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.