Reflections on the doctor-patient interaction

Last week, I shared two interesting articles on this blog, one of which was the transcript of an interview with Dr. Eric Topol, author of the book, ‘The Creative Destruction of Medicine’. Buried in this article was a very interesting question posed by the interviewer :

Is there a possible irony that in using all this technology to “personalize” medicine you “depersonalize” it instead ?

A valid concern indeed! While the advances in science and technology make it possible to treat every individual’s physiology as unique and we now often have the means to tell apart conditions that are symptomatically similar but in fact are different diseases altogether, in all the exhilaration about the advances in medical science we tend to forget that there’s a person-to-person connect that we humans yearn for – especially when faced with bad news, and this seems to be slowly reducing.

A few years ago, a friend’s father developed an eye problem that needed surgery. It was complicated and he was referred to a surgeon well-known for his expertise in the field. The surgeon examined him, confirmed the diagnosis, scheduled the surgery and then – undoubtedly with the best intentions – blandly told him to be prepared for the worst as the operation had a high failure rate. As luck (and the surgeon’s skill) would have it, the operation was successful and the gentleman is fine now. However, his children still remember their father’s distress at hearing the news and wish it could have been presented in a gentler, more humane fashion; at that time I remember that they bubbled over in anger and resentment at the “cold, heartless” surgeon.

I’ve heard similar versions of this story from multiple people that met a thoroughly competent but not-empathetic-enough doctor/ surgeon/ other clinician. Not just those suffering from an ailment of some sort, even pregnant women that visit their gynaecologist voice a similar desire for time, information, and most of all, reassurance.

Partly, our frustration and distress stem from the fact that as patients or friends and relatives of patients, we want the Doctor to be everything, Superman almost. We hanker for the simple comforting relationship and degree of involvement of earlier times, but with all the benefits of better diagnoses and effective medicines that are available today; we want the caring demeanour, the reassurance, the generosity of time that an old-fashioned family doctor gave; yet we also want this person to have the skills and knowledge of a specialist, to have invested the time to be up-to-date with all technological and medical advances and to have the latest scientific facts at his fingertips. Occasionally, we meet such people, but they are rare. It’s a very fine line between doctors telling the patient as it is and being positive about the outcome to keep the patient cheerful and positive. Unfortunately our medical system does not train well for this ‘fuzzy’ part of medical care, and hence it is up to individual doctors how they deal with it.

One that does it very well is an orthopaedist called Dr. Niranjan Deshmukh at Lilavati Hospital in Mumbai. Multiple people that I know have been to see him for various back, shoulder and leg injuries and have given glowing reports of their experience. Apart from a calm reassuring manner, this Doctor also spends time with patients explaining to them why they are in pain, the cure needed, how long it will take etc. He uses 3-D images of our skeleton with the network of muscles and nerves over it to give detailed explanations of the reason for the pain, how it can be mitigated and means of preventing a recurrence.

I think it is time to acknowledge that such Doctors are the exceptions and build a system for the norm; one that is built around our needs as patients for more information to help us feel a bit more in control, for reassurance, and of course, for guidance and treatment. As Dr. Gawande says in his article, we need pit crews.

In some ways, hospitals are beginning to respond to these needs. Some hospitals address this through talk sessions that all their patients and their families can attend. Sometimes, for metabolic ailments, a doctor and a dietician work as a relay team for diagnosis and then ailment management. Additionally, one member of the pit crew could also be a trained medical counsellor, contributing the ‘time to care’ component of ‘quality of care’; someone who would help patients and their family members traverse from denial and anger to acceptance and solution-seeking, giving them all the information they need so that they can make sense of the situation – explain what’s happening, understand treatments available, sort through options etc.

Of course, one key question is that of the payer for these services and to what extent they can be rolled out in a country such as India where large swathes of underserved or un-served populace lack access to even basic medical care. Nevertheless, I think we need to push ahead on both fronts, improving quality of medical care and the overall experience and increasing access.

  • Zenobia Driver

 

2012-05-28T06:19:52+00:00

20 Comments

  1. Richa May 29, 2012 at 6:33 am - Reply

    There are so many things wrong with medicine the way it is practiced that I don’t even know where to begin.

    When I buy a book on Amazon or Flipkart, I can see the ratings and comments by hundreds of customers. But when I need to choose a doctor, I have to rely on the inefficient and inadequate method of asking friends, with whom I may or may not want to share my ailments. This is true whether I am trying to find a GP or a surgeon. And after seeing the doctor, there is no way for me to rate him or her even mundane things like whether or not he shows up on time to the clinic! But I can find gigabytes of feedback about whether the keypad of a laptop model become sticky.

    Different people look for different things from a doctor: some may want the reassurance of the (imagined) old time family doctor, while others may prefer a “just give me the facts, I’ve brought my own sugar coating ” approach. Why assume that we have the same expectations from doctors while we have entirely difference preferences for the texture of our cookies or the preferences on our Facebook accounts.

    What we need is a thorough modernization of medicine inside out, not just from a technology (digital vs human interface) perspective but thinking through which aspects of medical care would benefit from more information and which aspects would benefit from more customization and personal choice and preference.

    We talk about customer segments and behaviour for all consumer products, but what about the ultimate consumer product — the one that determines our life and health?

    • escapevelocityblog May 29, 2012 at 7:41 am - Reply

      Hi Richa,
      Thanks for the lengthy comment. Agree with you on most of it.
      🙂 Am not sure doctors would welcome the thought of being rated by patients, but I like the idea, at least to the extent of some patient-friendliness and general efficiency parameters.

      Since not everyone reads comments on the blog, I’d like to run yours as a post, quite a few interesting thought-starters there. May I ? Would you want to add anything more to it first ?

      Regards,
      Zen

      • Richa May 29, 2012 at 6:44 pm - Reply

        Sure, go ahead. There are several typos and grammatical errors that should probably be fixed :).

        • escapevelocityblog May 30, 2012 at 4:31 am - Reply

          Thanks, Richa.
          Saw your mail too, will use the corrected version.
          Regards,
          Zenobia

    • Nana June 28, 2012 at 10:50 am - Reply

      Thank you for sharing your story, it raelly is an amazing feeling when someone really figures out what is going on with you. I also had seen many doctors and was written off all the time until finally I got a doctor who was intelligent and actually paid attention. It’s a relief to get a real answer, even if it’s a bad one.

      • escapevelocityblog August 29, 2012 at 1:22 pm - Reply

        Hi Nana,
        Glad you liked the post.
        Yes, your sense of relief at the end of a long process of finding a good doctor is understandable.
        Hope you keep visiting the blog.
        Regards,
        Zenobia

  2. Rahul Jhaveri May 31, 2012 at 10:11 pm - Reply

    Interesting article. And Richa’s comment is thought-provoking.

    It is something all of us deal with – going about trying to find the right doctor. There is often one doctor who is the golden boy (or girl) in a particular field who everyone wants to consult. Apart from this doctor there are usually four or five noteworthy alternative doctors based on different criteria people prioritize (better for personalized attention, more accessible, younger etc.). But all this decision making is loosely based on anecdotal information you gather from relatives and close friends. At times you just don’t have the time or the patience to pick from a short list do you stick with the assumed gold standard – someone everyone in your family seems to go to for instance.

    As Richa mentioned – in the ultimate consumer product there is very little information available on what is good for you and what is bad for you. I believe this isn’t only the case for doctors in India but the world over – a small network of recommendations and references drives you to “settle” for what you are made to assume is the best option without knowing what other alternatives are out there.

    In our family it is our GP who is considered the most important decision making in matters of health. He would refer us to his network of specialists not only because they are good in their respective fields but also are accessible to him whenever required. It is like having a glorified concierge service where no matter how the specialist is in interacting with the patient, we have a representative who is there to be a communication buffer. Even though I question some of his references at times I would rather not move out of his “network” because then I would feel like we would be in unchartered territory. I am sure this is a common phenomenon in medicine in India. It can be aggravating at times but there is no escaping it.

    As much as it seems like a perfect idea to have access to different people’s rating of particular doctors based on different criteria – I would be the first one to compulsively rate everyone I have ever visited – I think it woud end up confusing people even more. As Richa rightly pointed out – people have different preferences and what works for one person might not for another. A more effective model might be something which recommends a doctor to you based on your past preferences for other doctors. However, that would require a large pool of data, and a lot of information which might not necessarily be easy to capture or quantify. And even if there is a service like this available to us, how likely are we to make a decision based on it?

    Choosing a doctor is different from picking a film, a book or a hotel – perhaps because we NEED to put doctors up on a pedestal. It is an emotional decision, something which we can not decide based on a set of quantifiable criteria. It is much like picking a home, choosing a life-partner, or buying a pair of expensive shoes – other people’s preferences go out the door after a point because it is a decision which you would have to stick with for a long time.

    I apologize for my perpetually long comments. I’m a terrible editor.

  3. G.IMAM July 8, 2012 at 3:02 pm - Reply

    I was desperately in need of consulting an orthopedist for my wife who has developed knee pain for the last 3-4 months. My earlier experience with Hinduja Hospital has been terrible. I had taken appointment for a leading orthopaedist. . After waiting for about 10 days for the appointment date , we went to him. Surprisingly, after having a glance at my wife( he did not even discuss with her the pain she was suffering from, he only made her walk just 4-5 steps) he immediately told us to visit the another doctor ( a psychiatrist) and then come back to him quickly .We obediently followed his direction and had to pay another Rs.850/- to visit the psychiatrist. He called my wife into his cabin and asked me to stay outside. After sometime he called me and asked some unrelated question about my wife I dont exactly remember. He then prescribed some medicine which the chemist later told that they are sleep inducing (I am not sure about the authenticity of chemist’s statement, we did not buy that medicine) . We then again went to orthopedist with psychiatrist’s prescription he did not comment and again without examining my wife he asked his assistant doctor to scribble some medicine on the prescription which we later purchased . That cost us around Rs.5000/-. My wife consumed those medicine without an iota of relief. The haphazard manner in which a leading orthopedist of Hinduja Hospital handled us was really terrible and shocking. Looking back we just feel that our money{Rs.5000 (medicine)+ Rs.850( fees) + Rs.850 (fees)} gone in the drain.

    We felt like being cheated . We obediently followed what the doctor said thinking that he will do what is best for his patient but were very much disappointed the way we were treated. Meanwhile my wife continued to suffer from the pain . We were thinking of consulting some other doctor. I was just searching for the doctor on the net when I stumbled upon the piece above written by Zenobia Driver on 28th May 2012 in which the author mentioned his/her experience with a doctor in Lilawati Hospital . Reading the piece above about the orthopedist in Lilawati Hospital (where celebrities like Amitabh Bachchan is treated) we thought we have got our saviour and my wife will be hopefully relieved from acute pain she was suffering from. We immediately got in touch with Lilawati Hospital and to our antonishment got appointment for him the next day. No doubt, the doctor examined her very well and explained the reasons behind the pain my wife was suffering from. He then told that he will take the fluid from her knee for investigation and after the result he will start treatment. That looked logical but I just enquired whether taking the fluid from her knee will be painful. He said no , it will be just like any other injection. I agreed. I had in fact taken a printout of the above article and showed to the doctor . He became very happy and told that he did not know that people write such good things about him. I gave him the printout and told him that he can keep it. He then told me that he is about 99 per cent sure that this pain is due to rheumatoid arthritis and told that he would inject some medicine in her knee and she will not feel any inflammation/pain in the knee for about 8-9 months . I then asked him “Sir, will it not be ok if you inject that medicine only after you get the investigation report of the fluid “. He told that that will be perfect thing to do but asked why you want to put her to pain twice . He told that he will inject her for taking out fluid from the knee and also give her injection (kenakort 40 mg) in the single sitting. He further told that the injection will give her relief for 8-9 months . Still I was hesitant but on the prospect of my wife getting relief from pain for 8-9 months , me and my wife agreed to it. He then asked us to proceed towards path lab and wait . He came after sometime and went inside the lab, then came out and told that the lab is busy for some bone marrow extract from a patient, so you wait. We said ok , we shall wait. After 15-20 minutes he came again and told that the lab is still busy and asked me to follow him. He then told me that the lab is busy , he will get every thing done at some other place ( I did not know which place he was referring , whether inside hospital or outside) and asked me to pay Rs.1000 thousand in cash. I said I dont have cash on me , I have credit card. He got disappointed and asked me to wait outside path lab. After about half an our he came and asked my wife to come inside lab. I also followed her. He made her lie on the bed and the nurse prepared the syringe and applied some ether( it was told to me that it is ether for local anaethesia) on the knee for taking the fluid . The doctor injected the syringe but he was not able to suck out the fluid into the syringe , he took out the syringe and injected again, again he was not able to extract fluid , he repeated the process two more times but in vain. Finally, he told that there is no fluid in the knee. He then prepared for injecting the medicine which he claimed that it would give her relief from pain for 8-9 months( later it proved that the relief did not last even 8 hours) and tried to inject the medicine but he could not inject the medicine. He was able to inject only in the fourth attempt . My wife was crying in pain. I told the doctor please do not inject if you are not able to inject but he kept on trying. I felt he was a novice . I was cursing myself why I agreed for the injection. I was really surprised how incompetent he was. Later when I paid the bill for the entire process (Rs.1820/- ) I noticed that out of this amount Rs.1400/- was to be paid to the doctor by the hospital . Then the reality dawned upon me that to get this Rs.1400 the doctor forced the entire process on my wife .He then told that he as he was unable to take out the fluid, he recommended RA test for blood and said that RA test is not always perfect. Even if the result is negative the patient might be suffering from rheumatoid arthritis . He then recommended RA test (blood) and X-Ray (knee) and told to call him after getting the report. After getting the report we called him and told him that blood report is negative but the x-ray report is mentioning “Bilateral degenerative knee joint disease”. He told that as the blood report is negative , the disease is not rheumatoid arthritis but it is osteoarthritis for which there is no cure. When I reminded him that he had told on that day he was 99% sure that my wife was suffering from rheumatoid arthritis and gave that injection which would give her relief from pain for 8-9 months , he asked me call on me the next day for further treatment.

    I am really surprised that for a petty amount of Rs.1400 the doctor misguided me and forced upon my wife a process which was not at all required. He misguided about the injection that it will give relief for 8-9 months. In my opinion the right course would have been to get blood test and xray done before going ahead with any kind of treatment. This incident has shaken me. If a doctor in a such big and reputed hospital in Mumbai is so incompetent and greedy , what to talk about small hospitals in small towns. I dont know where should I go now. My wife is writhing in pain . Can anyone please suggest a Doctor in Mumbai whom I can consult and rely?
    G.IMAM, MUMBAI

    • escapevelocityblog July 11, 2012 at 9:31 am - Reply

      Hi Imam,
      Am sorry to hear about your wife’s troubles finding a solution to her knee problem and your lengthy search for a solution.

      Sad to hear that the Dr. others have had good experiences with (which were mentioned in the blog post you read) could not help you at all. Would like to mention that posts on the blog are in the nature of personal opinions / experiences / observations, and not intended as professional recommendations.

      Hope you find a good Doctor and the pain being suffered by your wife ends soon. Wishing both of you all the best.

      Regards,
      Zenobia

    • Dr. XYZ July 19, 2012 at 11:41 am - Reply

      Firstly I thank Zenobia Driver for writing about the feedbacks she received from her friends about our services in her blog. Very few people do such selfless things these days.

      This reply is in response to a comment left by our patient Mr. G.Imam (& brought to our notice by one of our patient who did not like what she read.) It is also an attempt to help the patient who is suffering & because of which Mr.Iman wrote this comment.

      Dear Mr. G.Imam,

      Our intention in medical practice is to relieve the patients suffering by suggesting & implementing the best possible investigation/ treatment option. Because your patient showed classical signs of Rheumatoid Arthritis (RA), we wanted to confirm the diagnosis with Joint fluid analysis (white blood cell count, rheumatoid factor & cyclic citrullinated peptide antibody which is very specific to RA), blood work: rheumatoid factor true positive in 75% of cases (increased number of false positives). The radiographs may show loss of joint space and bony demineralization which does not establish a definite diagnosis. Thus bloodwork & radiographs are more or less useless in establishing the diagnosis of RA. That is why we wanted joint fluid for analysis. It was not for the sake of money. We had requested you to follow with the investigations as soon as you get them. But you just gave a call on our cell phone on a sunday & asked us if there was a cure after reading out the reports. In response, we requested you to come to the OPD with the reports the next day.

      In knee joint fluid aspiration/injection we use a thin needle which is used to give intramuscular injections to children to withdraw the joint fluid. It is not a very painful thing to most people. But we could not withdraw the fluid from your patient as she was not able to keep her quadriceps relaxed which is essential to draw out the joint fluid, in spite of giving instructions + reassurance & local anaesthesia with ether (a coolant) to help her relax. In such cases we generally do this procedure in the operation theater under anaesthesia. This is what we were going to discuss with you when you came in with the reports which you never did. Instead you wrote a hateful & inaccurate review of our services to your patient. Such things do not serve any purpose.

      We sincerely request you to come & meet us so that we can solve her problem. If you cannot, we just want you to know that we always had a good intention in all we did.

      Dr. XYZ.

      • escapevelocityblog July 20, 2012 at 5:08 am - Reply

        Dear Dr. XYZ,
        Thank you for the detailed clarification. I hope your patient, Mr. G.Imam reads this and it sets his mind at rest.
        Regards,
        Zenobia

      • Dr. XYZ October 23, 2012 at 11:43 am - Reply

        Addendum:
        Patients can contact me on xyxyxyxyxy for an appointment, instead of just walking in @ Lilavati in the morning to avoid waiting/noshows (busy in the operation theatre in the morning at times). The cell number is an easier option than the always busy hospital phone line. And, the consultation fee for the afternoon (4-6 PM ) OPD is exactly the same as the morning OPD.
        Dr XYZ.

  4. G.Imam July 11, 2012 at 3:56 pm - Reply

    Thanks Zenobia very much for your best wishes.
    G.Imam

    • escapevelocityblog July 12, 2012 at 7:19 am - Reply

      Hello again,
      I checked with a few folk I know and there’s an orthopaedic called Dr. Bhojraj in Mumbai who’s quite good – at least at treating back problems caused due to spondylosis / spondylitis etc. Another friend also mentioned a rheumatologist called Dr. Balakrishnan that she’s been to and was happy with.
      Again, these are just personal opinions of my friends, I’m not at all qualified to evaluate these doctors professionally, am just passing on the info since it might be useful to you. Do check about these doctors yourself and then decide whether you want to visit them.

      Hope you do find a good Dr. soon and your wife is hale and hearty again. Do let me know when that happens. Till then, I’m keeping my fingers crossed for luck and hoping things get better for you soon.

      Regards,
      Zenobia

  5. Siddarth Dudjom October 26, 2014 at 10:49 am - Reply

    My mother had a problem of pain & numbness in her feet because of which gave her sleepless nights. I saw your blog & went to see Dr. Niranjan Deshmukh at Lilavati Hospital. He not only explained the cause of her problem (nerve compressions in the back), he performed an operation which completely relieved her problem. And she walked out of the hospital within 15 hours of surgery ! ! She has restarted her exercise now & blesses the doctor and you as well. Please keep it up & write more such things. Why don’t you construct a website containg authoritative collection of reviews for doctors in the country ? Would help a lot of people for sure.

    • escapevelocityblog October 26, 2014 at 3:17 pm - Reply

      Hi Siddarth,
      Thrilled to read your comment, really happy to know that your mother is feeling so much better now and so glad that the information I shared was useful to someone and helped them get better. Thanks for leaving a comment and telling me about it, this really made my day.
      Regards,
      Zenobia

    • escapevelocityblog October 26, 2014 at 3:52 pm - Reply

      p.s. Also, Do thank your mother for her blessings ; sure I don’t deserve them since all I did was share some info, but am always glad to receive undue credit.
      🙂
      Zenobia

  6. Siddarth Dudjom October 26, 2014 at 4:13 pm - Reply

    No..No. You deserve mother’s blessings & my gratitude. Your suggestion guided me & you are right about the doctor. He is really nice & honest. So thank you Zenobia and take the credit for her return to good health !

    • escapevelocityblog October 27, 2014 at 2:34 am - Reply

      You’re being too kind, but like I said, I’ll accept any credit that comes my way.
      So glad the information was useful and your Mum’s problem got solved.
      Regards,
      Zenobia

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