Year : 2018 | Volume
: 7 | Issue : 2 | Page : 288--290
Doctor in default?
Ajaya K Upadhyaya
Retired Consultant Psychiatrist, Hertfordshire NHS Trust, Hertfordshire, England
Dr. Ajaya K Upadhyaya
Hatfield Heath, Bishops Stortford, Hertfordshire
|How to cite this article:|
Upadhyaya AK. Doctor in default?.J Family Med Prim Care 2018;7:288-290
|How to cite this URL:|
Upadhyaya AK. Doctor in default?. J Family Med Prim Care [serial online] 2018 [cited 2019 Aug 19 ];7:288-290
Available from: http://www.jfmpc.com/text.asp?2018/7/2/288/236430
Imagine a doctor on call is woken up from sleep to attend to a patient brought into the casualty. He is bound to be in a state of some anxiety or possibly trepidation. The thoughts uppermost on his mind would be how to make sure not to miss the correct diagnosis or what test to arrange to confirm it and most importantly whether the chosen treatment would fix the patient's problem. The last thing crossing his mind would be how to defend himself from physical assault by the patient's family or friends in case things do not turn out right.
You might think this scenario is too farfetched. But sadly, this is the fate of many unfortunate doctors in India, who in recent years have suffered horrific injuries in the hands of the accompanying well-wishers of patients for their perceived shortcomings, thought to have caused the patient's death. In some cases, it is the doctor who eventually lands in the Intensive Care Unit for treatment of their injuries.
Mercifully this scenario is rare. However, it is mere occurrence and in increasing frequency tells an ominous story. Such situation was almost unthinkable when I entered medical school about forty years ago when Medicine was considered a noble profession and doctors were put on a pedestal next to God (“Doctor Bhagwan ka doosra roop hota hai”). The doctor-patient relationship was considered so special that beating up a doctor under any circumstance amounted to sacrilege. Hence, we have a sea change in public's attitude toward doctors. A lack of public protest in the face of well-publicized reports of violence toward doctors in many parts of the country points to this becoming an acceptable method of meting out instant and rough justice to rogue professionals. This disturbing trend indicates that some unspoken taboo has been broken; the “Lakshman rekha” has been crossed.
Clearly something has gone wrong. Doctors are human and no doctor can claim to be infallible. They can be negligent too. However, the readiness to resort to physical violence for their mistakes or misdemeanors underscores a deep sense of resentment toward doctors. Irrespective of the circumstances of these incidents, such naked aggression toward doctors points a totally tarnished image of doctors in public; Not a respectable professional anymore but a medical degree holder, licensed to make money out of suffering humanity.
There is nothing new about doctors earning a living out of their professional knowledge and skill. So what is behind this disaffection and resentment? The sociocultural milieu of medical practice in the last 40 years has changed, and so has the public's attitude. No longer is medical care confined to tending to the sick and distressed, it is being increasingly targeted at the worried well and to the affluent who believe in the dictum, “more medical care is better and more expensive care buys better result.” Medical tests and treatments have become commodities traded through advertisement and special deals.
Slowly but unmistakably the landscape of medical practice has been transformed. The traditional motto of medical practice was “treatment for the distressed dictated by doctor's judgement” whereas the mantra in the modern era becomes “treatment on demand at client's choice” Medical tests and treatments have become commodities traded through advertisement and special deals. In the old model, the deceased cried out for doctors in search of care, whereas now doctors, or hospitals on their behalf, seek out clients through websites.
Medical care thus has become an industry, driven by commercial interests, where patient care becomes a means to the end of maximizing profits. In essence, the patient-physician relationship has been redefined as a business transaction. The bond between doctor and patient now has a commercial reincarnation.
However, in this brave new world, market forces and the business model do not work well for the patients. Because the position of the doctor versus the patient in this trade is rather asymmetrical. Thanks to the internet, abundant information on all matters medical is available freely. Notwithstanding the public's remarkable growth of knowledge about diseases and medical interventions, doctors generally have the upper hand in these transactions as they can manipulate the information and prey on their fears.
With rising cost of medical care, the economic burden of illness compound the suffering of the sick and their family. People are known to have sold their land and mortgaged their property to meet the cost of medical care, in the hope of getting some relief, possibly a cure. When such hopes are dashed, and the outcome nowhere matches their expectation, the anguish of losing loved ones from disease gets amplified from the financial ruin it brings to the family.
The practice of medicine is largely an art and an inexact science at best, where uncertainties abound. Hence, despite the doctor's sincerity of purpose and best intentions, no outcome can be guaranteed. In fact, the end product in medical practice depends on factors much beyond the doctor's judgment and skill.
However, there are many instances where doctors, hiding behind “clinical autonomy” or “defensive practice” subvert patient's interest by distorting their clinical judgment to maximize their pecuniary gain. As medical tests and treatments come with price tags, it is not difficult to see how such distortion creeps into doctors' decisions, be it prescribing of antibiotics or putting in a stent or preferring surgery over conservative treatment. The inherent conflict of interest fuels the trend for unnecessary investigations and overtreatment. The implications would not be so serious if such practices impose only a financial burden on the patient, but they also put their lives at risk from dangerous adverse effects.
Here, I am not talking about a tiny minority of rogue doctors, who are intent on making money by hook or by crook, in the name of medical practice. The issue is a subtle shift in the prevalent culture of medical profession, an insidious erosion of ethical principles. This practice of distorting clinical decisions, conscious or subconscious, gradually becomes a habit when it ceases to prick the doctor's conscience. Effectively this becomes the new norm, and the end result is a culture of medical malpractice which no longer raises eyebrows.
The other strand to the rising violence against doctors stems from changing the outlook of modern society and rising public's expectations. On the wake of social media, we are bombarded with sensational images and news from all over the world, which we take in with gusto, rarely pausing to check their veracity. A new social malady has been borne, which combines an almost voyeuristic interest in lives of rich and famous and a sense of entitlement to the high life these successful people seem to be enjoying. As many such expectations are built on fantasy, the common man's life remains dull by contrast. This provides the perfect incubator for breeding envy and resentment.
Large chunks of Indian society, unable to share the economic progress of the country, feel disenfranchised who are particularly susceptible to such frustrations. The sense of injustice and unfairness in these marginalized sections turns them against the establishment and the successful, which includes doctors. With consumerism in medical care in the ascendancy, some doctors amass vast business empires of medical practice. Their visible and almost vulgar wealth combined with the public perception of corruption in medical practice produce fertile grounds for their distrust of doctors and anger toward the entire profession. Although there is no dearth of doctors who do an honest job against all odds, the entire medical profession gets painted in the broad brush of corruption and greed.
We are living in an age of anger, carrying this pent-up resentment in us, which spills out at the slightest of provocation. Sadly, some doctors through an unfortunate set of circumstances become the target of this unleashed fury, with disastrous consequences.
Some years ago, Amir Khan, a prominent Bollywood star hosted a series on Indian television titled, “Satyameva Jayate” (Truth alone prevails), aiming to raise public awareness of the social evils afflicting India. One of these episodes dealt with corruption in medical practice. These programs turned out to be extremely popular, and the handling of the themes seemed to be fair and even-handed. However, my first reaction to this was a sense of bias against the medical profession. As corruption is widespread in India, it seemed unfair to single out medical profession. Why not look into other professions, say legal or teaching? Doctors are a product of the society and their practice is bound to be influenced by the widespread corruption around them. So, is it fair to expect them to remain immune to the effects of corrupt practices they encounter in all walks of life?
The short answer to this question, I am afraid, is yes.
We doctors, at least of my generation, have lived in the golden age of medicine, when the profession was held in high esteem and doctors were treated with respect. Furthermore, technology put a wide range of user-friendly test and treatments at our fingertips and most importantly our patients were ever so grateful for our best efforts even though we could not cure their ailment.
Our life has been enriched by our patients who trusted our judgment and believed in our ethics and values. We acquired the art of medicine from them, learnt the course of diseases through their suffering, and we practiced our skills on their bodies. Of course, we earned a comfortable living, but their gratitude has been our greatest reward. There is no other profession, which gives us such privileged access to lives and minds of others. In return, we owe them a standard of conduct which inspires their confidence in us, and an obligation to rise above the average moral standards of the society.
Of course, it is in the interest of the wider society to address this. Unless the current trend is nipped in the bud, it would threaten provision of medical care in parts of the country where it is desperately needed. However, it behoves on medical profession to accept its share of responsibility in restoring the trust of society.
Although it is tempting to look to governmental and institutional measures to improve safety of doctors in the workplace, this would amount to mere symptomatic treatment of the malady afflicting the profession rather than tackling the underlying etiology.
For a start, doctors need a dose of introspection to shake off their complacency. Instead of deflecting the blame for their predicament on the society and relying on external redress, the reflection should be directed at improving their credibility and image. An honest acceptance of the insidious corrosion of our values would be the first step toward resetting the barometer of our ethical standards.
Let us get back to the opening scenario of the doctor who is called out from sleep to attend to the patient. In preparation for dealing with the emergency, the doctor's action plan should go beyond patient's diagnosis and treatment to include repercussions on his own safety if things go pear shaped. The strategy marshaled should cater for all eventualities, striving to save the patient by all means but with a contingency plan for saving his own skin, literally!
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There are no conflicts of interest.