MEDICARE
Patient power
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As the Information Age brings answers into living rooms, Dr. K. GANAPATHY examines the impact on medical accountability.
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R.V. MOORTHY
With the information explosion, the patient is calling the shots.
"I do not want two diseases, one Nature made and one Doctor made." Napoleon Bonaparte
"One must educate the public that seldom does a patient receive the best treatment." The Flexner Report, 1910
THE doctor was trusted and dominant. The patient was uninformed, grateful, and believed in fate. If something went wrong, patients often wouldn't know, and if they did, they wouldn't complain. Few hospitals entertained complaints. That was the 20th Century.
In the 21st Century, the Information Age demands that there are no presumptions. The complexity of modern medicine leads to more opportunities for error. There is a perception that holding doctors and hospitals accountable for treatment decisions will improve Medicare. Public access to specialist information, the cornerstone of accountability, is today only a mouse click away. A search in Google revealed 2,46,000 articles on headache, 112,000 on aneurysms (including 2490 on incidental aneurysms), 93,300 on deep brain stimulation, 47,200 on skull base surgery, 39,600 on Radio-surgery and 10,100 on cerebral embolisation. Even the crudest search yields several thousand references on the most bizarre topic. Documentation of results, in the form of outcome studies, is the order of the day. The information explosion has resulted in patient empowerment leading to decrease in medical autonomy. Doctors must produce evidence for their patients. The health care industry is perceived as being too big, dangerous and costly to entrust its working solely to white coated doctors.
Tomorrow's doctor will be a health care provider dealing with quality control, audits, protocols, regulations, guidelines and frequent inspections. The patient will be a consumer — a hard negotiator buying a product, calling the shots and capable of changing the system. Will tomorrow's health care provider have to follow a written script? Technological, social and economic forces have created a demand for quality measurement, quality control and quality improvement in health care. Systematic measurement of outcome of patient care is the precursor for instituting continuous quality improvement (CQI) techniques used in monitoring industrial processes. Doing the right thing and doing the right thing right are today's buzzwords.
CQI techniques used in monitoring industrial processes are now used in tracking patient care. The health consumer is trying to ensure that customer delight, not satisfied doctors, is the new slogan for the health care industry.
Serious outcomes due to medical errors are perceived as isolated and unusual events. We have no reliable statistics of how often medical "misadventures" occur in India. Every doctor has, unfortunately, had his share. With nine million physician/patient encounters every day in the United States and with increasing use of IT the "cure that killed the patient" is detected more often not. Three to five per cent of hospital admissions in the U.S. are for adverse side effects due to the treatment. If the Federal Aviation Administration makes one small mistake it kills people a planeload at a time and that is big news. When a doctor makes one small mistake only one is killed and that is not news.
RITU RAJ KONWAR
While pilots are constantly re-evaluated it is not so with doctors. Medical textbooks are often outdated, and journals go unread or unheeded. Continuing medical education is not always translated to better medical practice. In 1995, the New England Journal of Medicine estimated that five per cent of doctors in the U.S. "ought not to be practicing medicine".
In health care, geography is destiny. Indications for tonsillectomy, appendectomy, prostate surgery, hernia, mastectomy and haemorrhoid surgery depend on where one is. Breast conserving surgery was 48 per cent in Ohio compared to 1.4 per cent in South Dakota. An elderly patient with back pain in Florida was four times more likely to undergo surgery than one in Manhattan. Caesarean sections for the same problem on Minnesota women in different parts of the State ranged from nine to 48 per cent. Harvard University researchers opined in one study, that 25 per cent of bypass surgeries, angioplasties and catheterisations on elderly heart attack victims were probably unnecessary. Unnecessary appendicitis was coded as chronic remunerative appendicitis. A study of 67,000 hospital admissions costing $217 million revealed that two-thirds of the hospitalisations for low back pain were unnecessary. In three of eight hospitals audited, none of the admissions for back pain was needed.
Inappropriate blood transfusions were common. Antibiotics infused in 15 minutes instead of 60 minutes caused major problems. Routine foetal monitoring during labour probably only contributes to increased caesarean sections! A two-year study by the American College of Surgeons and the American Surgical Association, found that half of the non-fatal complications and a third of the patient deaths were preventable. In 2001, in Florida hospitals alone there were 54 surgeries on the wrong part of the body, 16 wrong procedures performed and nine wrong patient surgeries.
Doctors do not require more sophisticated equipment, but better training and tools to help them interpret the evidence dealing with therapeutic conundrums. Unfortunately, in the absence of a compass or road map, people may not even know they are lost. The most sophisticated computer system will not lead to better care, unless caregivers are willing to act on the information. A computer can call a doctor directly to warn that the serum potassium level of a patient has fallen dangerously low, but the doctor has to institute corrective measures.
The hackneyed phrase "clinical judgement" is giving way to standardisation of care with a view to consistency and predictability. There is always a gap between the scientific evidence about what works best and the care a patient actually receives. A doctor may follow the results of one study, disregard the findings of a second, and be unaware of a third. The Indian Medical Association campaigned unsuccessfully against the inclusion of medical services under the Consumer Protection Act. In Spain, a patients' association is planning to publish on its website a list of doctors who have been found guilty of negligence. Other countries are following suit.
"Physician, heal thyself" is no longer a cliché. The medical profession must realise and accept the fact that tomorrow's well-informed patient will also have a major role in the decision making process. Medical accountability should not be viewed as displacing the physician from the pedestal he has been sitting on for centuries. Tomorrow's physician will have to work overtime and prove to the world that they indeed deserve the pedestal.
The author, a Chennai based neurosurgeon, is also an Adjunct Professor at the Anna University and Medical Director of the Apollo Telemedicine Networking Foundation.
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