Changing time force professionals to safeguard their well-being. *Defensive Medicine and what it means to you and your family (non-doctors)*
-by Dr. Pranav Kodial
This article is primarily for non-doctors, to create awareness about the fast-growing problem of Defensive Medicine, a problem that will soon affect every non-doctor and his family.
_“Staring at danger may not be pleasant – but closing your eyes will not make the danger go away, and with closed eyes, you will surely be destroyed by it.”_
― Isaac Asimov, Catastrophes!
I watched the lady leave my surgeon friend's consulting room with a disappointed look on her face. Then I turned to my friend, puzzled. "I don't understand...why did you refer this patient elsewhere saying that her case is too difficult for you? As far as I know, you are the best in Mumbai for this type of cancer surgery."
My colleague looked at me gravely and said, "What you don't know, is that lady is closely related to Mr. ABC. The same fellow who gathered a mob and attacked our gynaec colleague last year, blaming her for his daughter's C-section complications."
He continued with a sigh, "I am fully confident of operating this lady, even though her case is complicated. But I am also fully confident that if anything goes wrong, ABC's goonda-mob will burn down my hospital and/or beat me to death."
I said nothing. I couldn't blame my friend at all. He had chosen his personal safety over the patient's well-being. सर सलामत तो पगडी हजार, as they say in Hindi. But I also felt sorry for the patient. She could have benefited from Mumbai's foremost expert in that specialised cancer surgery, but now wouldn't because my colleague was practicing 'Defensive Medicine'.
You may not have heard this term before.
Defensive Medicine is a type of clinical practice wherein a doctor manages a patient in the interest of his own safety rather than the betterment of the patient.
It is the tragic but inevitable result of widespread violence (verbal and physical) and reckless litigation (suing for malpractice) many doctors in India have to suffer if something goes wrong with their patients, despite doing their best for them.
More on that later but first, how does Defensive Medicine affect you and your family?
Defensive Medicine affects you depending on its type: 'positive' or 'negative'.
Usually, doctors use their own judgement, knowledge and skills to investigate and treat an illness. Only the most common or likely diagnosis is suspected first, investigated and treated accordingly. And then only if necessary, additional advanced and costly investigations, specialist referrals and treatment is advised.
In Positive Defensive Medicine, doctors don't want to take any chances. They fear that if they don't consider a rare diagnosis or uncommon/expensive treatment right at the beginning, the patient and his relatives may later accuse them of negligence—why they did not recommend that test/ specialist referral or treatment in the first place. Consequently, these doctors may advise every kind of test and treatment, so as not to miss anything.
And guess who has to suffer and pay for all that? Yes, you and your family.
Next, Negative Defensive Medicine.
Many doctors are beginning to believe that it is far better to be known as a mediocre doctor but remain alive and healthy, than become an excellent and famous but psychologically broken, physically crippled or dead doctor.
Like my surgeon friend, they don't want to accept difficult cases even though they can successfully treat them. Forget that, some doctors transfer even EASY cases where the patient or relatives appear even slightly demanding and aggressive—warning signs that they might sue or beat up the doctor in case of any complication or "failure" of treatment.
Doctors now often assess whether the patient and his relatives are 'safe' and THEN decide whether to treat them. Yes, 'safe'...never thought this term could be applied in this context, no?
Again, guess who suffers the expense and inconvenience of transfers, and deprivation of less expensive expert care? Correct. It's you and your family.
By now you must be asking yourself: How bad is the problem?
Answer: Defensive Medicine _is_ on the rise in India. And it's growing exponentially with every incident of unwarranted litigation and violence to doctors.
At this point, sensitive, intelligent and proactive citizens would probably want to know: "Then what should WE do to help? How can we make our doctors feel safe so they can give us of their best without the swords of violence and litigation hanging over their heads?"
Answer: Most problems can be solved with correct understanding.
Understand that the news media and public gossip thrives on sensationalism. Use your intelligence and don’t get influenced by the emotionally charged ‘news reports’ and juicy gossip condemning some doctor for malpractice. Understand that there is another side to the storcy—the doctor’s side—which will never become public. Even worse are ‘social activists’, politicians and celebrities—nothing gets them more moral, social and political mileage than ‘exposing’ professionals of a noble profession. Tip: Note how their language and presentation subtly (or even overtly!) flaunts their own moral and ‘compassion’ superiority whilst simultaneously lamenting the degradation of medical ethics.
Understand that no doctor wants to hurt or kill your patient. Why should he? In fact, the successful management of your patient will enhance his reputation. Understand that after a serious complication, the doctor feels as bad as (or worse than) the patient and his relatives.
Understand that Medicine is an imperfect science where an imperfect human being treats another imperfect human being using imperfect methods, all of whose fate is decided by God. If you are an atheist, then call it Destiny or 'factors beyond human control'.
Therefore, understand that complications and death are an UNAVOIDABLE part of medical treatment. There will ALWAYS be complications and deaths while treating a patient. Repeat, ALWAYS.
So if things go well for your patient, praise God, not the doctor. And if things go bad for your patient, don't blame the doctor. Accept it as one of the challenges/ difficult situations that God-Destiny brings into everyone's life.
Understand that healthcare services are not like a car garage or Zomato or Pizza Hut services. Don't expect 'results' just because you spent money. This grossly incorrect, consumerist _paisa-vasool_ attitude of many patients has greatly contributed to the problem. Labelling patients as consumers has done a great disservice to healthcare—for both doctors AND patients. As explained above, God decides the results. Let us deeply assimilate this truth.
Understand that every doctor fixes his fees according to his skill, knowledge, experience, and hospital/clinic expenses. You are paying his fees for all that, and NOT for results.
Understand that the high cost of medical treatment in many cases is not necessarily because of the doctor being a greedy _lootera._ It is often because medical scientific advancement comes at a price—cost of new medical equipment and machines, necessary maintenance and material for the same, the cost of training the doctors incur for that expertise etc. You want advanced treatment at unreasonably low cost? Pressurise the government to provide such healthcare. Fun fact: Indian governments (State and Central) have one of the lowest healthcare expenditures in the WORLD!
Understand that healthcare expenditure is NOT unnecessary or wasteful expenditure. Especially if you don't mind spending on things like expensive smartphones, cars, restaurants, liquor, cigarettes, shopping sprees, vacation trips etc. Understand that doctors try to keep you alive and well. Consider your medical expenditure as investing in yourself. Tip: Following a proper diet, exercise, sleep, relaxation and regular health check-up schedule will save you a lot on medical expenses.
If you do strongly feel negligence has occurred in your or your patient's management, seek legal help. Resist the temptation to resort to violence (verbal and physical). Resist relatives and friends and 'well-wishers' who poison your mind against your doctor and encourage you to act wrongly. Especially 'helpful' political people and 'social workers' who will only want to use your tragedy to get political and social mileage. Remember, it may be that the doctor has genuinely tried his best for your patient. Then punishing your genuine well-wisher who has sincerely cared for you/ your loved one will be your most sinful action in this life.
If you are in a situation where your friends and family have begun to unnecessarily blame the doctor for their patient's death or complication, console them and then convince them that it is the will of God and taking out their anger and sorrow on the doctor is wrong and won't help matters. Your words of wisdom may make them understand the situation in the correct, positive way.
Hopefully, with an effort by patients to become ideal, respectful patients, and also by doctors to become ideal, ethical doctors, we can restore the glory of the doctor-patient relationship and eliminate Defensive Medicine.
By now you must be wondering, “But what’s all the fuss about? Why should doctors stoop to Defensive Medicine? Why are they so afraid of litigation? Can't a doctor easily prove in court that he did the right thing and be declared innocent of malpractice?
Answer: Yes, many doctors can successfully defend themselves in court, but only after enduring torturous mental stress for months and years—you know how courts work in India. All that unnecessary stress because they did their job correctly, but the patient and his relatives wanted to blame their doctor for their bad luck.
Also, our Indian public and media act as self-appointed fast-track courts and award punishments much before our regular courts. By the time the regular court declares a doctor innocent, the media and public trials have already sliced and diced his reputation.
In the US and many other western countries, rampant and often greed-fuelled (for undeserved compensation) litigation has resulted in 50 to 90% of doctors practising Defensive Medicine. I dread the day we begin to see these statistics in India.
Your next question will be, “Is the violence issue _really_ that bad? We don't hear of that many instances…”
Answer: Violence to doctors in India _is_ bad—up to 75% of Indian doctors have faced it at least once in their life. And remember that it can be both verbal and physical. It's just that you don't get to hear about it every day. Like domestic abuse or workplace molestations, 99.9% of the victims would much rather suffer it silently, than make a noise and become the subject of public gossip.
Also, violence against doctors goes unpunished in India, or at best, 'punished' with a token rap on the knuckles. Tragically, it is fully supported by much of the public, politicians, the government and the law—illegal FIRs registered against doctors by the police themselves, public support on social media for every violence incident, our politicians turning a deaf ear to every plea to enact severe laws for these crimes...the list goes on.
"Okay, okay," you will say, "but doctors have brought this upon themselves, haven't they? So many doctors indulge in unethical practice...so naturally the public will get frustrated..."
Answer: We all live in a world that is going from bad to worse regarding morals and ethics, especially dishonesty and greed. The doctor community too has its share of evil, disgusting _kalanks_ (tar-black sheep) on the name of the noble medical profession, deserving of SEVERE punishment by our medical council. There is a tremendous lot doctors need to introspect about and change regarding themselves and medical practice.
But does that condone your taking the law into your hands?
And isn't this moral and ethical degradation true with ALL professions and jobs? How many times have you experienced/ heard of wrong judgements by 'fixed' judges, loss of lakhs of rupees to lawyers who lost your cases, bribes to ever-hungry government officers, substandard products that have even endangered your life etc? In these cases, how many times have you collected a mob and threatened or thrashed those judges, lawyers, government officers, product manufacturers etc? Or destroyed their offices and establishments?
Not once. Why? Because they are effectively protected by Law. Unfortunately, not so with doctors in India.
The most frustrating and bitter reality for doctors is that our society assumes the doctor to be wrong unless proven otherwise. Worse, it sympathizes with these violent relatives-mob and actually CONDONES their violence, excusing them for their 'disturbed state of mind after their patient's complication or death'. Imagine what would happen if everyone started using violence to vent their anger on others citing 'disturbed state of mind' as a valid excuse...
Finally, you must know that doctors practising Defensive Medicine are not proud of it. In fact, there is nothing more shameful and frustrating for doctors than to practice their profession in this way. Because managing every patient properly, especially a difficult case, is a very fulfilling achievement for a doctor.
But being a human being just like yourself, many doctors are now increasingly being forced to prioritise the safety of their own life, limb and property, over doing the right thing.
Sad, isn't it?
Sad not just for doctors, but also for you and your family.
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