THE MYTH OF THE RATIONAL DOCTOR
The healers’ conundrum!
Doctors are expected to be compassionate and caring but also clinically detached, composed, scientifically updated and objective at the same time. Almost every doctor tries to treat a patient to the best of his knowledge and capability, as is expected of him by his patient, and his profession. However, doctors are humans and can they always make rational decisions, or are they also influenced by other factors beyond their control?
In a bygone era, the practice of medicine was a personalized process with an unexpressed bond and a high degree of trust between the patient and the physician. With time, medical practice became somewhat commercialized and at the same time the courts of law designated doctors and hospitals as service providers and patients as consumers, in black and white. This was in complete contrast to the practice of medicine which often treads a grey zone, where opinions of two experts may be diametrically opposite and both may still be correct.
This mandated a shift from ‘eminence based’ medicine to ‘evidence based’ medicine. Now decisions made in good faith but even slightly in contravention of currently accepted practice, came to be looked down upon and, with time, shunned completely. Every decision, every prescription, every plan now had to be backed up by peer reviewed, published data. Personalized treatment slowly made way for protocol based management. This became almost de rigueur in the West but is less of a problem in India even today. Still, we are slowly but surely getting to the point where treatment decisions are being questioned (and sometimes suggested too) by insurance companies. A nameless, faceless, often under qualified person sitting at a desk somewhere in an IT hub can casually ask why a particular medicine was used or why a particular surgery was done (instead of some other procedure). The person the query is directed at is often an expert with decades of experience in the field. The motive is evidently reduction of the claimed amount if not outright rejection for some flimsy reason.
This is often compounded by the fact that the insurance agent did not disclose a preexisting illness in an attempt to reduce the premium paid, to please the client. The client often pays for this folly after many years when claims are rejected for this reason and the few hundred rupees saved per year on premiums pale in comparison to the thousands or even lakhs which will not be reimbursed. But we are digressing by discussing mis-selling of health and insurance policies and we shall let this matter rest for now.
The near sacred doctor-patient relationship was, by now, flagged as a legally binding contract by law and mandated treatment decisions which had to be always backed up by medical literature. Life was made more complicated (or easier?) by the burgeoning publications where it was not difficult to find ten papers which proved a point and another ten which stated the exact opposite, often depending upon who was sponsoring or funding the study. Nowhere is this more evident in Urology than in the multitude of papers published on prostate cancer where any and every treatment plan one can think of has been proven and disproven many times over. A lot of contemporary medical literature probably functions more to obfuscate facts than clarify them. Many medical journals nowadays resemble political debates on TV: everyone has an agenda, everyone is speaking at the same time and trying to humiliate someone else, no one is listening to anyone else and nothing makes sense to the viewer (or the reader of the journal in our case) both of whom just disregard the noise and ultimately do what they feel is correct. Expecting universally acceptable protocols to arise from this Tower of Babel is laughable at best.
Which brings us back to the distracted, but dedicated doctor, whose decisions often have to factor in another variable: cost! Many MNCs have learnt the cost sensitive nature of the Indian consumer soon enough on their foray into the Indian markets. This same issue often plagues healthcare also, especially because a large part of the population was, till recently, still not formally covered by health insurance. This has been rectified in part by the Ayushman Bharat PMJAY scheme which has an ever increasing penetration. However, it is also not the panacea which it is made out to be. The lure of getting something for free, including healthcare, is irresistible for most Indians, a fact which is borne out by the multitudes of well to do patients enrolling for and getting free treatment privileges under such govt schemes. But all that is not the lookout of the physician or surgeon who is just trying to sincerely manage his or her patient. While, offering a treatment which the patient can afford, is looked upon as the doctor’s responsibility, the clinician’s frustration at being unable to offer the best to his patient due to factors beyond his control, very often goes unnoticed.
Also, many of us will all so often advise a medicine or procedure which, in our experience, has given good results, the literature be damned. At the same time ,we are cynical upon reading such recommendations made by others, forgetting that they may be responding similarly to many of our decisions. What goes around, comes around!
Sometimes, decisions taken in good faith do not give the expected results, but help to expose the enemy within. Imagine a scenario where a decision to perform a surgery was taken in good faith but unfortunately, there occurred some post-op complications. There is often a junior who will try to portray you as old-fashioned or outdated, a contemporary who will say that decision was incorrect or the technology used was inferior to what he would have offered and finally a senior who will try to paint you (and other juniors in general) as less experienced, money-minded or even incompetent.
I agree that these statements are scathing and may touch a raw nerve. But there is no scope for outrage, because, admit it, we have all been guilty of professional jousting at some point of time or another. We have all had our moments when common sense receded and our egos made us pass some derogatory or condescending remark about a colleague, which converted a professional difference of opinion (a healthy attribute) into personal vendetta (an ill-advised and unprofessional attitude). Upon reading the previous doctor’s recommendations, the sly smile, the subtle shake of the head in disapproval, the display of surprise or disgust, all are enough to sow the seed of doubt in the patient’s mind. But does one not realize that one has just fuelled a fire which may burn down one’s own house some day?
That we spend more time in our clinics and less in courts of law is testament to the fact that in spite of all these distractions, we seem to be able to keep our minds focused. But, by now it should also be amply clear, that a lot weighs upon our minds as we go about the task of healing.
Further perpetuating the myth of the rational doctor.