centre for Complimentary and Integrative Health: https://www.nccih.nih.gov/health/homeopathy

Once the disease manifests fully in the form of a major structural abnormality, it requires surgery. This usually cannot be cured by body’s natural intelligence. In this situation, alternative therapies have a role only as complimentary therapies and not as mainstay of treatment.

Instead of improving the health education, healthcare facilities and promoting research into the usefulness or futility of medical systems, our government’s decision to bridge the gap by quick fix solutions is not good. As mentioned in previous posts, major chunk of the cost of modern medicine is in setting up the facility, equipment, and maintenance. Simply by creating “doctors” and “surgeons” through back door will not solve the existing problems. It simply will create more problems, confusion, and add to the woes of all concerned.

Complications and failures

Complications during treatment are just like road or domestic accidents. No one in their right mind wishes to have an accident. Similarly, no patient or doctor or hospital would like to get complications during treatment. However, despite the best will in the world, facilities and expertise, complications do happen during the course of treatment.

Reasons for complications are myriad. They could be due to the doctors, hospital staff or the patient themselves. Errors from doctors and staff are wrong diagnosis, illegible prescription, inadvertent administration of incorrect medicine, over dosage, manufacturing errors, laboratory or imaging errors, not following the safety standards and inefficiency in performing a procedure or operation.

All these are avoidable mistakes and are due to inadequate training, incompetence, faulty equipment, overwork & fatigue or rarely sheer negligence. There are various standards for hospitals and doctors to minimise these errors by having proper background checks before employing doctors or staff, regular training programs, equipment maintenance and auditing all the mishaps.

Complications are fraught with heavy penalties for everyone concerned, directly or indirectly. No hospital or doctor can afford to have repeated mistakes. In the present competitive environment, hospitals and doctors are proactive in trying to prevent and minimise any complications.

Majority of complications are due to the patients’ failure to respond to treatment or abnormal response to standard treatment. Even though all the medicines go through various phases of trials, before they are approved for clinical usage, small proportion of patients respond in a completely unexpected manner; called idiosyncratic reaction. Some people may get allergic reaction to the medicine.

All medicines have side effects. In addition to the wanted effect, they can give unwanted side effects. Just a simple example; it is common to prescribe blood thinners to patients having heart or brain strokes, to prevent further strokes. These medicines may cause bleeding in some patients, which sometimes can lead to significant treatment and cost. This again varies from patient to patient.

The nature of the disease, its severity and the patient’s innate immunity may not be conducive to quick and smooth recovery. Some patients do not respond in a predictable way. When the patient is not responding to treatment or gets a complication, doctors always try to do various things to get the patient better. Longer the hospital stay, especially in an ICU, more likelihood of further complications and bad outcome.

In these patients, the treatment gets prolonged and the costs pile up. When the outcome is bad, relatives or the patient see the treatment as futile. Most people do not want to pay any further money to the hospital when a patient dies. Hospitals wish to recover their bill for the services provided, despite the outcome. This becomes a sore issue. In their grief and emotional outbursts, they start blaming the hospital.

Doctors are caught in the crossfire and are accused of wrong treatment and negligence. For the doctors who have tried their best, this is extremely hard to digest. On one hand they feel bad that they are not able to make the patient better, on the other hand they have to face these baseless allegations and they have to face the internal scrutiny of the hospital administration.

All these will make the doctors risk averse and make them defensive in their attitude. They become less “patient centric” and concentrate more on how to safeguard their own skin. It is not uncommon for the ICU doctors to spend more time with the patients’ relatives explaining them what is happening to the patient, than the time spent on patient care!

One major issue is not having a quick and fair redressal system when there is actual or perceived negligence or wrong treatment. Because of this people are resorting to quick justice by gathering a mob or trial by politicians/media. This is not a proper solution. A quick, efficient, impartial, and thorough enquiry should be carried out and compensation given to the patient/relatives when there is a lapse in healthcare delivery.

Honorable supreme court has categorically ruled that failure of treatment is not to be construed as negligence. Until this is understood by all the concerned people and a fair redressal system is in place, doctors will be hounded, will be defensive and may not take up seriously ill and high-risk patients.

Masterly Inactivity

Masterly inactivity is the word mentioned in one of the surgical textbooks to emphasize the fact that, in some situations “no treatment or intervention” is the best option. Majority of the common ailments are self-limiting. All that is required is to give some comforting medication and observe. Human body has the capacity to deal with a variety of afflictions. In some people, this natural defense mechanism may not be sufficient and additional treatment is needed. A good clinician knows when and how long to wait. It is a calculated judgement.

There are a variety of areas where this “wait and watch” policy is necessary. Most of the viral illnesses are self-limiting. As we are witnessing, even the dreaded COVID is self-limiting in majority of the patients. Dengue is another viral illness that is causing grief in recent years. Only a proportion of patients whose platelet counts drops to dangerously low levels need platelet transfusion. Others only require simple supportive treatment.

Acute pancreatitis is inflammation of the pancreas gland, which is usually brought upon by alcohol intake or gallstone disease. In the initial days, all that is required is to give rest to the gut by keeping the patient fasting and giving intravenous fluids. No specific treatment is required. After the initial days, as the disease evolves, additional treatment is administered in a serial “step-up” fashion, sometimes culminating in major surgery.

Some patients with severe pancreatitis may succumb despite all the treatment. For the observer it is natural to think that the lack of aggressive treatment in the initial days is the cause of deterioration subsequently. They get baffled as no major treatment is being administered in the initial days for such a serious disease.

With increasing availability of ultrasound scan and the advent of health check-ups, there are several people being diagnosed with stones in the gallbladder. Some of them do not cause any problem and are called “silent gallstones”. Once the stones come to light, it is a matter of dilemma for the patient as well as the doctor. There are no major population studies that can guide us regarding the natural history of these silent stones.

Some of them may continue to remain silent and some may cause problems with passing of time. A small proportion of them may cause pancreatitis described above. Depending on the age of the person, any co-existing diseases and the size of the stones, surgical removal of the gallbladder is advised for some people. Others are advised to just wait and watch.

Another area is the terminal cancer. After a certain stage and trying to cure cancer, it is futile to continue aggressive treatment. It simply prolongs the life span by a few days or weeks at the most. If such a stage comes, it is better to give comfort care in the form of symptom relief and withhold treatment aimed at controlling the cancer.

In all the above situations, the treatment is tailored based on many factors and decision taken on an individual basis by the treating doctor or the team in consultation with the patient and the family. Both doctors and patients need to understand these issues and try to make decisions together based on the patient’s condition and needs.

In our society where medical care is mostly driven by fear, anxiety and unrealistic expectations, some doctors do not bother to discuss the issues with the patients for them to make an informed choice. Even if the doctors try to discuss, some patients do not or cannot decide..

Patient centric doctors: an endangered species?!

In the previous posts we looked at some of the issues in the healthcare industry. Anyone in their right mind would like to be treated by a patient centric doctor. However, with the changing scenario, it is becoming increasingly difficult for the patient centric doctors to survive in the system.

Patient centric doctor has the following characteristics. 1. Honest with the patient about the disease, discusses the treatment options and the possible complications & outcome. Tries to educate the patient and guides through the treatment process. 2. Does not prescribe unnecessary tests and medicines. Does not do unnecessary procedures/operations. 3. Where payment is involved, tries to minimize the costs without compromising care. 4. Keeps up to date with the latest knowledge and emerging treatment options. Tries to review his/her results, do audit/research where necessary and changes the practice as per local circumstances. 5. Tries to keep the professional charges less. 6. Keeps cordial relationship with colleagues & hospital administration, seeks help when necessary and tries to help the patient wherever possible to overcome the difficult period in their lives.

All this sounds fantastic, isn’t it?! You may be thinking why all doctors are not like this. First, a good number of patients & their attenders are so naïve and conditioned by fear/dogma/misinformation, they expect unrealistic things from the doctors. When the doctor is trying to tell them something, rather than listening to the doctor and following the advice, they come up with several things that are a mere waste of time.

Just a few examples: where a test/procedure/operation is not required, they want it to be done, “just to be on the safe side”! When an antibiotic is not needed, they want it. After an operation, people want tablets to hasten the healing. Healing is a natural process and takes its own sweet time. At the most, one can take vitamin and protein supplements.  Other than controlling any co-existing diseases, there are no magic pills that hasten the healing.

When the doctor is honest and says, “I do not know”, they are bewildered. Doctors are supposed to know everything! As mentioned earlier, doctors can only give an educated guess about the possible outcome but can give no guarantee. Before a procedure or an operation, if the doctor tries to tell them about the possible complications, most people do not want to listen. All they want is false reassurance that “Everything is going to be fine”. There should be no risk involved and successful outcome is to be assured.

On one hand they expect the doctor to know everything and on the other, they cling to their own dogmas. Quite a common dogma after an operation is the notion that one should not move, lest the sutures will not heal. This is a dogma that has its origins several decades back, when the suture material was not as good as it is now. There are several factors that can adversely affect the wound healing. When the sutures do not heal for whatever reason, while confronted, it is much easier for the doctor to say that the sutures have not healed because you moved or coughed or sneezed, rather than elucidate the reasons for failure in wound healing.

When instructed to get out of the bed, people come up with all such dogmas. These days early ambulation is the key to prevent several complications. Most common these days is the information gathered from internet and media. It takes a good 10 years of training for a person to practice independently. When you meet a doctor with more than 10 years of training and experience, should you listen to the doctor or educate the doctor by telling your dogmas.

It is quite alright to mention once to alleviate your doubts. But arguing with the doctor simply saps him/her of the energy. Rather than keep educating a person who is mired in fear and dogmas, it is much easier for the doctor to yield and give whatever the patient wants! Or keep the communication to the minimum and be authoritative. This is construed as being secretive and not divulging information. All these lead to further dogmas, fears, and misinformation amongst patient/relatives/general public.

When the doctor is judicious with tests/medicines/operations, it is not conducive to the business of the healthcare industry. When the market forces and patients are driving for tests/medicines/operations, for different reasons, it is exceedingly difficult for the doctor in the middle to be patient centric.

Not all people are like this. Some still have common sense, have some understanding of the body mechanisms, and observe their bodies. Some may try different things and come up with their own observations. As long as the fear & anxiety is removed from the equation, these people actually help their doctors in giving better treatment. If the doctor is receptive, it may better their practice too.

In addition to the above issues, these days, doctors are worried about their own safety and survival. There is something called “masterly inactivity”, where one needs to just wait. In order not to get into trouble or wasting time in explaining, most doctors are not using this option and are going with the flow, doing extra tests etc. Unless people realize the issues and take remedial action, patient centric doctors are an endangered species.