Wednesday, July 04, 2012

Doctors, patients and policy makers

There is a big difference in the way doctor’s view the world, as compared to say, lawyers, policemen and policy makers . Often, the policeman treats everyone who comes to him as a potential criminal , because that's the kind of person he is used to seeing. Similarly, lawyers are much better at identifying problems rather than finding solutions, as contrasted to an entrepreneur, who wants to move ahead and tackle problems as and when they arise. A lawyer deals daily with deals that have gone sour, and understands that it’s his job to make sure that problems do not crop up later on, which is why he is so anal-retentive about dotting their “I”s and crossing their “t”s. .

In contrast to bureaucrats and policymakers , who usually take a top down, big picture approach , doctors adopt a bottom up view. Their focus is on one person at a time because all their energies are devoted on the single patient sitting in front of them . Their professional training teaches them to answer the question - What can I do in order to help my patient ? This is why the doctor’s approach is very personalized , and he tries to do what is in his patient's best interests. Also, note that the doctor focuses on solutions. “ The human being in front of me is in pain and has come to me for help. What can I do to make him better ? “

This is why, when you have a problem , you first go to your doctor her help.  You want him to fix your problem for you so that you can get better quickly. You don't care about anyone or anything else in the world at that time – you  just want your doctor to focus on you and get you better. This is what doctors are extremely good at doing , and most of the time, there is no conflict and things work out extremely well.

However, sometimes there are decisions which are made by lawmakers and policymakers, which affect the entire society as a whole. It's when these policy decisions conflict with an individual’s personal desires, when the friction starts happening. Unfortunately it's often the doctor who's stuck in the middle, because he's the one who needs to both balance the needs of the individual patient sitting in front of him as well as the laws and guidelines which are laid down by society .

The patient doesn't care about the laws or guidelines ! Let’s consider a thought experiment here. Let’s assume your dad gets kidney failure . He needs dialysis and leads a pretty miserable life because he needs to spend hours cooped up at the dialysis center every 2-3 days. Your doctor suggests kidney transplantation as a better alternative, and you sign up for this. You find there’s a long waiting  list , but as a law abiding citizen, you don’t have a choice, so you add your name to this. . After 6 months, a kidney does come up, but does not match your dad. Your dad is quite fed up now and is talking of how he’d rather die than continue with the dialysis. Your driver offers to donate his kidney for a large sum of money , and you find that it’s a perfect match ! You are very excited , and are looking forward to the transplant, so you dad can resume a normal life. However, the organ transplantation committee rejects your driver as a donor because he is not related to your dad. You cannot understand why they are being so pig- headed. You feel this is a win-win situation , and there is no coercion involved.  Your driver benefits and so does your Dad , and both are adults, so why should the government interfere in such a personal decision . How is it any of their business ?

You want your doctor to do the transplant for you. After all, he is your personal advocate – someone who you hope will move heaven and earth in order to get you better. What happens if the law does not permit him to ?

The doctor would like very much to do the transplantation , so that your Dad, who is his patient , can continue to lead a productive life. However, his hands are tied , because the government has set guidelines which he cannot flout. The doctor understands the big picture behind the guidelines – their purpose is to protect poor citizens , because illiterate kidney donors have been exploited in the past by unscrupulous doctors and greedy middlemen. However, this is clearly an exceptional circumstance, but his hands are tied and there’s nothing he can do – the autonomy to make the best decisions for his patients has been taken away from him. Suppose you are a VIP, and start putting pressure on the doctor to bend the rules ? Suppose the doctor does do so , whether his motivation is to heal his patient, or to make more money. That's when the problems start  - and when one doctor gets into trouble in the process of helping his patient, the reputation of the entire profession takes a beating. The media is very unlikely to be sympathetic – and will just harp on the fact that doctors are greedy and are out to break the law. Even you are likely to shut up and let your doctor take all the heat – after all, your Dad has had his transplantation, so why should you stick your neck out ? In fact, patients will then claim that they would never have broken the law if the doctor has explained the rules to them !

Should your doctor bend the law to heal your dad  ? Should he make an exception for you because your case is "special" ?  What if the law does not make sense in your  personal case and the doctor agrees that you deserve to be an exception, but that his hands are tied ? Do you go looking for another doctor who is willing to be more “ flexible “ ? How can we find the right balance ?

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  1. The right way is to influence changing of laws. Breaking laws, however wrong they are will create more problems.

    Vishal Singh

  2. Yes, breaking laws is not recommended, but the medical profession needs to speak up and provide inputs when the law is being formulated, to make sure that laws are fair and just.

    Also, if a law is bad, we should do our best to repeal it, rather than take a passive attitude which causes our patients to suffer. Laws are not written in stone; and as time goes by and technology improves, the laws need to be amended and improved as well, for the sake of our patients.

  3. What is important, individual wellness or the wellness of the society?

    Dr, why do you talk about kidney transplantation? Imagine this: a couple comes to you with a wish that they need a boy child, they already have one girl child and they are rich enough to support another child - you find that situation perfect without any issues, but your hands are tied because of the PCPNDT act, what will you do? :) Obviously you will send them back saying you cannot do it, right? Then they find another doctor who has enough political influence and has enough clout to handle police and law. Thus they make their wish fulfilled or they undergo so-called illegal scans and abort the girl foetus until they get a boy child! :) In the poorer section of the society they either kill the girl child or abandon them when they are born (because they do not have enough money or influence to find a scanning center who can do the scan for them). When I am in India I read everyday in newspaper about girl child abandoned or they are killed and thrown away. In this situation, the law has not only miserably failed but didn’t preserve individual wellness as well as the wellness of the society. Infact it is harming innocent women and their girl child! When somebody tries to point this out the so-called social activists go hyper and emotional and put a full-stop to all further talks! Long live irrational minds!


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