Doctor-patient relationship: the importance of the patient's perceptions.SK Pandya
Department of Neurosurgery, Jaslok Hospital & Research Centre, Dr. G. V. Deshmukh Marg, Mumbai - 400 026, India. , India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 11590282
Source of Support: None, Conflict of Interest: None
Keywords: Confidentiality, Human, India, Knowledge, Attitudes, Practice, Patient Advocacy, Patient Participation, Patient Rights, Physician′s Practice Patterns, Physician-Patient Relations, Social Perception, Treatment Refusal,
Indian Express Friday, 12 January 2001
Mumbai, January 11: Fifty-year-old Dr. Vasant Waman Jaykar, who was attached to Jaslok and Lilavati Hospitals, was shot dead at about 1.30 pm after he was leaving his dispensary in Latakunj Building, 12th Road Khar.
Indian Express Wednesday, 17 January 2001
Commissioner of Police MN Singh said the murder of Dr. Jaykar was fallout of a deceased patient’s relative seeking revenge. It is believed that prime suspect Deepak Sewani nursed a grievance against Jaykar for the death of his younger brother Ball, who was suffering from cirrhosis, a chronic disease of the liver in February ’99.
Indian Express Sunday, 21 January 2001
Mumbai, January 20: With the recent killing of known city cardiologist sending shock waves in through the medical fraternity, various medical organisations have decided to get their act together and start awareness campaigns to educate patients and to bring a general improvement in the doctor-patient relation.
According to Dr Lalit Kapoor, spokesman, Association of Medical Consultants, doctors of today are more guarded today and tend to go for a lot of investigations and tests, which has resulted in a huge increase in cost of treatment. With practically every patient being referred for a CT scan, ultrasonography and MRI, the pinch is already being felt by the patient, who tends to blame the doctor for anything that goes wrong, he said.
It should also be remembered that a consultant does not have to be with the patient throughout the day, and his job only is to diagnose the problem and then prescribe the treatment, Dr. Kapoor explained. It is the junior doctor who actually administers the dose or gives the injection, and this is misunderstood by the patient, he said. In this age of telemedicine, when consultants in other cities diagnose the problem and then give treatment, how can a patient expect a consultant to sit with a patient for long periods, he pointed out.
Commenting on this situation, Dr. VH Vihurkar, general practitioner, said that patients often feel that they are being fleeced by the doctors and this goes contrary to the earlier image of the doctor working without any profit motive.
Indian Express Sunday, 21 January 2001
Dr. Arshad Gulam Mohamad
There is a genuine grudge held against certain doctors that they have attachments to multiple hospitals and cater to too many patients at the same time. This is true of many top consultants and their patients do suffer because of this. Such busy schedules prevent these doctors from spending a little time with their patients to explain to them their ailments and discuss the modalities of their treatment. A poor communication skill is another problem the medical profession is afflicted with. Because of this there are misunderstandings, heated arguments, inflamed passions and even litigations. The doctor-patient relationship is under severe strain at this point of time. And unless both doctors m well as patents understand every nuance of this relationship, Jaykars and their patients will continue to suffer.
Bombay Times, 23 January 2001, Page 1
The murder of Dr. Vasant Jaykar has brought into sharp focus the doctor-patient relationship, which, from a close-knit association, has transfigured into one filled with mistrust and doubt. Roshni Olivera spoke to Consumer Activist MR Pai for his views.
RO: What are the common grievances of patients today?
MRP: The biggest grievance is that people do not have a proper forum under the Indian Medical Association to register their complaints. There is no proper machinery, which can ensure that a patient’s grievance is listened to expeditiously and in a just manner.
There must be a machinery with a doctor and two others who are non-doctors to address problems. So, also, patients often feel that they are not getting enough attention from the doctor who is handling many cases at the same time. Problems occur when there are tests involved and hospitalisation entailing surgical and other complications.
RO: What about the complaints of too many referrals by doctors and information not being provided to patients?
MRP: Yes, these are some of the common complaints. Too many referrals by a doctor put a financial strain on the patient. There is also the problem of doctors not giving patients their case papers and adequate information when they are entitled to it.
The fact is that many doctors are weak in documentation, despite there being good computer software packages, which can help them, keep track of all information.
The Times of India: 26 January 2001: Letters:
The much-publicised outrage expressed by doctors in the city seems rather unjustified. The reported admission of some senior doctors that they had received extortion threats recently calls for some serious introspection on their part, especially by top-ranking consultants.
Can all these worthies honestly declare that the charges that some of them extract from their patients does not amount to a form of extortion? In fact, we are reminded of an incident a few years ago when a senior cardiac surgeon in Mumbai was reportedly assaulted by the frustrated relative of a patient who could not afford his exorbitant charges.
Even the demand by some doctors that the police should take steps to ensure that members of their profession are not harassed by anyone is shocking. Indeed, why only them and not every citizen, irrespective of his/her profession? It is high time the upper echelons of our medical fraternity take a more compassionate view of the community they work with instead of adopting a demi-god like status.
Amarnath Kamat, Mumbai
Once deemed to be a truly noble profession, medicine today is perhaps amongst the most commercial professions after politics. Today, doctors treat patients as if they were milking cows rather than fellow human beings. The notorious ‘on-money’ charged by specialists is nothing but a form of extortion. Some doctors charge you from Rs. 200 to Rs. 500 just for writing a two-line prescription. God forbid you should ask some more queries about your illness - and don’t be surprised if you are shown the door.
B. R. Singh, Mumbai
The respect from patients and their families generated by doctors in times past has been replaced by suspicion, distrust and anger. We are no longer confidants of the patient and his family. Our statements are subjected to multiple verifications. When the patient’s treatment comes to a close, there is often no display of affection or satisfaction by patient or relatives. Instead, there is evidence of a sense of being cheated or swindled.
The blame, in no small measure, falls upon us. In the past the term ‘black sheep’ was used to denote a person who causes shame or embarrassment because of deviation from the accepted standards of his or her group. What term do we use when the entire group’s standards have deteriorated unacceptably?
The number of medical professionals who flout the norms of medical ethics has grown exponentially over the decades. The rest of us have failed to do anything to stem the rot. Statutory agencies such as the medical councils, established to ensure that we adhere to the highest professional standards, have, themselves been riddled by corruption and inefficiency. Our national and state bodies such as the medical associations, academics and societies have turned blind eyes to malpractices.
Our misdeeds -acts of commission and those of omission - are now recoiling upon us. Aggrieved patients and their families are no more content to suffer in silence. Earlier they would bring their plaints before the administrators of the hospital or medical college. Later, sanctions were sought from courts of law. As these means for obtaining redress became increasingly time-consuming and inefficient, some have resorted to extreme measures - threats, destruction of property, violence and, in Dr. Jaykar’s case, murder.
Dr. Arun Bal and his colleagues at ACASH, Mumbai, have analysed scores of complaints against doctors made by patients and their families. In almost every instance, when the facts of the case were analysed in a transparent manner by independent doctors and explained to those making the complaint, annoyance faded and aggression subsided. When, for instance, it was shown that the doctor had, indeed, done everything humanly possible for the patient and that death was inevitable, given the nature and extent of disease, the family readily accepted the explanations. They were now asked whether they wished to proceed to judicial action against the doctors, a common reply was, “Why should we? We have no ground for complaint.” “Why, then, did you protest in the first place?” “Because the doctor never explained the situation and the treatment provided in the way you and your colleagues have. The doctor had no time to talk to us, answer our questions or keep us informed about how our patient was faring. We were not sure that he had done all that was possible for our relative.”
The relationship between doctors and their patients is manifestly unequal, in favour of the doctor.
The patient is sick, miserable, in pain. He is ignorant on matters medical. He is afraid of his illness and fears the worst consequences. He is worried about expenses, whether he will be able to return to work and the handicaps he may have to overcome.
He comes seeking help, guidance, relief and, if possible, cure from the doctor. He places his life in the doctor’s hands.
Under these circumstances, the principle of equity demands that the rights of the patient take precedence over those of the doctor.
Autonomy: In essence this principle holds that the patient has total control over his self and what can be done for and to it. The doctor may advise, based on knowledge, experience and wisdom but it is for the patient to accept or reject such advice.
Confidentiality: All exchanges between the patient and his doctor must remain confidential. Information about the patient or his illness may be passed on to a third person only after obtaining the patient’s consent. Whether or not the third party is paying for the patient’s tests and treatment is irrelevant.
Beneficence: All advice offered by the doctor must have, as its goal, the welfare of the patient.
Non-maleficence: The obverse of the above principle: the doctor will not do anything that will harm the patient.
Justice: Given the scarcity of resources, their allocation will be on the basis of the patient’s needs and prospects of improvement under treatment. Station, political might, wealth, caste, creed and other such factors will not play any role in decision-making.
· This is a legal entity.
· It is dependent upon the mutual willingness of the patient and doctor to form an alliance for the health and welfare of the patient.
· This relationship can be terminated by either party. In the event of an emergency, the doctor is duly bound to avert the crisis before terminating the relationship.
Every patient has the right to expect reasonable medical skill and care from his doctor.
This legal term includes
· a careful and detailed clinical examination,
· the ability to arrive at the correct diagnosis,
· relevant tests at the least possible expense,
· a request for an expert or senior opinion from another doctor when the situation is beyond the examining doctor’s competence and effective care so that a cure is achieved where possible and relief provided in other cases.
Such skill and care implies a concern for the patient’s welfare.
The patient, like every individual seeking help anywhere, is also entitled to prompt and courteous attention, especially when the illness is grave and distressing.
In practical terms this means an unhurried consultation, undisturbed attention to the patient’s symptoms and narrative, judicious use of tests (bearing in mind the escalating costs all round), referral to other doctors only when necessary and use of the least harmful and least expensive forms of therapy.
Unfortunately, increasingly effective means of therapy have prompted the physician to move from the healing of dis-ease to the treatment of disease. Consultation times are being progressively reduced.
Questions from patients and relatives are discouraged. No one has the time or the inclination to talk to worried relatives even when the patient is dying.
The patient is entitled to an explanation of the nature of his illness, the reason why one or wore tests are being requested, what may be learnt from them and the rationale behind the drugs, surgery or other procedure/s recommended. In each case, the pros and cons must be clearly spelt out in simple terms and possible hazards explained.
The patient and his family have a special right to information when events take a turn for the worse. When the patient’s condition is critical, the family, must be kept informed of the patient’s condition, reason/s for worsening and what is being done to help him at every stage, They also have a right to prognosis, especially when this is grim.
The patient has a right to the maintenance of an accurate medical record to which he has access when necessary. Certainly, he has a right to information on his blood group, allergies and hypersensitivities, illnesses, findings on investigation or surgery and prescribed therapy.
The right to information entails transparency on the part of the doctor in all his acts concerning his patient.
· This is the basis of doctor-patient relationship.
· It ensures accurate, detailed history.
· It is especially important when the patient has a disease such as infection by HIV.
· The rule of confidentiality is not absolute. It can be breached in the interests of public safely or the health of those around the patient.
The patient has a right to seek a second opinion.
The doctor must lay aside personal feelings and act in the best interests of the patient by providing a detailed referral note and request opinion, advice.
In case the doctor feels that the person whose opinion is being sought by the patient is not the right consultant, he is at liberty to suggest others, Should there be a disagreement which is not acceptable to the doctor, he should terminate the doctor-patient relationship and ask the patient to proceed to the other doctor for further treatment.
The patient has a right to refuse any or all of his doctor’s suggestions but in doing so he takes upon himself the responsibility for the consequences of such an act. A doctor, handicapped by such refusal may decline to continue to look after him and recommend that he seek treatment by some other doctor.
The patient has a right to expect that all charges are itemised so that he and his relatives know how much has been charged and for what. He has a right to a receipt for every payment made.
The ability to talk to patients and their families has to be acquired and needs effort.
This ability is based on:
· understanding patients’ worries and concerns
· a willingness to express empathy
· a willingness to encourage patients to take an active role in discussing options in care
· a willingness to negotiate differences of opinion when necessary
We must talk with the patient and his family not to convince them to do what we desire, but rather to understand their concerns. Decisions can then be made that are acceptable to them and to us.
Many worry that such discussions may mean spending more time when we are already in a rush. Others may feel frustrated that they are ‘wasting’ time on financial or logistic aspects of health care rather than focusing exclusively, on medical concerns.
In fact, such discussions do not decrease efficiency and may actually save time in the long run by avoiding patient dissatisfaction. By involving the patient and family in all decision-making processes, we are also ensuring compliance and willing cooperation. Most important of all, we shall make friends instead of generating resentment and suspicion.
When I was a child, the family physician didn’t even have penicillin. Treatment for most conditions was symptomatic, palliative.
Physicians were graded not on skill (with the exception of surgery), but on how they dealt with us. The doctor’s role was often similar to that of the priest - a compassionate handholding against fate’s furies whilst doing all that was possible.
Patients trusted their doctors and recognised that much of life is not ours to control.
We have lost this trust and the faith of our patients. As a consequence, risks and adverse effects receive much higher priority, in the minds of patients.
We need to look deep into our own deeds to seek the causes and eradicate them. It is essential to restore a trusting relationship between physician and patient. This is the bedrock of medical care.
We cannot hope to do so as long as we prefer our own interests over those of our patients or as long as we’re mindless of their needs and fears.
If present trends continue, patients and their relatives, empowered by the huge mass of data available on the world-wide web will inevitably and increasingly snatch authority from the physician. When the clinical situation takes a turn for the worse, the blame will be squarely placed on the physician and ‘appropriate action’ taken against them.
Do we want others to suffer Dr. Jaykar’s fate?
An old woman having lost the use of her eyes, called in a physician to heal them, and made this bargain with him in the presence of witnesses: that if he should cure her blindness, he should receive from her a sum of money; but if her infirmity remained, she should give him nothing.
This agreement being made, the physician, time after time, applied his salve to her eyes, and on every visit took something away, stealing all her property little by little. And when he had got all she had, he healed her and demanded the promised payment.
The old woman, when she recovered her sight and saw none of her goods in her house, would give him nothing.
The physician insisted on his claim, and. As she still refused, summoned her before the judge.
The old woman, standing up in the court, argued: “This man here speaks the truth in what he says; for I did promise to give him a sum of money if I should recover my sight: but if I continued blind, I was to give him nothing. Now he declares that I am healed. I on the contrary affirm that I am still blind; for when I lost the use of my eyes, I saw in my house various chattels and valuable goods: but now, though he swears I am cured of my blindness, I am not able to see a single thing in it.”
Aesop. Editor George Fyler Townsend - 1880.
During the release of Ms. Rohini Nilekani’s book - Stillborn - a medical thriller - there was a panel discussion on medical ethics in Mumbai. Over the preceding few days, the newspapers had carried prominent reports of assaults on medical practitioners by goons in the city at the instigation of aggrieved patients.
A well-informed gentleman in the audience asked a question: “A relative has been mistreated by a doctor. What avenues does he have to seek redress?”
A member of the panel suggested the Maharashtra Medical Council and, failing that, the Medical Council of India.
“What are the chances of the patient obtaining a fair and prompt hearing? Will these august bodies take immediate action against the erring doctor? How many doctors have been tried by these august bodies and of these how many were found guilty in the past decade?”
“Alas!”, confessed the panellist. “Both these bodies are inefficient and ineffective. To the best of our knowledge few doctors have been tried though several complaints have been brought before these agencies.”
“Is there no other avenue for my relation?”, asked the gentleman.
“Well, there are the courts of law,” started the panellist.
“I’m afraid that’s a non-starter. I should know.”, said the gentleman. “The courts are clogged and no decision can be expected for decades.”
The panelist shrugged
Then came the bombshell, delivered only half in jest by the gentleman. “In that case, perhaps the underworld has it right. It might be best to bump off the offending doctor.”