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New Medical Criminals

New Medical Criminals
© Dr. Rajas Deshpande

“Doctor, Will My Dad Survive?” asked the anxious son.
“Very unlikely, we are trying our best though” said the desperate doc.
The highly qualified son had brought his father late night on a Friday, over 24 hours after he had developed a paralysis. Patient’s blood pressure was high, and heart status was fluctuating. An urgent MRI was advised.

“I will get the MRI done outside, I have a friend who gives me concession” said the son, and returned with an MRI after three hours, it did show a big clot in the patient’s brain. The son had insisted upon admission in the ward instead of a critical care unit, saying that his father “did not appear critical” to him and his family. “You want to admit in ICU because that will increase the bills. I know” he had bluntly told the doctor. The doctor had asked him to sign the refusal to admit in critical care, then sent the patient to the ward. Routine treatment for stroke and blood pressure was started, and tests sent.
“I will also get the medicines from outside the hospital, I have a pharmacist friend who gives me concession” he had told the doctor. © Dr. Rajas Deshpande

Early next morning, the father developed chest pain, and the cardiologist advised immediate stenting, as he was developing a block in the heart. . The son had insisted on using the cheapest stent. Although the angioplasty went well, the patient developed a bleeding in the brain, a complication known in stroke cases. He became unconscious. As the bleeding caused increased swelling and pressure upon the brain, a neurosurgeon was called in to decompress the brain (take off a small portion of the skull bone, to relieve pressure upon the brain). The surgery is usually safe, but the condition in which it is done is usually ultra-critical, thus risk to life is high. The son asked for a guarantee for a good outcome, and was explained that there cannot be any guarantees in medicine. He then refused the surgery, saying “I have read that surgeries are done without necessity by scaring the patient”.

Within hours, the patient’s brain swelling increased to the level of almost a certain fatal outcome. In the evening the son said he was willing for the decompression surgery, it was almost too late. The Neurosurgeon still operated him late night to make a last attempt to save life. After the surgery, the father was shifted to the recovery room. © Dr. Rajas Deshpande

It was here that the son had asked the doctor: “Will my father survive, doctor?”.
The doctor politely replied: “Sir, you have all the reports, you know what is his medical condition, so you can now google search and also ask your political leaders through their famous apps what will be the outcome, what is the next step”.

“But you are the treating doctor, you know better. You are like God for us” said the desperate son.

The doctor uttered the only two words that the doctor would want to use after hearing this:

“I Wish”.

Every Tom, Dick and Harry in the government and in the Media has become a critic of the extremely overburdened Indian medical profession made up of some of the best doctors in the world. Those who cannot run their own govt. hospitals well, cannot provide quality heatlthcare to the taxpayer, those who have corruption seeping through almost every office they own, those in whose authority (read govt. hospitals) hundreds of patients die helpless without care, compassion or treatment, those who suspend peons, ward boys, nurses and doctors for deaths that result from inadequacies like lack of essential facilities at hospitals owned by the govt., are out telling the world how Indian medical practitioners are corrupt, instead of praising how they shoulder what the govt. fails to recognize as its own responsibility: healthcare for the majority.

There are bad doctors, bad diagnostic centers, and bad pharma companies, protected by politicians and working on ‘lowest quality-lowest price’ principle. There indeed are “profit sharing set ups”. Among these, if a good doctor / specialist advises the patient to go to a particular doctor or lab or choose a particular brand, the patient automatically presumes that that the doctor is looking for extra money. So most doctors now tell the patient to “go wherever they want” for specialist consultation or tests. © Dr. Rajas Deshpande

When I must refer a patient to someone, the only thought in my mind is to offer the patient the best: because the patient’s trust is most important for me. This is how most doctors think, every doctor wants to make a good reputation, which is impossible without also good outcomes. I need to be able to discuss and be comfortable with that specialist, so we can plan best for the patient. If a suspicion about financial misappropriation looms over everything that a doctor does, it is difficult for any doctor to work. There must be accountability, but for both: the treatment and the doctor’s time, energy and skill. The doctor must be able to choose the best for the patient and the patient should have more trust in the doctor than the rumors. .

The last person who should play with trust and faith in other professions is a politician.

The patient did not survive. Neither the leaders who spoke lose and caused paranoia to affect the outcome, or the son who delayed admission, the pharmacy that sold cheapest drugs, nor the family that refused a life saving surgery had any blemish upon their reputation.

It was easier for all of them to blame the doctors who tried hardest for the patient.
© Dr. Rajas Deshpande

Thank You Dr Nusli Ichaporia for the technical assistance.

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The Power

The Power

© Dr. Rajas Deshpande

“He is probably brain dead” said the daughter, holding back tears.

“Now we have to make a decision whether to continue treatment or not. We are not that rich. Can you help us decide?”.

Not very pleasant, nonetheless the inevitable duty of a doctor: to decide when to pull the switch off. We suffer these decisions too. I went with them.

The patient had developed a heart attack just after a supra major heart surgery, the risk was already predicted by doctors and accepted by the relatives. Now he had no visible signs of any brain function, and the doctors had updated the family so. What with film stars alleging that “some hospitals keep dead patients on ventilators”, most hospitals and doctors now are on the overprotective / overcautious drive, especially with a society that has more blind faith in cinema than in medical profession. © Dr. Rajas Deshpande

As I examined the patient, the handsome junior cardiac resident doctor, Dr. Paramjeet, standing by my side kept on informing me details. An uncorrupted mind of a resident doctor, who wants to do good to all patients, save every patient with heroic efforts was too evident in his demeanour. As in most cardiac care units, the smartest and fastest nurses were hovering around, silent angels who do such enormous complicated brilliant work without any hoopla about it!

I found some doubtful signs of life in the patient’s brain. I told the relatives “His brain is alive, we do not even have a right to think of stopping treatment at present”.

“Don’t worry, Sir, we want to continue. Make all efforts for him please, we will make arrangements too” said the daughter, with something that most doctors see every day: tears, smile and a heavy throat all at once. © Dr. Rajas Deshpande

As I instructed about the changes in prescription, I noticed that Dr. Paramjeet was tearful too.

Outside the CCU, I asked him what was wrong with him. He told me he had had an argument with his boss that morning, when the boss had told him to inform the relatives about this patient being probably brain dead. He had assisted his boss for this surgery, and was reluctant to let the patient die under any circumstance. However, the boss had seen many more seasons, and knew what was legally required, even if it was against common sense sometimes. The boss cared for the patient as much, but was aware of how things go wrong when the relatives are suspicious and faithless.

I received a call from that unit after two days again. The patient had started moving one leg. Dr. Paramjeet and the nursing staff were very excited when they told the details of his improvement. There definitely were more signs of life. The family was completely cooperative, and repeatedly assured the doctors of their trust in the on-going treatment and the staff’s efforts.

In another week, the patient opened eyes. In a month, he started speaking a few words, and standing without support. He was discharged. © Dr. Rajas Deshpande

Yesterday, the whole family came for a follow up. Dr. Paramjeet accompanied them too, happily carrying his gift bag. The patient had regained almost all his faculties, the cardiac surgery had given him a new life. The family told him once again in front of me, what all had happened. Then the wife, who was always there by the patient’s side but had never spoken a word, folded her hands and handed over to me a box of sweets and a shirt and started to speak, but choked upon her emotions. “You returned me my husband” she said. © Dr. Rajas Deshpande

Well, my mental OCD acts up sometimes too, and I told her that it was the cardiac surgeon, Dr. Paramjeet and the nursing staff who saved her husband, not me.

“Yes, but it was you who told us we must try. You doctors have powers like God” she said.

That was simple to answer.

“Tai (Sister)”, I replied to her, “Whenever a patient completely trusts the doctor, it becomes an automatic responsibility of that doctor to cross all barriers and make every effort to save that patient. That power is in your faith. We have just done our duty”.

When they left, Dr. Paramjeet showed me his gift: a wrist watch and a gold chain. “I am gifting these to my Mom and Dad, Sir, when I go home this diwali!” he told me.

I knew how his parents would feel. Every doctor knows it.

© Dr. Rajas Deshpande

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The only way towards a solution: A 13 point charter for Doctors

The only way towards a solution:
A 13 point charter for Doctors
Happy Doctor’s Day!
© Dr. Rajas Deshpande

1. If we want to survive without being exploited and improve healthcare, we must forget all our differences and unite for this cause. We must be able to overcome all personal differences to realize what great strength we are. This is the only solution for ourselves and our dear patients!

2. We must form specialty-wise groups of doctors in each city / state and elect a steering committee that will decide the regional regulations. The charging system for consults, procedures and investigations according to “gradation” of hospitals (facilities, location, quality of advanced care, nursing) etc. should be devised by these regional steering committees alone. State committees should elect a National Medical Steering Committee.

3. The specialty groups in each town must include all consultants from that specialty, and decide the correct fees for consultation, procedures, intensive care, emergency availability and surgeries based upon seniority, qualifications, skill, time, complications and other factors intrinsic to that specialty. This schedule must be binding upon all the small and big hospitals in that region, insurance companies and private practitioners. Sharing fees must be the doctor’s prerogative.

4. There should be no free cases, except those below poverty line and in emergency. Doctors should get tax benefits for every free patient (CGHS /CSMA/ ECHS or BPL in India) treated by them, as per the regional schedule. There should be a regional coordinator for all the Free beds in private hospitals, which are often misused by rich officials. Every consultant must see free patients one day in a month by appointment.

5. Govt. must provide all cost of prescribed medicines, surgeries, equipment, medicines and manpower for the treatment of free patients. This should happen real time, as sometimes the dues are not paid to hospitals by govt. for decades. All existing dues should be settled immediately, so hospitals can provide better care. In patients who cannot afford costly treatments / medicines / surgeries, the funds allotted to the local representative (MLA / MP) may be used by priority. Also allow the pharmaceuticals to pay for the poor patients upon request by the treating doctor.

6. Every hospital must provide free available treatment for all the consultants working for that hospital and their families. All doctors should be collectively insured against: illness, disability, death, accident, loss of job, medicolegal cases and violence induced damage (mental and physical). This must be done at state / national level. The medical insurance companies which earn billions by eating from the doctor’s plates must insure them against all these calamities. Also the corporates and other healthcare giants should be answerable to the regional committees.

7. Any medicolegal case / negligence issues must first be presented to these committees, which will refer it to the national committee, whose decision will be recommended to the courts of law. The current compensation system based upon inequality of “value of life” should be eradicated. All patients are equal, and the compensation value of every life must be the same. If one expects “Indian rates of Treatment”, one must accept “Indian rates of Compensation”. In cases of patients treated free, the govt. should pay the compensation to the patient, otherwise no private doctor will want to treat free patients and invite more legal liability (the misuse of medicolegal cases by the poor and political is an emergency in waiting for future generation doctors). Patients should also have an option of committing complete faith in the doctor and signing a “No Legal Liability” bond, which will make it easier for the doctor to do his best for the patient, unaffected by legal fears. Also, any interference in patient care including intimidation, threats etc. must be punishable by law.

8. Doctors must collectively develop a national medical research funding by compulsory contribution, and start advanced centers for research which are not imprisoned by the lack of initiatives , funding, or intellect. This should be autonomous and purely merit based, with no interference from govt. or anyone else. We should also find practical solutions to accessibility and excellent rural healthcare system. Only we can, govt. never will.

9. There should be revamping of medical education: MBBS in four years, internship, one year bond of rural service, then PG, SuperPG, Fellowship and then practice. This is long enough. All other bonds must be cancelled. Payment structures of all Medical officers, Teachers should be compatible with highest in the govt: IAS / IPS, as these doctors deal with life and death everyday, saving millions. PG exams must be conducted on time, and court interference must be avoided, the decisions of National committees must be final. This will save millions of youth-years of generations of doctors. PG seats should increase every year, there must be unified national payment strategy for PGs. They must also get free food, hostel and internet, and compulsory 8 hours daily sleep time.

10. Doctors must also introspect and improve wherever they are really lacking in the social eye: proper compassionate communication, dignified behavior (avoid this talk of the town when someone overdrinks especially in conferences). We must also start “Positive Connection” strategies with patients, and limit / improve upon the existing crisis of faithlessness by encouraging and rewarding trust. There should be doctor-patient coordination committees in every town to facilitate this.

11. A unified “Paperwork and SOP” National committee of doctors must make such paperwork available on the internet for all doctors to use. The laws governing hospitals must be freed from the innumerable “NonMedico” interferences, red-tapism, corruption etc. roadblocks and must be common all over India.

12. Violence against doctors/ hospital staff must be severely punished. All govt. hospital deans must request 24/7 casualty police.

13. All practicing doctors must receive a compulsory paid vacation at least one month in a year to de-stress, and if the govt. or their own hospital cannot pay for it, let other parties willing to pay be discussed without objections or paranoid suspicions. All said and done, it is extremely stressful to be a doctor. Yearly paid vacation is only human.

This is a sweet dream. But what’s life without a dream? Don’t we wish each other sweet dreams? I mean it this time. Let us work to wake up in this dream. We are a great force, let us overcome our differences and become the Great Doctors who ably carry the Nation’s healthcare like Pros, not slaves.

This seems to be the only way. Happy Doctor’s Day
© Dr. Rajas Deshpande

Lifehacks for the Doctor

Lifehacks for the Doctor
With interview of a renowned Cardiologist.
© Dr. Rajas Deshpande

Lifehack:
a strategy or technique adopted in order to manage one’s time and daily activities in a more efficient way.

Are you talented, hardworking, hurried, bitter, artificial, irritable, insecure, obsessive, egoistic, money-minded, dissatisfied and longing for a better life? Yes? Then you must be a successful Doctor!

While medical practice is of paramount and sacred importance, the duties as a spouse and parent are absolute too, there is no replacement for you there (Well, in most cases!). If your “Kick” of being completely swept away by the needs of your practice and competition drowns your own personality and the requirements of your family, you may be a overindulging doctor who is a terrible parent or spouse. Only your family will carry you in their arms few years from now, no one else. Rethink how you treat them today.
Are you really earning “For Them” or for your own super-ego, for overcoming the ever widening valley which converts every luxury into a necessity you must have? The justified feeling that “If I have learnt so much and am so talented, work so hard, I must earn real good”. Has money / affluence become your self-assessment criteria? If so, you may be no different than an attention seeking, beautiful, very very attractive but dumb individual. You trade health, family and life for money.

Calm agility of mind and body are hallmarks of a doctor, and too many tasks, irritability, bitterness, insecurity and lack of satisfaction are making this impossible.

Let us identify how we can reduce stress and improve the quality of life. The only life we have.
1. Separate work and family cellphones. Switch off the work phone outside work hours, except on emergency day. Provide all your patients with casualty / emergency contacts, and only your assistant should be able to reach you on your personal number.
2. Hire and train assistants when feasible, they may assist you with secondary/ nonclinical tasks, paperwork etc.
3. Take a big picture look at your day / time correlation, you will be surprised:
Work (8-10 hours),
Commuting (1 hour),
Sleep (7 hours),
Kids (1 hour) till they are 18.
Spouse (dedicated 1 hour: you married for togetherness all life, right?),
Communication / emails / Internet (1 hour), and
‘Self’ time (1 hour)
Total = 20-22 hours.

You will still have 2-4 hours left for cooking / housekeeping / etc. (to be done by both if both are working). If we expect the society to be modern, we must also give up the traditional “wife at home however educated or smart” and “husband rules” attitude. Family is equal responsibilities to be shared with mutual agreement.

If only one partner is working, it is easier to arrange schedules. If both are working, one may prefer non-clinical / paraclinical duties till kids can take care of themselves. Singles are anyways happier till a certain age!

It is extremely essential to disconnect from the work to be completely with your kids / spouse. Strictly avoid talking about workplace at home, especially do not take your stress to bed.
Switching off cellphone at night is a big step in the evolution of a Doctor’s peace of mind.

You can practice far better with a calm and healthy mind. Hence the necessity of good sleep and self time.

4: Find an activity that makes you feel calm and happy. Don’t need to explain this to anyone, don’t need to feel guilty, this is therapeutic. This must be done alone for an hour everyday , with all communications switched off. Some suggestions:
Music: Listening, Composing, Singing, Learning
Writing, Reading, Painting
Gardening, Watering plants (magically calming effect).
Swimming, Cycling, Dancing, Gymming, Yoga
Long walks / drives if good, uncrowded roads nearby.

One of my senior colleagues Dr. Jagdish Hiremath (Director of the Ruby Hall CathLab) is one of the busiest and renowned Cardiologists in the town, and never skips a smile when a colleague crosses him. Always appears at peace with himself and others. I asked him how he manages such a stressful life of a successful interventional cardiologist. As we talked, I realised his answers are worth what every doctor must think about:

Dr. JSH: “I prefer to be in the present 100%, whether with patient or otherwise. I concentrate upon the task in front of me and blank out all else, so I can do justice to that task. When I am with a patient or in cathlab, my cellphones are diverted to my assistants or receptionist, and I am not disturbed. This helps me, and the patient also feels happy about it. My assistants filter out unnecessary calls and pass on the genuine ones to me as a message, I call and talk to them on my way home”.

Me: “Newcomers, especially superspecialists, face the dilemma: that cut-practice or referral practice is the only way they can start, as no one offers any salary till you have a good patient-base. It is almost impossible for the beginners to start in a decent place without submitting to the existing pay structures”.

Dr. JSH: “Yes that is a shortcoming in our system. But then, the concepts of ethics, morals are quite twisted in medicine today. We must never compromise in doing the best for the patient. But then, others should not decide or dictate how the medical charging systems work: neither insurance people, nor media, community or anyone else. Because they never understand / acknowledge the importance of talent and skill”.

Yes, I thought: who else will allow other professions/ government, society or insurance companies to decide the value of their services? Will they allow others to dictate how they use / share their charges? It is only the doctors who have allowed this, and it is high time everyone else shuts up about this and doctors redefine the charging structures.

Me: “Sir, medical education has become “Earning PG” oriented. MBBS doctors do not get good teachers, and are not clinically well groomed. They are smarter and have better net-knowledge, but not good clinicians. They have become “MCQ Doctors”.

Dr. JSH: “I have always said that MBBS should be ‘the making of a doctor’, and not only stepping stone for PG. We need better institutes, better teaching. A doctor must grow as a human being lifelong, and it must start at this level. Even the PGs are exploited too much. Their teachers should understand that they are no more traditional ‘students’ in college, they are grown up married doctors with families, and must be treated like employees rather than servants”.

Feeling a sense of having learnt something invaluable, I thanked him and left.

There’s this “Becoming a Man (or Woman)” of every Doctor: when they start treating independently and confidently. Then comes the phase of an “All Out” effort to increase practice: extreme self neglect and hardwork, running from one hospital to another. Then one day they wake up to the reality.

All the stories of Morals and Ethics taught and expected of a Doctor are like the things that parents tell their kids not to do, while doing these themselves.

The Indian Doctor’s Enlightenment (approximate latency 5-7 years in practice) comes packed in bitterness and depression towards the very society he / she serves. They realise that the society has lost trust and respect towards us, even the recognition of the extreme education and hardwork doctors have to perpetually live in. An educated patient expects global standard healthcare at Indian rates. The uneducated look upon the doctor as a bandit.

So if you have become the typical successful doctor “Hurried, bitter, artificial, irritable, insecure, obsessive, egoistic, money-minded, dissatisfied and longing for a better life”, it is time for a reboot. No medical bodies stand by or defend doctors. So we must learn and try to sort out this mess ourselves.

For life is change, and wisdom lies in the wish for a better life.
It is high time Doctors learn to take care of themselves.
Wishing all Doctors best of health and a beautiful, rewarding life of success and satisfaction.

© Dr. Rajas Deshpande
(This is Part II of “Delusions, Doc?)

Special Thanks
Dr. Jagdish Hiremath,
Director Cathlab Ruby Hall Clinic