Wednesday, October 07, 2009

Medical malpractise flourishes because good doctors keep quiet

My friend underwent an angioplasty today for treatment of his ischemic heart disease. His interventional cardiologist , Dr Kirit Punamiya, is an extremely talented doctor. He has a team of competent technicians; and has single-handedly performed a number of extremely complex and technically challenging procedures such as atherectomics with a rotablator; and clot aspirations in patients with acute myocardial infarction. Cardiologists from all over the world recognize his technical expertise and invite him to demonstrate advanced procedures and teach them .

The tragedy is that very few patients know about his skills. Most patients simply do not have the ability to judge a doctor’s technical expertise. They feel that all interventional cardiologists are equally good - and often end up selecting an incompetent doctor because he is cheaper ; has a “good reputation” ( often for the wrong reasons); or because he operates at a nearby hospital. This is true for patients from all strata of society , no matter how rich or educated they are.

However what I admire most about Dr Punamiya is not the fact that he is a technical virtuoso. Let me explain. My friend had already undergone an angioplasty 9 months earlier. His angina recurred shortly after the stenting, and he had developed an in-stent restenosis. The cardiologist who had done the earlier stenting had advised him to go in for bypass surgery. In fact , it was the cardiac surgeon we consulted who referred us to Kirit, because he felt that the problem could be solved without open-heart surgery.

Dr Punamiya studied the old angiograms and agreed that stenting would be an effective solution, because his LAD ( one of the branches of the coronary artery was clean) . At this point I need to emphasize that an angioplasty can be a very expensive procedure and each stent can cost a lot of money , which means that it is quite profitable for an interventional cardiologists to insert as many stents as possible. However , when Dr. Punamiya did the initial angiogram, he noted there were multiple lesions which had not been detected on the earlier angiogram ( which was of poor quality). He felt these would be better tackled with open surgery rather than multiple stenting. Rather than continue with the procedure , even though everything was set up for the angioplasty, he stopped and advised the patient that an angioplasty was not a good idea in view of his extensive disease.

It was a refreshing change to come across an ethical doctor who will not perform a procedure just because it is technically possible or because it is profitable. Unfortunately, many cardiologists today have a bad reputation, because patients feel that they overuse technology to maximize personal gains.

We need doctors like Dr Punamiya to educate patients about the role of angioplasty; when it can be useful; and what its limitations are. Unfortunately, he is reluctant to do so. He feels that talking to patients can be misconstrued by others as advertising; and he does not want his colleagues to feel that he is soliciting for patients.

While I understand his apprehensions , I actually feel he is doing a dis-service to himself ; the medical profession ; and to patients, by refusing to talk to the public . The word “ doctor “ is derived from the word “docere”, which means “ to teach”. If good doctors do not fulfill their responsibility of educating people about their health, this actually encourages the spread of myths and misconceptions and allows medical malpractice - and bad doctors - to flourish. It's very easy for bad doctors to lie to their patients within the four walls of their clinic. It is easier for them to get away with these lies if good doctors keep quiet.

Many patients feel that doctors cover up for each other and refuse to criticise their colleagues. Doctors need to act as responsible professionals - and while I agree this means that they do not need to bad-mouth others, it also means that they do need to tell patients about what is good medical practise - and what is not !

Doctors have a moral responsibility to educate patients . When they refuse to do so because they feel they do not want to be seen as marketing themselves, they end up harming the entire medical profession, which gets a bad name because of a few bad doctors, who get away with their malpractises, because good doctors keep quiet !

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