Counselling the patients and relatives 2

 Our psyche is stuck between two opposite ends. One end of the spectrum is the old-fashioned way, where the doctor used to diagnose any ailment by checking the pulse and giving a medicine out of his/her box. Other end of the spectrum is the present ‘state of the art’ diagnostic tools, instruments, medicines, and various specialists.

Back then, Allopathic treatment was a miracle. It cured so many diseases that were not amenable to indigenous methods. An injection was considered as an ultimate treatment. Operations or general anesthesia means near death experience. Surgeons used to have extreme reverence in the medical field and in the society. Cost of the treatment was also not much.

This naturally led people to flock to allopathic medicine and subsequent developments. Compared to 50 years ago, allopathic medicine has advanced tremendously in all aspects. We are able to cure many diseases, increase the life expectancy, reduced the infant & maternal mortality, reduce the surgical complications & mortality considerably and make surgeries less painful.

Along with the improvements the populations expectations have increased. They are expecting 100% success in all the situations and not able to accept any failure during the treatment process. Some people are naïve (or arrogant enough) to ask, “Our patient came to hospital alive; how can he/she die?”

As mentioned in the previous posts, modern healthcare costs money. Some people think, costly treatment means success is guaranteed! It is not so. As we witnessed several times, the (so called) best doctors and hospitals across the world are not able to save the most influential and wealthy people.

Instead of understanding and accepting the mortal nature of our body, this again has increased the anxiety and search for even better doctors and hospitals! This and the inherent nature of human mind seeking betterment all the time, healthcare industry is coming up with more equipment, medicines, and treatment methods in pursuit of immortality. (Read as more costly methods and treatments!)

Our psyche wants the best of medical treatment, guaranteed success with little cost. It is not possible. No one can guarantee a successful outcome. All that the doctors and hospitals can do is to give treatment to the best of their abilities and hope that the patient’s body mends with the treatment given. Following is a statement from one of the revered surgical textbooks: Faced by a patient who has lost the power to heal, the most famous surgeons are reduced to impotence!

If the doctor is honest and tells the facts as it is, people do not like it. From the doctor they want to hear the words “I will take care of everything, you/your patient is going to be fine”. Doctors are not able to give such statements these days as that statement is not correct in the first place, secondly if things do not go as planned, he/she will not have an explanation and it does not sit well with the modern ethos of keeping the patient informed and making a part of the decision process.

When people are out of touch with reality, it becomes rather difficult to counsel them about the treatment options, costs and the possible outcomes. This often happens when the patient is stuck in the ICU and is not improving. As there is no improvement, they start having doubts about the treating doctors and the treatment process. They start seeking multiple opinions and keep cross examining the treating doctors.

There is nothing wrong in seeking a second opinion. However, there is no point in cross examining the treating doctor and educating him/her with the knowledge & wisdom gained from internet, friends and family. This will only increase the frustration of the treating doctor and is a waste of time. It is not uncommon for the doctor to be overly cautious while counselling the relatives and treading extremely carefully so as not to have trouble later.

The doctors’ time and energy could be better utilized if they can be open with the relatives, giving the facts as it is and thinking about the patient’s condition, rather than trying to defend the cross examination of the relatives. People must do their due diligence before deciding upon the doctor and hospital. But once decided, have faith in them.

Counselling the patients and relatives

It is not an easy thing to counsel the patients and their relatives who are having morbid fear and anxiety, due to the illness, treatment, cost or the potential outcomes. For very minor issues like lipoma under the skin (excessive collection of fat cells under the skin) which is a common and not a serious condition, some people get extremely worked up. It is a condition that will not be cured with any medicines, indigenous treatment or prayers.

Only treatment is removal by doing a minor surgery, which is usually done by giving local anaesthesia to numb the area and patient sent home soon after. The moment the word “surgery” is mentioned, some people start having a panic attack. The alternative is just leaving it alone, as most of them do not cause any significant problem. Patient is afraid of keeping the lipoma as someone might have told them that “lump” may turn into cancer.

It is true that a small number of lipomas can turn malignant over time. There is no way one can predict what will happen over time. One must take a decision whether to keep it, observe and have it removed only if having any warning symptoms. Otherwise, have it removed straight away. It makes the life of the doctor difficult; if he/she says, leave it, they worry about cancer; if he/she says remove it, they worry about the “operation”!!

Doctors are having to invent new names like “procedure” to avoid triggering the panic attacks. Another word that triggers anxiety is “biopsy”. When the doctor says we are sending the tissue for testing, people equate with cancer. It may well be cancer. Most of the time, any tissue removed from the body is sent for testing these days to avoid any surprises in future. People keep asking in their anxiety or ignorance, what do you think the report is going to be?! If the doctor knows what the report is going to be, what is the need to do the test in the first place!!

Removal of lipoma under the skin is smallest of the operations. For something like that, some people make a big hue and cry. When someone is undergoing a major operation or having treatment in an ICU with serious illness, the counselling becomes even more difficult.

One of the problems contributing these days, is the variety of treatment options available in terms of types of procedure and type of anaesthesia. Another compounding factor is the choice of doctors and hospitals. Doctors tend to have their own opinions and preferences for various reasons. The difference in opinion and choices available are increasing the confusion of patients.

These days doctors are not supposed to be patronizing. Doctors should inform the patients about various treatment options available, the pros & cons of different options, give their recommendation and help the patient choose the treatment they feel is correct for them. It is called “informed choice”, which is the buzz word in treatment philosophy these days.

It is a joy to discuss the treatment options available with a patient who is level-headed, understands what is being told, discusses logically, makes an informed choice and participates in the treatment process. Such a thing happens only rarely in our society, where the predominant emotion usually is morbid fear and anxiety.

Sometimes even after adequate counselling, patients or relatives deny having been told about adverse outcomes. Most of the times it is due to the doctors not counselling in a way the patient or relative can understand or they not understanding what the doctors said or denial, where the mind preferentially ignores bad. Rarely it is the patient or relatives trying to outsmart the system and trying to get some compensation.

Patient is the center of the healthcare industry. Everyone who is in healthcare industry and allied industries should keep that in mind and have a “patient centric” attitude. Most important emotion doctors and preferably all healthcare professionals should have, is empathy. However, in modern healthcare the patient centric attitude is getting increasingly challenged.

We as individuals or groups have a variety of characteristics, emotions, priorities. When one feels secure and strong, he/she will be willing to and be able to help others in a better way. The way things have taken shape in our society, doctors are not feeling secure, with regard to personal safety, litigation, loss of job etc.

Whether it is the hospitals or the allied industries, everyone is pursuing exponential growth in their balance sheets and expanding their businesses to increase the market capitalization and share value. They are afraid of their own survival. At all levels there is insecurity and fear in the society. This needs to be addressed. Growth should be based on the healthcare needs of the society, not the other way round. Hospitals and doctors should feel secure without the fear of balance sheets and profit margins.

Good number of patients do not help themselves. Out of ignorance and fear, they sometimes get many consultations, investigations and treatments which are totally unnecessary. Some are too smart for their own good. Population should be educated properly, (not haphazard, half-baked knowledge through media and internet), so that they have correct perspective about disease and realistic health goals.

Spectrum of doctors and healthcare facilities 2

While undergoing treatment in a hospital, if things are not improving or worsening, it is always a dilemma for people whether to stay put in that hospital or move to a higher centre with better facilities. This can be a big problem for people who are getting treated in hospitals outside of major cities.

Close family members are generally distraught as the patient is not responding to treatment. They want some “knowledgeable” person to guide them. Best person who can advise whether to shift to a higher centre or not, is the patient’s treating doctor or the team. Ideally the treating doctors should guide the patient’s family whether shifting to a higher centre is needed, whether the patient is stable enough to be shifted, which hospital to be shifted to, talk to the team at the receiving hospital and co-ordinate a smooth transfer.

Patient’s family members are usually unhappy with the treating doctor or the team as the patient is not improving despite their treatment. Most intense feeling in their mind is “Why is my relative not improving despite your treatment?” Generally, they are skeptical to follow their local doctor’s advice.

Local doctors are usually feeling bad that they are not able to make the patient better and it is sort of, loss of face for them. Most doctors feel like they are the best doctor, and their hospital is the best. Yet another factor is which hospital to shift to. This is too much to ask for in our mostly disjointed system. Doctors may be accused of forming nexus and guiding patients with some motive. Sometimes the doctor may indeed have an ulterior motive in referring patient to a particular higher centre, which again is the reason for skepticism on the part of patient’s family.

An important factor to consider in shifting a critically ill patient is the additional risk associated while shifting. An air ambulance is ideal, but it is rather expensive and beyond the means of most people.

It is common sense and general belief that better treatment results in better outcome. But it is not always so. Some patients may recover with treatment in the peripheral centre, whereas some patients may not recover in the hands of best doctors and hospitals that money can buy. It again boils down to the three cardinal factors mentioned previously: patient factors, disease factors and treatment factors.

Doctors and healthcare facilities also come in wide spectrum; from an MBBS doctor practicing in a small peripheral area to a transplant surgeon in a tertiary care hospital in a city. Not every patient requires the ultramodern services in a tertiary care hospital. The highly specialized doctor cannot provide the basic health requirements.

What is needed is a stepwise approach to the problems and smooth transition from primary care to secondary to tertiary care depending on the clinical condition of the patient. As mentioned before, there is enough time in most patients for this to happen. But due to the anxiety, coupled with misguidance (by themselves, media or healthcare providers), people want everything done quickly.

Unfortunately, there is a lot of blame culture in our society. People usually want to blame someone or something when things go bad. Due to all these issues doctors in peripheral area hospitals may not entertain the discussion about shifting to a higher centre, leave alone guide the relatives, for the fear of getting blamed if things do not work out during transport or in the higher centre.

Spectrum of doctors and healthcare facilities 1

Just like there is spectrum of diseases from very mild to profoundly serious; doctors, laboratories, hospitals and other healthcare facilities have a wide spectrum in the services they provide, their capability and quality. This can lead to considerable amount of confusion and mistrust.

Let us take the example of a CT scan, which is manufactured by different companies. Machines belonging to different companies come with the usual industry standards. Every company tries to innovate and improve the specifications to better the standards. It is a continuous process. There will be some variation in the specifications based on the company, which may or may not affect the image quality.

The first-generation CT scanners (1972) used to take a single cross-sectional image of the body in one direction – across the body (Axial), hence they used to be called CAT scan, meaning Computerized Axial Tomography. The person is made to lie on scanning table which moves through a gantry (like a big donut). The table moves in increments of 2-10 mm for each section to be taken. The process is repeated until the body part that needs to be checked has passed through the scanner.

First generation scanner took about 5 minutes for each section. Since the initial scanners used to take time, 10mm sections were taken to reduce the time and the person must hold breath to scan chest and abdomen as any movement would affect the image quality. So, any lesion in abdomen smaller than 10mm can be missed. With further developments in technology in 70s and 80s it was possible to bring scan times substantially to about a couple of minutes for a brain scan and 5-10 minute for a body scan.

Major technology breakthrough in slip ring technology in 90s resulted in Spiral CT where the scanning table moves continuously through a continuously rotating gantry, making it possible to scan the body in a breath-hold. Further developments like multiple row detector scanners with 4, 8, 16, 32, 64, 128, 256 and now 320 row detectors. These state-of-art scanners further reduced the scan time, made it possible to obtain sections of less than a millimeter. Several hardware and software developments reduced the radiation dose by 2-3 fold.

The entire abdomen can be scanned in a single breath hold within 10 - 15 seconds. Sometimes a contrast injection is given to enhance the tissues scan is repeated. Timing of the injection and acquiring the images is important. In addition to increasing the resolution, the reduction in scanning time is especially important while scanning moving body parts like heart. The scanning can be done with less than 1mm sections and using software, the images can be recreated in three dimensions and viewed in any direction we want, not just the axial view. That is the reason the “Axial” is dropped from CAT.

To put into perspective, it is like taking photos using the early 1 mega pixel camera and the latest 108 mega pixel camera. The clarity of image is much better with the latest scanners and small lesions can be picked up. But increased image quality does not always equate with better diagnosis after a certain level.

New features are being added to the scanners and the latest scanners always costs money to buy. State of the art scanners are not available everywhere. Most centers in periphery do not have the latest machines. For majority of the patients, even images taken on previous generation scanners are good enough. Sometimes, when patients come for second opinion or treatment in a higher center, , if the image quality is not optimal for the clinical question to be answered, the scan may need to be repeated. This does not go down well with the patients as they must pay again for the scan of same name and they feel cheated.

The same situation can happen across all tests that are being done to diagnose a patient’s condition. For laboratory tests, equipment quality, maintenance, calibration and even the way sample is collected are important to get correct results. Sometimes it is counterproductive to believe the reports from other places for a variety of reasons. It is better to get the tests repeated to give second opinion or treat. For many doctors, it is not easy to explain all the above matter to the patient, increasing the gap in communication and mistrust.

Predicting outcome of illness

As mentioned in the past; course of the disease and the outcome are dependent on the host factors, disease severity and the treatment given. For ease of explaining and understanding, disease process, especially due to infection, can be classified into four zones.

Let us say the first zone is white – this is the group of people who will not develop the disease as their immunity is high or the exposure to the infective agent is small. They do not even know that they have got the disease. Consequently, they do not need any treatment.

Next group is the green zone. This group of people have enough immunity to fight the disease. The disease is self-limiting. Whether we treat them or not, the disease will be cured. Any treatment that they receive is superfluous. It is mostly to satisfy their psyche that they are getting some treatment.

Next is orange group in which the treatment is crucial and makes the difference in achieving a cure or not. This is the group that gets benefited by correct and timely treatment. Next one is the red zone. This group of patients will not be cured, no matter what treatment they received and where. Aggressive treatment is only going to prolong the inevitable but will not stop it.

Problem is that there are no clear demarcations between these different colour zones and many a times doctors cannot predict accurately which group the patient belongs to. Doctors decide on the condition of the patient and advocate treatment depending on the clinical condition, tests as necessary and the trend or progress of the patient with passing of time.

There are number of checks and balances in place to prevent avoidable mistakes. Despite all the precautions, while assessing the condition of the patients or giving treatment, lapses may be there due to deceptive external appearances, wrong test results or lack of experience of the healthcare staff. Major confounding factor is patient developing a complication, which may happen despite optimal treatment.

The treatment process goes on taking into consideration all the above things; patients are assessed periodically, and the treatment is tailored according to the individual patient’s condition and response to treatment. The time frame may be minutes, hours or days depending on the cardinal factors - host factors & disease severity. If the patient’s condition improves, the treatment is down sized; if it deteriorates, treatment is escalated.

Most of the time the patient’s clinical course runs in a predictable fashion. Rarely patient’s condition may deteriorate rapidly, like go from white or green zone to red zone. Undiagnosed diseases like diabetes, high blood pressure, blocks in blood vessels to heart/brain/intestines or other diseases may contribute to such situation.

 It is difficult to categorically say that the patient is in the red zone and that he/she will not recover. The sudden deterioration happens rarely and is the cause for the sensational news going round in the media, aggravating the fear and anxiety in the society. The doctors are not in a position to give an accurate reason for rapid deterioration and not able to counsel the relatives properly, leading to the widening gap between the public and doctors.

Patients or the relatives want to know what the outcome is going to be; whether they will recover or not, what is the risk of complications, duration & cost of treatment etc. From their perspective it is an innocent and reasonable request. But health is a dynamic process. All that the doctors can do is try and restore the lost balance in the patient’s body systems. Doctors can give the probability of various outcomes, but no doctor can accurately predict a given patient’s course or final outcome. It is only an educated guess.

Doctors are not fortune tellers. Patients and relatives do not comprehend this truth. They think that the doctors know everything and are not divulging the information. Truth is far from it!! Most doctors also do not like to acknowledge this and say, I cannot predict accurately. When false reassurances are given or not counselled properly and the outcome is bad, it is a recipe for disaster in doctor – patient relationship.

Continuing the colour scheme from last week, it is difficult to say where exactly the patient is in the disease spectrum. Majority of the times, there is time and the disease progresses in a slow and predictable fashion, giving time for treatment as necessary. Sometimes, it does not give much time. It is again dependent on the patient/disease factors elucidated in the previous posts.

One example is the heart stroke people get. One end of the spectrum is the silent MI (myocardial infarction – heart attack), where the patient gets a very mild attack and does not get any problem. It will be identified at a later date if they get heart check up for whatever reason or get some problem due to further attacks. Other extreme is where the patient gets a massive heart attack, collapses and dies all of a sudden or in sleep, without having any warning sign or giving time to treat. In between these two extremes, there are multiple ways a heart problem can present and is dealt with.

Sometimes a patient may get heart attack while undergoing treatment for some other problem. People in their ignorance ask why the patient developed heart attack while in hospital during treatment?! When a person can get a heart attack suddenly without warning at any time at any place, why can not they get it in hospital!! Someone in hospital have higher risk of developing further problems due to the physical/mental stress of their disease process or the treatment and the hospital environment.

It is partly out of their frustration also. When the patients get a new problem while undergoing treatment, everything increases – treatment, hospital stay, risk and cost. This is very frustrating for the patients and their relatives. In their ignorance or frustration, they keep doubting the doctor and the treatment process, which does not help anyone.

Consequently, it is difficult to say categorically when one should seek medical advice. It depends on the age, general condition, and severity of the illness. For minor ailments, especially recurring problems, one can simply wait or take over the counter medicines for few days to see if it resolves with time or not. If not improving or if there is any deterioration in the general condition, one should seek medical advice.

Due to the nature of illness and the issues in our society surrounding doctors and healthcare, doctors are also worried and not taking any chance. Sometimes, small lapses are leading to negative publicity, compensation, and legal proceedings. Doctors and hospitals are also gripped in fear and anxiety. Doctors are considering everyone to be having a serious disease, investigating, and treating accordingly, leading to defensive medicine.

Majority of the times, there is a window (usually a very wide window) of opportunity to give treatment and save the patient. Rarely, there may not be time and the window of opportunity is lost. Having seen such rare incidents, everyone is frightened that they may lose the window of opportunity and running amok.

Psychosomatic illness

Many people having lifestyle diseases ask innocently “Doctor, I want a permanent solution to my problem”. The permanent solution is in their own hands. Doctor can give medicines for temporary relief to their symptoms. Lasting cure can only be achieved by changes in lifestyle and avoiding the instigating agents. This type of advice does not go down well with many patients. They want a miracle pill or an injection from the doctor which can cure their ailment in no time and permanently. Doctors also do not have the patience or time to explain all this to the patient. It is much easier to write off a prescription with several medicines and get the tests done. It satisfies the patients psyche and is also conducive for the “industry”.

When the problem persists, some people get into the trap of psychosomatic illness. There are a variety of reasons for psychosomatic illness. Most common is fear and anxiety. People who have extreme fear or anxiety tend to get various manifestations in the body like increased acid secretion in the stomach, irritable bowel, pains in various parts of the body, etc. The fear and anxiety could be for a variety of reasons.

With comforts brought by the modern age we all are pampering our bodies in many ways. Our mind and body are getting used to pleasure so much that any pain is becoming intolerable. Added to this is the fear of anticipated pain or suffering brought on by an imaginary illness (usually cancer. COVID these days) after seeing the plight of someone in the known circles or on the other side of the globe through social media.

In some people fear alone can cause problems in the body in the form of palpitations, heartburn, pain in various body parts, weakness, etc. Some people have a minor disturbance in the body due to various reasons, which most people ignore after seeing the doctor once or twice. Whereas those with fear and anxiety tend to see their problem through a magnifying glass and keep going round various doctors. Either way, unless the underlying psychological issue is dealt with, the physical problems will not go away.

In an already anxious patient, addition of a health issue aggravates the problem and becomes a negative biofeedback loop, perpetuating the problems. After consultation with the doctor and having gone through necessary tests, if nothing significant is diagnosed, it is best to work on reducing the fear and anxiety.

Most people acknowledge and try to correct their mindset. Some people are in denial and do not even acknowledge that they have, fear and or anxiety. Many people do not want to seek psychological or psychiatric help due to social taboo. It is important for the relatives and doctors to be sympathetic with these people rather than just blaming them that they are imagining things. They need to be gently made to understand their problem and sent for appropriate psychological or psychiatric counselling, diagnosis and treatment.

If you are an anxious person, try to reduce your anxiety. But please do not diagnose yourself or brand your relative with a psychosomatic illness. This diagnosis should be made by a doctor after seeing the patient, examining and doing necessary tests. 

Lifestyle diseases

The modern life along with comforts, has brought with it a new set of health problems. For most people, especially those in cities, life has become fast paced. Dietary habits, inadequate sleep, work stress, monetary issues, road rage, air pollution, smoking, alcohol abuse are leading to a variety of health problems. Most common is increased acid production in the stomach leading to abdominal discomfort, bloating, burning or even pain. Some other problems are high blood pressure, diabetes, overweight, chest problems, vitamin deficiency, sleeplessness and a host of psychological problems.

Some people do not even know that the food that they are eating, their lifestyle and habits are the cause of their health problems. Some people, even though they know, are not changing their lifestyle for a variety of reasons. Either way, our body is in constant interaction with our environment through breathing, drinking and eating at physical level. The sensory inputs affect at psychological level. What we consume, has effect on our body systems. Body has enormous capacity to adjust the variations in these inputs. But the body has its limitations.

It is again a balance between the person’s constitution and the amount of proper maintenance or abuse that decides the onset of imbalance or disease. Many people have the awareness and correct the instigating factors. While some feel that they can continue to abuse the body and get it corrected by medication or treatment. It is a common misconception that health can be bought.

Health can never be bought. Most of us are born healthy to start with. If we do a little bit of maintenance in the form of exercise and healthy lifestyle, body is unlikely to contract disease. Medicines cannot reverse the aging process and bring back the lost health. All we can do is to try to restore it as much as possible and may be replace the worn-out joints.

These days people are relying too much on doctors and medicines for their health. The threshold for seeking medical advice has come down due to lowered pain tolerance and fear. The biggest doctor in the world is our own body. It has enormous amount of repair and regenerative capacity. Without realizing that fact or maintaining their body and mind, many people are going round the hospitals for trivial issues. It is important for people to realize that they are responsible for their own health and take appropriate precautions.

Doctors can only guide the people to some extent. Even doctors can sometimes be wrong. The entire medical community and population is misled for close to half a century about the bad effects of dietary cholesterol. Now we took a U turn and say that it is not as bad as it was thought to be, and white sugar is a big culprit. People think that doctors know everything and have answers to all health problems. Doctors know many things and can control many things, but not everything.

There are people who take this too far. They neglect the initial symptoms of the disease and do not seek advice until the late stages of the disease. This is also not good. Any ailment that does not clear away in 1 or 2 weeks needs checking by a doctor and tests if necessary.

Doctors and medication should be used judiciously for short periods as and when necessary. In other times, it is one’s own responsibility to take care of their health. Even the chronic diseases like diabetes and high blood pressure can be better controlled if the patients take responsibility of their health and make lifestyle changes.

Healthcare “Industry”

Healthcare is no longer a simple “Patient – Doctor” relationship. Gone are the days where a doctor used to check the patient’s pulse, use a stethoscope, come to a diagnosis and give one of the limited treatments available. Now our diagnostic armamentarium has increased, and the treatment options also have increased many folds. Now there are several stakeholders in healthcare provision, many of which are individual industries themselves like the Pharmaceutical industry.

Private tertiary care hospitals can be seen as star hotels with added healthcare provision. The stakeholders are – patients, doctors, nurses, paramedical staff, ambulance services, people in training, hospital management, countless support departments, insurance companies, organizations who have tie up with the hospital for provision of healthcare to their employees, diagnostic centers, pharma industry, medical representatives, biomedical equipment companies, health department officials, other government regulatory bodies, media, NGOs etc.

In addition to providing the required services towards provision of efficient healthcare, all these stakeholders have their own selfishness in the form of income, growth and long-term survival. In private enterprises, the payment structure is always linked to the work throughput and expertise. Even for people on fixed salaries like medical representatives, they need to show year on year growth to get bonuses and to stay in the “business”. The providers in the system wish to get more money out of it, whereas the users want to get the services for as low cost as possible, if not for free. Sadly, in our society there is nothing called “fair trade policy”.

Either at individual level or at organizational level, people try to exploit each other. It is a common practice to take insurance policy after having diagnosed with an ailment that requires costly treatment. It is equally common practice for the payers to disallow various things on some pretext or the other. The same medicine comes in different packaging by different companies and is sold at various prices. The same test is priced variously by different establishments. Part of reason for this is the belief in society that something that is new or more expensive is better! Many patients do not like to pay for doctor’s consultation. They feel that they are not getting anything back in kind. They do not mind paying for a test or medicines, which is a contributory factor in getting unnecessary tests. Some patients demand tests for “peace of mind”!! Doctors do not like being honest in reporting adverse events for the fear of backlash, which is leading to suspicion in the society. So many such things across the board.

All in all, the healthcare and allied industries are not healthy for a variety of reasons. Public and patients still think the doctors are in control of healthcare industry. It is not at all so. Doctors, especially the youngsters, have no say in a big multi-specialty hospital, whether it is a private set up or a government hospital. Doctors have become a small cog in the massive healthcare industry. Due to this helplessness or due to their selfishness or greed, many doctors have failed to be patients’ advocate. This has led to ever worsening “Doctor-Patient” relationship. Despite all these factors doctors are still seen as the “leaders” in healthcare industry and are held accountable to many things beyond their control.

All these things will take considerable understanding from all the stakeholders and a concerted, decisive action from all. That may or may not happen in our lifetime. That is the reason individuals must take care of their health and make provision like adequate insurance in the event of ill health. Some people have the misconception that hospitals will give unnecessary treatment to patients who have good insurance coverage. In majority of the situations, it is not so. Despite all the hardships, for majority of the doctors, patient welfare is still the core philosophy. There may be some unscrupulous elements everywhere. That should never be a deterrent to have a good insurance policy.

Primary Healthcare

With increasing success of modern medicine, people started relying on it more and more. For every health problem there is a pill or an injection. Slowly, people have transferred the burden of keeping their health into the hands of doctors. Even the smallest of the things, people are turning towards doctors in the hope of getting a “better” or a “quicker” solution. 

Most of the diseases, especially the infections, must run their course. There is a saying: “treated cold lasts one week and untreated cold lasts seven days”! Seven days seem a long period. People are seeking better cures all the time. There is a limitation to what the medical profession can deliver. Most of the ailments like the viral fevers are self-limiting. We can certainly give something to ease the pain or discomfort, but the disease must take its course. If I ask the patient to take a simple pain killer and wait, they do not like the waiting. They want a new medicine that cures them fast. It is much easier for me to write a prescription and get that patient out of my room than keep on telling that it is a self-limiting disease. 

With the increasing demands, the healthcare industry is coming up with new ideas to satisfy the patient’s psyche. The same multivitamin tablet needs a new name and wrapper, otherwise it does not work!! I am not demeaning the genuine advances in modern healthcare. Tremendous inventions and discoveries were made in all aspects of healthcare, making the life of healthcare professionals easy and better outcomes for the patients. 

My criticism is not about the real diseases and their treatment. It is about the minor issues arising in everyday life and those that can be cured by home remedies or over the counter medicines. With the fear or with the greed of getting better quicker, people are resorting to overuse of antibiotics and various other chemicals in the form of medicated soaps, nutritional supplements. Medicated soaps tend to alter the normal commensal bacteria on the skin. These bacteria are part of our body and help in preventing the disease producing bacteria. It is easy for the companies to come up with a better soap or liquid that can kill all the bacteria and advertise accordingly. They portray all bacteria as bad! Stronger the soap the better!! They do not want to tell you that there are good bacteria that are needed for normal functioning of the body. Some people may need medicated soap, which should be used on the advice of a doctor, preferably a skin specialist. Not based on the advertisement on TV!! 

Have you looked at the contents of the nutritional supplements? Most of them contain a good amount of sugar! Whenever there is some health problem, people are imagining the worst and doing all sort of things based on their fear and panic. Fear and panic are real boon for the healthcare industry! The other side of the coin is people are not trusting doctors because of various misconceptions. 

I am not asking people to neglect their health. All I am saying is to increase the awareness, practice healthy lifestyle and use the medicines and healthcare industry judiciously. If you need a doctor, preferable to have a good physician who you need to use as a family physician. Better not to choose the specialist yourself. Sadly, for various reasons, the concept of family physician and primary healthcare has not developed in India. Let us hope that the future brings better health awareness and healthcare.

I am just venting my ideas and observations. Please let me know your views and experiences. It will help me to get a better understanding of the situation. Take care.

Preventive care

Preventive care can be started at any age. It is essentially the measures that we take before getting into trouble. There are a variety of things one can do. The following are for general guidance and applicable to most people. If you have any health issues or have concerns, please check with your doctor.

1.       Diet: whole food vegetarian items are better. Take more fruits and vegetables. Carbonated drinks, white sugar are the worst. The so called “health” drinks and breakfast cereals contain a considerable amount of added sugar. Check it out. Less amount of processing involved in food processing, the better. Reduce salt intake. Limit the hours you consume food and beverages. Keep it to 2 or 3 meals a day with no munching in between.

2.       Do regular exercise. Doing in open air is always better. Any exercise is good. Do as per your personal circumstances and facilities available. Make it a habit. Even if you cannot do the whole 20 to 30 minutes as advised, do for 5 minutes. Once you get the hang of it, you can increase.

3.       Yoga is a good way to keep your body and mind fit. Irrespective of your religious faith, you can practice yoga. By practicing yoga, one will not become a Hindu. Yoga is beyond religions and is the technique to align the individual energy with cosmic energy. There are a variety of programs available online, choose any of them. Even if you cannot do the whole process, at least meditate for five minutes each in the morning and evening. Have faith in God (of any religion) and thank everyday for everything. Do not keep complaining and blaming others. Try to improve your own self.

4.       Make sure your weight is in the optimal range. If you are not a diabetic, fasting (not dieting) is an excellent way to lose weight. There is a large amount of information on the net about “Intermittent fasting”. Even if you are not overweight, you can still do fasting. It is shown to improve the health.

5.       Sleep on time and give adequate rest to the body. Do not get habituated to substances like gutka, cigarettes and alcohol.

6.       Take simple precautions like wearing a helmet, seatbelt, carrying a torch in dark areas and going slow in poor visibility. Most of the prevention is common sense!! Be aware of your circumstances and take precautions as the situation demands. Take preventive measures in workplace also; having a good chair and correct posture is a simple example, but the list is very long.

7.       You should not become paranoid about health and stop living! You must enjoy life but do things in moderation.

8.       Take health insurance for at least 5 lakhs from a good company that covers all diseases. Take a policy that has least exclusion clauses. One never knows when the ill health visits. Modern healthcare costs can cripple most people’s finances.

Dynamics of disease

Our body (any organism in nature) has inherent capacity to adjust any deviations arising from within or without. This is called homeostasis or maintaining the balance. The body has enormous capacity to repair itself. When this mechanism is transgressed or not sufficient, disease manifests in the body. The diseases may be congenital or acquired. Acquired diseases could be due to infections, injury, degeneration due to age and cancer.

For any disease process there are three main considerations that will affect the outcome of that illness. First is the nature and severity of the disease process, second is host factors and finally, treatment given. Disease process is trying to pull the body down. The other two are to support the body and win over the disease. When the host factors and optimal treatment take upper hand, the disease will be cured. Otherwise, the disease will take over the patient.

Infections are caused by a variety of microorganisms or parasites. Not all microorganisms are dangerous. We harbor a variety of bacteria in our body called commensal bacteria which are helpful for normal body functioning. Loss of normal bacteria in our body due to excessive usage of antibiotics and disinfectants can lead to imbalance between good bacteria and bad bacteria. The body has capacity to identify normal microorganisms from harmful agents and take remedial action. Whenever it identifies a hostile virus, bacteria or fungus, it immediately tries to mop it up and protect the body against the invading microorganisms. Memory is built into the immune system that it can react much faster and more efficiently if it encounters the same organism again later. As we are witnessing right now, if the microorganism is virulent (meaning strong) and new, it becomes difficult to control it.

Similar mechanisms help fight the cancer in the early phases. Formation of new cells and destruction of aged cells is a continuous process in the body. You can see this clearly in the skin with old superficial layers of skin peeling off and new skin growing. The same process happens in many areas in the body. Without our knowledge, whenever the cells replicate in the body, we all tend to produce abnormal cells. Some of these may become cancer cells and lead to cancer. Body has the capacity to identify the abnormal cells and remove them as and when they form. Only when this mechanism fails for a variety of reasons, some of these cells manifest as cancers.

The body continuously tries to repair itself as needed. Despite this, some wear and tear is part of aging process. When the wear and tear is more in a particular body area diseases manifest. One example is the joints getting worn off the cartilage and leading to arthritis. This could be due to excessive weight or improper posture which gives more strain to the joint, leading to enhanced wearing off.

The host factors are age, body weight, smoking, alcohol and any existing diseases like diabetes. Diabetics are more prone to infections due to the effects of diabetes on the body. Another host factor is the medicines one is taking. Even though we give medicines to cure disease, every medicine has some side effects. These may sometimes interfere with some of the treatments.

The final thing in the equation is the treatment. It is important to give appropriate treatment at the appropriate time. The balance will tilt in favor of the patient only when host factors and treatment factors take upper hand. Hope that your doctor gives you the correct treatment at correct time and gets you out of trouble.

In this balance as you can understand, if disease factor is low and host factor is strong, you may not even develop disease or may have a minor illness which does not require any treatment. When the disease factor is strong and host factor is weak, treatment is required. The amount of treatment depends on the level of imbalance in the first two factors. If the imbalance is more, increasing treatment will be required. When the body does not have some resistance capacity and reserve, even the best doctors and treatment is of no use. Try to improve the host factors which in your control. Improve the chances of successful outcome by trying to stay fit with regular exercise, avoiding substance abuse, not being overweight, taking care of any existing diseases well and keeping the mind positive…

Healthcare Reforms

Healthcare reforms are long overdue in our country. Government is making some efforts to streamline the process, especially in controlling the medical education. Many of these like NEET and Vaibhav are good and laudable. There is lot more that needs to be done especially in healthcare delivery.

Most stakeholders (doctors, patients, society, government) in healthcare industry are unhappy. Different stakeholders are trying to outsmart each other and trying to get "more for less", causing the friction, escalating the costs and restlessness. This is applicable to everyone concerned. As a person (patient or doctor) or as a hospital unit or a payer (government/insurance/employees' health schemes) as a whole, the psyche is "get more and give less". Greed is a natural human tendency. When it goes out of control and is added to the vulnerable aspect of human life (health), the results will not be pleasant.

People should try to understand the nature of modern healthcare and try to adopt "less for more". When all the stakeholders understand, participate and put the common good above individual and collective greed, a truly "more for less" system will emerge and everyone will be happy. (My wishful thinking!) Unless people realize and start making changes, things will not improve. System cannot be changed overnight. Takes time. But we should make a start.

Following are some of my views and suggestions which came out my observation after having gone through medical education in India, going to the UK for higher surgical training, working there for a decade, returning to India and practicing in a tertiary care private hospital for 17 years. The ideas and opinions are completely mine.

The idea is to increase the transparency, make healthcare available to everyone at reasonable cost, improving the training standards and making all stakeholders take more responsibility. Healthcare industry should not be a money-making industry, from the vulnerable and gullible people.

Hospital set up: Hospitals must be healthy first two provide good healthcare. They should be categorized into Government, Private non-profit (run by philanthropic trusts or as corporate social responsibility) and Private for-profit. In each category, there should be three categories based on the level of care provided: primary care, secondary care and tertiary care facility. The level of care to be provided, equipment to be available, personnel including doctors, number of beds to be available, training facilities should be clearly defined in each category. This type of framework is already there to some extent but is not being implemented efficiently.

Once the healthcare facility is clearly defined and the services provided are defined clearly, the tariff and source of funds needs to be addressed. Government hospitals will be free anyway. Provision for private paying wards can be made to generate some income and encourage staff. The tariff for these services should be similar to that of the trust hospitals. Second category is the facility run by not for profit by Trusts. Tariff in these facilities should be fixed taking into consideration several factors like staff salaries, equipment cost & maintenance. The staff salaries, especially those of doctors are to be decided depending on the type of facility, seniority and the contribution they make. Ideally, the salaries should be similar in government facilities and the Trust hospitals. Salary should be decent and attractive so that bright young minds get into the profession. Incentive for doctors should be in the form of job satisfaction, rather than purely money. The government and non-profit hospitals should be able to provide major chunk of healthcare and take care of education & training. The for-profit private hospitals can have flexibility in their tariffs over and above the first two categories, depending on the star facilities they create. As the philosophy of care in a for-profit hospital is providing personalized care for payment, there should not be any doctors in training in this category of hospitals.

Funding for hospitals is four types. First is from the government for the government hospitals. Second is from various health schemes either employee welfare schemes or government schemes like Arogya sri or Ayushman Bharat. Third is the insurance companies. Finally, patients paying out of pocket. The tariffs should be fixed depending on the level of care and services provided.

The tariff for surgical procedures and other interventions is skewed by the professional fee. As these procedures are dependent on the skill and expertise of the doctor, they expect more money out of the procedure. Consequently, major variables in healthcare spending are the professional fee and cost of medicines & disposable equipment. The doctor remuneration should be fixed in the first two categories of hospitals. There may be end of year bonuses based on the quality and quantity of work done. The tariff structure for the procedures should be fixed in the first two type of hospitals and the first three types of funding.

The tariff structure should be uniform across all the various schemes and the patients paying out of pocket also. Otherwise, it leads to the private patients cross subsidizing the other group of patients and bitterly complaining about the high costs. Payments from insurance and credit organizations should be prompt. Otherwise, it affects the cash flow of hospitals and they may end up extracting more money from cash paying patients. If a patient belonging to the first three categories of funding wishes to get treatment in a for-profit hospital for whatever reason, they should pay the difference in tariffs themselves, or take a booster insurance policy.

Hospitals should be established based on the above principles and tariffs as dictated by the government. Last few decades, doctors and hospitals had a free run of tariffs. This needs to be streamlined. There is considerable amount of skewing in doctor fees, hospital charges across various specialties and different parts of the country. It is difficult to control the tariffs completely while there is so much greed and self-centeredness around. Government should try and improve the facilities in the first two categories of hospitals. They should be maintained in par with the third category hospitals without the frills. People who have the capacity to pay or higher insurance coverage can go to the third category hospitals for the added luxury.

More number of people, ideally the whole population needs to be brought under the umbrella of one of the first three categories of payment. The existing arrangements of Government funded health schemes are not providing the entire gamut of healthcare. They should be expanded to include all the ailments and treatment. That money may be utilized for improving the government hospitals rather than outsourcing private hospitals. The patients in the first two category of hospitals having some form of insurance should not be made to pay any money out of pocket.

The tariff structure should be such that everything is covered, and the tariffs are viable for the hospitals. People should realize that ultimately all the money must come from those using the facilities. In the first two categories of hospitals, money can be spent efficiently, and care provided for a lesser cost. In the third category, cost will be more for the added luxury.

Insurance sector should be encouraged, and more people should have health insurance. There should be more transparency in the tariffs and insurance payments. At present, cost of the same procedure can vary widely in the same hospital depending on the doctor, between hospitals in the same city and in different cities!! This needs to be streamlined. All this needs a considerable effort, understanding, cooperation and will to change for good from all the stakeholders. There should be two types of policies, basic and higher package. Basic policy will be valid in the first two categories of hospitals whereas the higher one in the for-profit hospital. People having a basic package provided by the employer or government may be able to take a booster package to make them eligible for the higher package.

In addition to all this effort, most important thing is the mindset of the people in healthcare industry. As mentioned before, the incentive for doctors should be job satisfaction. The self-centeredness, craving for self-glory and monetary gain should come down. Doctors should stop being money making machines and philosophy of the hospitals should not be the profit margins. Altruism, caring for the needy and enhancing the art of healing should be the priorities in the doctors’ mind. This can only be achieved when the doctor has job security, job satisfaction, retirement plan, and a decent workplace with good infrastructure and facilities. Doctors should not have to run from pillar to post to get something or the other to treat a sick patient. Providing the facilities and maintaining the supply chain is the responsibility of the administration. Healthcare professionals should not be under constant threat by the public and media or the manager breathing down their neck to get more work done. Workplace ethics and discipline should improve.

Majority of the healthcare provision goes smoothly. Despite so many lapses in the system, still most of the time there are no major issues. For planned healthcare, people have time to plan, enquire and go to a place that suits their pocket. Major problems arise in case of emergencies; either road traffic accidents, heart attack, stroke or a patient developing some problem while undergoing treatment in a hospital. These should be ideally managed in the first two category of hospitals. The healthcare facilities should have adequate insurance coverage themselves to take care of any professional indemnity to cover the treatment of any complications arising in their hands. Depending on the size of the hospital, if a greater number of claims are arising, it should be scrutinized. Government should try to bring the entire population under some scheme to provide healthcare, especially the emergency and tertiary care. The highest care should be available in the first two category of hospitals.

Health education should be part of the school curriculum. Children should be educated on the importance of hygiene and to take responsibility for their health. Importance of regular exercise, contemplation, coping skills and healthy habits should be inculcated to children. General public should be educated regarding the nature of modern healthcare and the costs involved. Society has a variety of misconceptions about health and what is involved in the treatment process. It is surprising to see even the intelligent and educated people having these misconceptions. India is one country where people are afraid of hospitals and doctors.

Ethics, communication skills, teamwork, coping skills and other soft skills should form part of the curriculum for medical students. Patient centric approach, importance of seeing the patient as a co human being, alleviating their suffering, and taking a holistic approach should be taught to young doctors. Importance of teamwork for the better delivery of healthcare should be impressed upon the budding doctors.

There are a number of areas where unscrupulous elements are present in healthcare industry and the allied industries. Corruption may be as simple as an ambulance driver using the siren when there is no patient in the ambulance to doctors/hospitals trying to market procedures of unproven value. Theft may be as small as staff pilfering material from hospitals to as big as the doctors/hospitals/patients/insurance companies defrauding or trying to defraud each other. It is never possible to clean the system completely when the society itself is corrupt and degraded in various aspects. What the government should try to do is reduce the number of these unscrupulous elements by encouraging transparency and rewarding the honest practices in healthcare delivery.

Government should look at primordial prevention; In schools with health education as mentioned above, laying & maintaining the roads to good safety standards, increasing the road awareness & imparting traffic discipline to public, personal & social hygiene, reducing substance abuse, improving farming & animal husbandry practices to reduce the use of harmful chemicals, proper sewage disposal, reducing pollution, occupational health and corrections in other areas which impact the health of the people in the society.  

Primary care should be strengthened and should be available to every person in the country. The role of primary care is to treat the minor & self-limiting diseases, to monitor the chronic diseases, reassure the patients and refer to secondary or tertiary care when necessary. We have a variety of indigenous alternative therapies.  Research should be carried out to see the efficacy of these alternate therapies and made part of the primary care. Primary care doctors or Family doctors should be trained in alternate therapies that are effective and made part of the preventive care strategy. Alternate therapies have no role in secondary and tertiary care. They may have a role as complimentary therapy. Either the government or the public should not waste the money on treatments that were discarded by the rest of the world. That money can be utilized for better primary care.

People should be educated regarding primary prevention by having lifestyle clinics in the primary care set up. A good proportion of our society does not fit into the WHO definition of health. Importance of regular exercise, healthy diet and avoiding substance abuse should be constantly reminded. People should be made to take responsibility of their health and plan for the healthcare spending rather than running around after getting an illness. Doctors should lead by example by taking care of their own health, leading a healthy lifestyle and avoiding substance abuse.

People want the “best doctor”! There will be only one best doctor and he/she cannot treat the whole population. The emphasis should be on improving the training standards and standard of care. Every doctor and hospital should be safe, efficient and trustworthy. Both doctors and society should come out of the person-based healthcare delivery and move towards establishing/improving systems and protocol-based healthcare delivery which is evidence based.

There is no quick and fair grievance redressal system. People are resorting to violence which leaves an awfully bad taste in the mouth for all doctors when seen in the media. Patients who have genuine grievance also are having to go through a prolonged legal battle. The following is a suggestion which can be amended. The IMA should take a lead in this area and work with the help of Government. Doctors in general and IMA also has failed to safeguard the interests of the patients in the event of a mishap. It is a common practice to support the doctor or hospital and deny any negligence or iatrogenic complications. This contributed to increase the suspicion about healthcare providers by the society and losing the faith in doctors. All practicing doctors should be members of IMA and should have indemnity insurance. The IMA branch should have a grievance redressal cell consisting of local IMA President, district collector/RDO/MRO (depending on the jurisdiction), or his/her representative, representative of local police, local MLA or his/her representative. This cell should be able to convene periodically or as necessary when a grievance happens and sort it out quickly. Their mission should be fact finding and see if the mishap is avoidable or due to negligence. Post-mortem examination should be sought to establish the cause of death if necessary. There should be openness, transparency and fairness. In case of avoidable mishaps, appropriate compensation should be offered to the patient, which should ideally come from the doctor’s indemnity insurance company. Rules should be amended to allow this local arbitration and payment. If a decision cannot be reached or not agreeable to the concerned doctor or the patient party, it can always be escalated to a court of justice. Any aggression or violent behavior against the healthcare workers or damage to property should be firmly dealt with and appropriate legal proceedings started. This IMA cell or a similar one should take care of the vigilance on doctors too, to make sure their members are not resorting to any unscrupulous practices.

There should be good data recording and reporting systems. Ideally all the patients treated, nature of treatment given, and the outcomes should be recorded in a national registry. This will help in research, audit and planning for better systems. The health education should be streamlined and planned as per the need in the country. Unless the training and working conditions are improved in the country, healthcare industry may not be attractive to the youngsters and may lead to further imbalance in the system.

The credentialing system and titles should be streamlined. Any therapist can use the title “Dr” these days. This should be addressed, and measures taken to clearly identify the allopathic doctors from the rest of the people belonging to various other categories using the title of Dr. The specialists using various titles should also be streamlined.

This is just a basic framework. Government should establish a “Think tank” with representatives from all the stakeholders, take stock of the emerging situation and take remedial action in healthcare provision. Specialty associations should be involved in this process. Changing the system and steering the course is a colossal task. Any healthcare reforms should have long term view and should be done in consultation with all the political parties and stakeholders. There is no point in bringing in a system which will last till the next election and is discarded.

Pharmaceutical industry and other industries allied with healthcare should also be looked at. The same medicine manufactured by the same company is being marketed with different wrappings by different companies at different prices. This leads to unhealthy practices. Sale of medicines should be controlled with clear demarcation between over the counter drugs and prescription medicines. These are just a couple of examples. There are many other aspects that need looking into. There should be more transparency in the allied industries. Healthcare industry and allied industries should have the ethos of service and healthy growth. Not simply expanding their business and increasing the profit margins year on year. Healthcare industry alone cannot be purified without controlling the allied industries.

There should be some advertising standards control so that hospitals do not advertise excessively and improperly. It is usually “for-profit” hospitals that resort to marketing and advertisements. They need to promote their new equipment, facilities and create work for themselves. This will lead to unfair advantage for them against the first two category of hospitals. All the money spent on marketing and advertisement will be borne by the patients only!! Media should try to reduce the fear and anxiety in the society by not sensationalizing the events, good or bad.

All these things need constant vigilance and checks & balances. Regulations may mean, breeding more corruption in our country. The regulations should be self-governed by the doctors and healthcare industry as much as possible by drawing guidelines themselves and by willful participation. Society, doctors and hospitals should own their responsibility. There is no point in blaming each other.

Society in general, especially politicians and bureaucrats, also should introspect and take remedial actions themselves. When there is so much greed, self-gratification, self-glory, insecurity and cutting corners to achieve success or money in the society, it is bound to affect the healthcare and allied industries too. As health is associated with added fear, people become gullible in the hands of unscrupulous healthcare professionals or the hospitals. Unless the government machinery takes a hard look at itself and brings in healthy reforms with transparency and fairness to all concerned, we will continue to be in this chaos. People in power should remember the oath they have taken at the time of taking up the post and try to implement it.

These are purely my views and may be biased in some areas. Anyone can use any of these ideas for the betterment of healthcare. It is not my intention to blame anyone. My intention is to see affordable and transparent healthcare delivery to every person in the country. Anyone should be able to walk into any hospital with confidence and without the worry of being looted or given wrong treatment.

Jai Hind.

Prasad Mallipudi

Hyderabad, 2 October 2020                                                                                            V 1.3

Healthcare costs 3

Nothing is free. We made our lives in such a way that only the air that we breath is free. (Now we are wearing masks which may be a permanent fixture if we do not take care of air pollution. If we do not stop the rampage on mother earth, our woes will continue to increase). Even the water, we are not able to drink from the source. It must be processed before we drink!! How can anyone expect the healthcare to be free?!

Everything mentioned in the previous posts, is in an ideal situation where everyone is well trained and has wide experience, tries to minimize the cost, and uses the facilities judiciously. Doctors are heavily dependent on ancillary services and staff. People have not come out of the mindset of doctor treating by checking the pulse!! There is always an element of over investigation and treatment as people do not want to take chance in a patient who is critically ill.

In addition to the above one needs to add costs of medical audit and research to deliver the healthcare properly. The equipment needs to be replaced periodically. If one adds the greed and inefficiency of the system and individuals, the cost will escalate further.

Someone must pay for all these facilities and services. One way of funding is the socialized medicine, where the government pays for everything. Sufficient funds are allocated in the budget or special tax is levied which is used for healthcare provision. A country like UK is struggling to maintain this model as the costs of healthcare have gone up in recent years. Another way of funding is where the patient pays himself or herself. This sometimes can ruin the patient and their family financially. The way forward is to fund the healthcare through insurance or a combination. This model has its own problems and is struggling in the US. One main problem in this model is the increase in the amount of paperwork as everything needs a code for charging purpose.

Governments have come up with various popular schemes, but these cover the cost of specific treatments only. If the disease or treatment is not listed, it will not be covered, and the patient must make his/her own arrangements. Tariffs of these government schemes and a host of employee health schemes may not be viable to hospitals, resulting in various ways to compensate the loss.

The government must strengthen the existing public sector healthcare infrastructure and try to incorporate all the diseases in the ambit of insurance. Government and private hospitals must be stratified depending on the level of care they can provide and the cost of treatment. There should be more transparency as per the cost of treatment and remuneration to doctors. Not all the money charged in the name of a doctor is paid to the doctor. Majority of the times, the money goes to the hospital and the doctor receives a fixed sum from the hospital.

We need to understand the problems and try to create systems that are robust. All these things are not so easy to implement. The government and bureaucrats must have the vision to create healthcare infrastructure and policies that will last long rather than till the next election. Government should never loose grip over health, education and health education. Unless we make a start, we will never be able to do and will remain in this mess forever…

Healthcare costs 2

With the overuse and abuse of antibiotics & disinfectants in our society at personal level, healthcare facilities and in farming, poultry & animal husbandry, bacteria are getting smarter and devising ways to become drug resistant. There are several bacteria now which are resistant to multiple antibiotics. Infection is a major problem in tertiary care ICUs. Infection may be the primary problem or can happen as an add on to some other disease. Either the disease or the infection can lead to failure of organ systems in the body. When an organ system fails, we have means to support it as and when required. The level of support varies depending on the amount of malfunction.

Simple example is the usage of supplemental oxygen when the respiratory system is affected, and the lungs are not able to maintain the oxygen levels in the blood using atmospheric air. The oxygen supplements are given through simple cannula in the nose or a mask at low flow rate. Depending on the necessity the flow rate is increased. If this is not sufficient, specialized masks are used. Next level is administering oxygen at a pressure more than the atmospheric pressure using machines, which can monitor the pressure levels of air pumped and avoid damage to lungs due to excessive pressure. Up to this level of support, patient is conscious and will be breathing on their own. If masks and increasing the pressure are not sufficient, then a tube is placed directly into the windpipe of the patient and connected to a ventilator. This is called invasive ventilation and all the breathing is done by the ventilator. Patients are generally sedated and paralyzed so that they do not ‘fight’ the ventilator. New generation ventilators are smart, able to identify patient’s breathing effort and can supplement, as necessary. All these are done by the intensive care specialists who have the necessary gadgets and tests to monitor the patient’s condition continuously.

If the oxygen saturation in the blood is not being maintained despite the highest level of invasive ventilatory support, the next available option is called ECMO – extra corporeal membrane oxygenator, artificial lungs in simple terms. If this also fails, in select patients, lung transplantation is an option. Simultaneously the original problem of infection or other systems must also be treated and supported, as necessary. At some point in time, the patient’s lungs and other systems must improve and start working again. Otherwise, all these outside supports are of no use. The main problem is no one can predict accurately whether a particular patient is going to be benefited for sure or not. When the patient is deteriorating despite the support given, it is natural tendency to escalate the treatment.

In view of the COVID affecting the lungs primarily, I gave the example of lung failure. Like this, kidneys, heart, intestines, or liver may fail and need support. Each support system has increasing levels of complexity, cost and risk of collateral damage associated with it. Despite the best will and efforts by experienced doctors, inadvertent injury or complications may arise during the process of treatment. If this happens, it may worsen patient’s condition, needs additional treatment and incurs more cost.

Machines used for these supports are reused but, a major chunk of equipment used these days is discarded after single use to prevent cross infection. All these cost monies. Whether the patient makes a successful recovery or not, money must be spent in the effort to save the patient.

Healthcare costs 1

Modern healthcare costs money. People do not like the ambience and facilities in a government hospital. The queues are long, one must wait and there may not be personal attention. The government could not keep pace with the exponential growth healthcare industry has undergone in the last three decades. Private entrepreneurs have taken the opportunity to create facilities and provide state of the art healthcare. Tremendous advances were made in understanding of the disease, new treatment methods, new drugs and in biotechnology. Computers, construction and manufacturing industry also has seen a lot of advancements.

All these have transformed the healthcare delivery in the last three decades. All these come with a cost – starting from hospital building, air conditioning, computers, latest CT/MR scanners, laboratory equipment, disposable items, medicines, staff salaries, maintenance, everything. Healthcare costs for primary and secondary care will not be very high. Many people can afford the cost, especially for ailments that can be treated within fixed cost packages.

Problem arises in providing tertiary care, for emergencies and complications. In these situations, the amount of treatment needed, stay in hospital and cost of treatment is purely an educated guess. No one can forecast how much treatment is needed and when one can expect improvement and the potential outcome. With increase in our capability and availability of facilities, we are treating more and more complex cases which were hitherto denied treatment and left to natural outcome. The more complex the disease status, more treatment and cost. In these situations, the outcome cannot be guaranteed. However in desperation, when a option of treatment is available, people want to grab it. If the outcome is bad, they are trying to blame the hospitals and doctors.

Doctors also tend to give an optimistic picture before treatment, which can come back to haunt them in the event of a bad outcome. Patients and attenders mostly meet their primary treating doctor only. They think that he/she is responsible for everything, especially the bill. In a big tertiary care facility, primary consultant is just the face of the team which has so many people working behind the scenes. When everything functions well only, the treatment process runs smoothly. The doctor can give and direct the treatment as necessary, but billing is certainly not in the hands of the doctors. The billing department works in the background and charges the services used.

Generally, the longer the treatment in a tertiary care ICU and use of more support systems means, the less likelihood of successful outcome. However, no one wishes to withdraw treatment. Both doctors and the family wish to continue treatment in the hope of improvement. When the improvement does not happen, everyone feels bad. The effort that goes into the treatment costs considerable amount of money. People do not want to pay for futile treatment. Problem is we do not know which patients do not respond to treatment and the treatment is going to be futile. The decision to continue or withhold treatment is individualized depending on several factors in each patient. The family needs counselling properly as to the available options, the cost and possible negative outcome.