The rise of Doctor 2

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I wrote earlier about Rise of doctors and the situation as we have today almost across the world. Of course I am not considering those exceptions where we do not have modern doctors or there is some “messiah doctor “who travels here and there just to help people. This is about any modern city with public/private hospitals, clinics filled with doctors, nurses and so on. Of course the only way I can see the world is through my eyes and my experiences. However, based on conversations and general reading, I am convinced that unless you are not a big player e.g. a big sports person, a rich businessman, a politician or so, you are struggling to get a proper help from your doctor. It does not matter if the doctor is in public health system getting his regular salary or in private setup where he is paid by number of clients or operations per day. The end result is that there are unsatisfied patients, patients in pain out there who do know what to do about it.

Before I list any specific example about the situations, I believe it is good to highlight once more the role of a doctor in our modern, delicate life. Today, doctors a profession is one of the most respected profession. People when they go to a doctor, usually have respect in their mind. Just observe the difference in your attitude when you go to a doctor and when you go to a market to buy a fruit. Do you talk to or treat the sales guy or vegetable vendor the same way as a doctor? I would bet no. If one feels this is not a valid comparison, then compare against a lawyer; do you have the same feeling, same tone in the back of you mind when you meet a lawyer as against a doctor? Today, we believe that “every” doctor is special and we expect to receive some help from him. This is related to another believe that doctors are somehow superior to the rest. It is amazing how we do not consider that “bell curve/Normal distribution” apply to doctors as well. And here I am just considering their professional expertise on what they know. But, how does a doctor interact with a patient, how does a doctor deals with what he does not know are completely another dimensions of evaluation matrix. For some reason we do not consider that a doctor is just another human being is who is molded by his attitude, his politics, his greed, his laziness, his ignorance. On the flip side, it is not just patients who consider doctors as special. Doctors themselves seems to have a special superiority complex simply because they have read some different books than the person in front. They seems to completely forget in their chairs that at other times they are in the patient’s seat e.g. in a lawyer or accountant office. This divide starts already in their education phase, when they have not even become doctors. With that in mind, I would like to consider some cases based on personal experiences. This way, I hope that reader does not believe that I am just making it up.

Attitude (towards helping the patient ):

I think this is the most heavily skewed dimension. If this falls in place it will open up the interactions with other dimensions as well. I was in my college when I first time felt a pain in my back. I went to my doctor and I got some pills. This is all I got. Of course it helped to cover it up, but that was not the solution. I believed the doctor and continued with my life. In couple of years, it developed into a serious back issue that it was hard to walk, sit or sleep. Especially the transition from one state to another was painful. The couple of doctors I went to, all have pills as solution. Thankfully at that time, I was in travel mode and had the habit of buying books on railway stations. There is a bookstore chain “A.H.Wheeler“, that is present on almost every medium to large size railway station in India. From novels, to comics to self help books, all are available there. It was at Mumbai central station that I found these books on back pain. I read those on my travels and started to work as per the method. Within a month I started to see the benefits and in 3-4 months I was playing badminton. We had an inter-university competition that year and our team was 3rd!! The books were also written by doctors. Apparently, he mentions similar reasons that happens in practice as I am highlighting here, as to why people keep on living with their back pains with no solution and unfortunately many cross the line to never heal back.

Similar attitude I noticed, once I had a motorbike accident and was taken to hospital by some kind people. The doctor came saw the “visible wounds” and put some stitches. I told him that I feel there is some problem with my right shoulder. Surprisingly, he just looked at me and declared that it is ok. I had to put pressure and only then he ordered an X-ray!. Now he agrees that my collarbone was separated. He put in some support and sent me home. On the way home, we checked in another hospital to get 2nd opinion. The doctor was known as specialist. He looked at the shoulder, re-adjusted the support and said all is fine. I told him that it does not feel at the right place. His answer was, “Don’t worry, it is a soft joint, it breaks easily and heals easily. If anything is wrong then we are here.” I didn’t know what to say. What do you mean, if anything is wrong, come here? The joint may get fixed at wrong position and I come to you after 6 month, what will you do…. Break my joint again to put it back??? Well, not much can be said, so I went home. During my 6 weeks in bed, we went to couple of other experts in our city for checkup. They also had the same attitude. My collarbone was clearly visible 1-2 cm above the normal position as compared to the other side. Although it was late now, but still when I mention it, the doctor will adjust my shoulder in such a position that it may look similar and would say, here it is, they look the same now!!!!!. No more energy left, I gave up.

I know it all :

The life went on, after about 6 months, I could move my arm, was able to drive car without a lot of pain. Couple of years later the pain I used to get during winter time also went away. With time I forgot about injuries and started to play again. I started to learn tennis, which didn’t feel like much different from badminton, but unfortunately, I did not prepare myself properly before increasing the intensity of movement. One wrong movement again brought back the pain in my back. Of course, the first thing I got was pills. After than I went to available doctors, physiotherapists, chiropractors and osteopaths for more than a year and half. Everyone would believe that they have the solution and theirs is the right one. The normal medical doctor did not even see any problem at all! If I asked what exactly is the problem, I would get different answer. Chiropractor would say my sacroiliac joint is dislocated, physiotherapist would blame the muscles and osteopath would try to link them both. I asked the normal doctor and these “specialists” if they can refer to another specialist, everyone said “No”!

One day, I went to hospital, in emergency, faking high pain as that was the only method to reach the public hospital. The 1st level doctor performed the standard tests and did not see any problem. This I knew already as for some reason those tests didn’t work on me, but I had my own tests that can invoke the pain. To my luck, she said, “I did all the tests that I could and it seems alright. Let me call my senior to check”. Five minutes later another doctor came. She asked to take off my pants/trousers ( Don’t get any wrong ideas!! 😜) . She then took a bird feather and moved it along the outside of my right upper leg and left upper leg. She asked if I feel any difference in sensation. I told here yes, I do. She immediately asked for MR and few days later we knew that I have discuss hernia in L4-L5!

Now simply because others were not willing to accept that they cannot help me, they won’t collaborate or refer me to someone else. That caused me to go through more than a year of manipulations and adjustments without even establishing the base of the problem.

Maybe someone have an assumption that this maybe the case in India or other developing countries. Let me clarify that all the specialists I visited in relation to discus hernia was in Switzerland.

Laziness :

Laziness is one thing we are all prone to. Isn’t that why a lot of us would take a motor-vehicle even if we can reach by foot or a bike? We would take our own vehicle rather than public transport, because it is convenient. That trip could be to go to a meeting about carbon footprint. Doctors are not immune to laziness and they cannot pick and choose when and when not to use it. This creeps in their work too. Many a times you go to a doctor, they are just waiting to close the topic and move on to their break or shift to get over. They probably would half listen to you and say, “oh, it’s nothing. Just take rest” or “It’s just in your mind”. It might be a valid analysis in some cases, but what is the patient suppose to do, if it is “just in mind” ?

I was once at an osteopath and later at a chiropractor for my collarbone dislocation. In this case it was for the left shoulder. Apparently, I was unsatisfied with this “inequality” of having just one collarbone out of place 😂. Only that in this case, I had no idea what happened. I did not have any accident or fall or any heavy work. They both told me,” Oh, it happens. Nothing special about it. One can dislocate collarbone even when lifting a cup of coffee..”. Now, I am not denying that it cannot happen, but to what %age of people does it happen?; what is wrong with them that it happens?; what kind of predisposition they have to get injured so easily?. For me, it is easy to make a vague statement, which can be valid in very small population and get out of the discussion. Because to find a root cause and then develop a solution would take a hell amount of time and effort, why bother?

( In case any one is thinking alright, Swiss is special and they are just constrained by their rules and specification, so nothin special. The above 2 doctors were in Italy and Germany)

I had an even simpler situation. I got a blood test done and got a report that says deficiency in Vitamin D. I went to family doctor, who sent me to as pecialist that has the authority to prescribe Vitamin D pills. Specialist wrote me a prescription and said that we will do a test in 6 months. Apparently prescription was just for 4 months! There was a control for which some other doctor came. As soon as I entered, it was clear he wanted to close the topic and send me home. He told me all is fine and no more visits needed. As we met for the first time, I told him that I have Vitamin D deficiency and we were supposed to test the current status. Without looking at any report, he said oh that does not make sense, you have a dark skin like me and we get lot of Vitamin D from sun. Now I would have liked to say, ” Dumbass! Check the reports before you open your mouth!” Instead, I said, ” I understand one takes Vitamin D from sun, but in my case I have deficiency and here is the report. He looks at the reported value and asked where are the references; apparently he could not find it on a report written in English. When I showed it to him, he made strange statements, ” oh, in India you guys do too many unnecessary tests!!”. Then he adds, “values can change based from day to day, season to season. They are really not that meaningful!”. Finally he says,” if you have deficiency, then you can take those pills for 2 years and not just 4 month!” . To get prescription he asked me to contact my family doctor, who apparently does not have the authority to write the prescription!!!!. Can one get more lazier than that? Maybe.. ( This is the case in Croatia).

Economy :

There are different opinions about how economy works especially when it is related with human motivation. There is stick and reward model and the recently Universal Basic Income model also, which seems to assume that people somehow love to work. In the world of medicine there are mainly 2 models. Public sector model; Doctor get paid monthly salary, does not matter what he/she does. Private model with 2 variations. One where a Doctor has his/her own clinic, another in a private hospital, where earnings can be related to throughput of patients/surgeries etc.

In both cases, doctors, as any other human, are bound to be effected by other human attributes e.g. greed, profits, rat-race, competition etc. In a public health system, it is quite often that the same doctor has a private operations running somewhere. Doctor in that case is not interested in taking care of the patient, as he knows in that case one or other way patient may end up on the private side and he get additional money. In the public institute, he gets his pay and goes home. Most of the time he may be distracted by calls for his private work or his own thoughts and plans about it.

In the private sector, while one can say that “open marketplace” would make it competitive and would make doctors more accountable for their work. But, its gets into muddy grounds very quickly when hospitals and investors are involved to up-hold their reputations. You take an appointment with a doctor. He listens to you probably for 5 minutes, either gives you his diagnosis without additional inquiries or will send you to do some tests. This 5-10 min may cost you from 50-100 USD!. What did you get back as a result? To pay more money to get some tests, which at times are not needed? Why not just do the tests anyways and come to doctor thus saving cost of first visit?

Just to complete this section with an example. As a follow-up for my shoulder problem, I was in private Orthopedic clinic, the guy said, it is ok, just take rest and that would be 50 dollars! I know that already! I am here to know if there is reason for it and something I might to do to safeguard it further. Unfortunately, after a couple of month I got a pain in my right inner thigh muscle. I went to him again and told him that I have history of discus hernia and recently I had shoulder issue. Are these somehow related? In 5 min I got the answer, they are not related but are independent injuries. Especially the thigh is caused by repeated use injury!! I was in shock, what do you mean repeated use injury? I play once a week now and just normal walk to buy groceries or so. Answer came immediately, that it could be from previous repeated use, manifested now, just take rest. He calls for next patient and I get a bill of 50 USD!

I tried the public institute method, as someone mentioned about a famous successful doctor. I waited for 4 months to get an appointment. She also, being popular, had no time. I told her my story in 5 min, she checked in 2 min and says seems ok and I may have issue today because of the right shoulder injury that happened 15 years ago, which left an imbalance in my body. For that, they do not have a cure in the system, but her friend runs a private shop with a special therapy and I can contact her and “see if that helps”!. At that time I was already doing a lot of reading and asked her, if she would do the Vitamin D test. She said,” We did the tests needed. There is no need for Vitamin D”. Now, I do not know since when I developed Vitamin D deficiency, but after about 1.5-2 years of that meeting I found out that I have Vitamin D deficiency!!!!

System :

This one of course is favorite of us all. Patient and especially doctors would like to pick it on every given day. In one way insurance companies, with expectations of people, managed to make insurance a mandatory part of income cycle. Maybe there are benefits, but it in-turn increased the cost many fold as we moved away from direct payment and accountability. I saw it at my place as insurance became more and more prevalent, the cost of medical services increased. An operation that used to cost lets’ say 100 USD suddenly started to cost 5000 USD!!! Simply, because this would be paid by the insurance company when needed. People did not mind paying 200 USD every month to insurance in order to get insurance that in case needed, which of course can be tomorrow as mentioned by insurance guy, insurance company will cover the cost of 10000 USD! Now when the medical industry sees this, they increased their price. I remember, once I went to a private hospital in New Delhi and the doctor advised me to take single room or max double for patient and not dormitory. When I went to check, the administrator staff said, they do not have single room, but they can give me VIP room at the same price. I got the details and saw that in distribution of cost, the cost of operation also increased as the level of “room” increased from dormitory to VIP. I asked, why is so? Is the doctor going to do any special operation in single room than what he will do in dormitory? Answer was, “Sir, operation will be the same. Why do you worry, anyways you have insurance, the company will pay it. Here is your form, so that we can directly send it to the insurance company”…. By the way dormitory there was just 6-8 beds!!

Another way I see system failing is that a patient, unless a lawyer or some big-shot, has no way to go against doctor, if things are not going right. E.g. in the case of Vitamin D I mentioned above, what action can I take against the doctor? Most probably it was not just me and the same is happening to others. If there is a procedure that even exists to report such incident, people are generally not aware of it. In case, it exists and one is aware of it, how to take it forward? What proof can I show that the doctor behaved like this? There are no CCTV cameras. If they are, they are the property of hospital/clinic. Let’s say you go to doctor, give your details. He writes in journal, what he wanted to write and not what you said. If you make a complaint and ask to check the records, it does not exist anywhere. This is one of those service industry, which is not based on aligned and approved documentation of requirement/problem statement and solution delivery. You cannot argue or make a case that “your” problem statement is not addressed. Of course one may say that doctor’s need to write in their “own language”. I would agree to that, but it does not mean that the original statement is filtered and recorded as per the understanding, awareness, alertness, knowledge and skills of a given doctor. Next month, a new doctor may come and you would have to start it all over.

Missing collaboration is another problem with the system. For different reasons, doctors and specialists do not want to collaborate, even if they can. In a private setting, one can understand that it simply means that I am losing my earnings to someone else, in case I refer it to next doctor. But even in a multi-specialty hospital or a public hospital, where there are different experts and usually not bothered by financial constraints, such a collaboration is missing. There it comes to overlapping expertise, different of opinions and clash of egos among other factors listed above. E.g. if you have an operation of a joint or muscle injury or something. Very often, the surgeon performs his task and patient is asked to relax for some time and that’s it. There won’t be any integrated process of physiotherapy, psychological or other therapies. If you ask for it, you may be referred to one, but without any passage of internal notes. As a patient you need to explain the whole situation once again to the next therapist, to whom you might just be able to explain that you had an operation of hip e.g. Will the patient be able to inform which specific muscles/tissues/ligaments/tendons were affected? I would say No!. What would you think will happen if the Queen of England or Mr. president get a small pain in the neck? Will it be the code of medical ethics driving that effort and care or the sheer power of the patient?

There are many ways and reasons in which doctors have managed to achieve this reputation. No doubt, that it is also based on very well meaning science and intentions to help the mind kind. However, like any other power or ideology, we forget that when it is released, it will also be used by those people who would not share the same empathy, ideology, intentions and motives of those who created it. Doctors and the related system is not immune to this. They share the same genes, and live in the same social system where they can be lazy, greedy, self-centered, ignorant, unethical, politically biased and power hungry. Today even in the doctor’s (especially the scientist) world the progress is challenged because of the integration of economic system. Some technologies are not favored or funded simply because it will impact the financially invested companies and not because of the lack of merits of it. But, that is another fight and in one or other way we have been in that fight and it will keep on fighting.

However, I would hope that doctors as “that superior lot” can change themselves simply in a way that everyday when they go back home, look into the mirror and ask themselves, ” Did they do everything they could to help the patient?” If they did, “will they be satisfied if some other doctor did the same to their father/mother/son/daughter?” Maybe this will start to bring some change in the life of patients who are running around from office to office and tired of being moved from one counter to another. Maybe we would see some smiles on the faces when they leave the doctors office rather than puzzled/stranged/confused look.

Keep Smiling

Love

Arundeep Singh

“That pain in your leg is caused by old age,” the doctor told Mulla Nasrudin. “That can’t be,” replied the Mulla. “THE OTHER LEG IS THE SAME AGE AND DOESN’T HURT A BIT.”

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