Friday, December 28, 2012
For 100% Success Rates....
I went to a wedding last week in chintadripet. Nothing surprising about going to a wedding you might say, but it was a one – off occasion for me because it was the wedding of a former patient of mine. Now, I am someone who firmly believes in keeping his professional and personal lives separate. I have rarely; or rather never socialized with patients, despite the wedding and other invitations I get on a frequent basis. Why I cannot say. Its not because I think that I am special or it would in any way not be the right thing to do. Its just that, I prefer not to think of patients and their problems in my personal time. Not that I dont. But I do try to keep it down to as minimum as possible. Or this job will suck you down. Being constantly around sick people, being around people in pain and being able to do nothing about it most of the time is as soul destroying as any other job but also has the added risk of not allowing you to tune your mind off other peoples worries and concentrate on your own problems. Hence, most doctors refer to patients as cases not as people to see if thinking in the abstract helps keep the mind of them. But still statistics show that doctors are in the high risk group for depression and doctors are some of the most vulnerable people to heart disease. Not that I am afraid of any heart disease or anything, for physical fitness has turned as important a part of my daily life as eating or sleeping.
Anyway to come back to the premise of the post, the reason I choose to attend this particular patient wedding was because I was proud of this girl. Or rather proud of my treatment and its successful outcome. When this patient had first come to me, I had turned her down like every other doctor she had been to recently. There was nothing I could do to help her in my opinion. And I would have stuck to “no” had not this been a VIP case. Yes, this patient had come to me with a recommendation letter, referred by my mom. The mother of the patient worked as a domestic servant in the household of a close colleague of my mother, the family was poor, they couldn't afford to spend any more money for treatment, the girls wedding had been fixed and the date was fast approaching and the family was in desperate straits and despite the fact that this patient would have to be treated free by me, if I knew what was good for me I would not turn down the patient and face my mom’s wrath at home (and probably get put on a bread-only diet).
The reason my instincts had screamed to decline this case on first examination was that the patient had already undergo multiple surgeries before coming to me and most of them had failed to cure her basic defect. Plus the previous surgeries had removed whatever useful bone and other tissues which were available on her body (as grafts harvested to be used in a different area) and had used them in a failed cause without achieving anything. So even if I had wanted to, there was nothing there left for me to use to make her better. But sometimes when you are forced to improvise, you surprise yourself. Or at least I did. Once I decided that the usual treatment protocols would never work with this patient, I thought up a different way to treat without treating (kinda zen- but I like describing it that way). I even thought up a fancy sounding name for it (to bamboozle other doctors who ask) but the idea was to do the minimum required with the minimum available to last her till her wedding. And mission accomplished. The little treatment I did for the patient worked like a charm and the patient and her family were very happy, grateful and insistent on my attending the wedding and hence I made an exception just this once.
Anyway, I have often thought about how reluctant doctors (or at least surgeons) are; to accept cases which others have treated before them. It’s not just a matter of not being able to see the original condition of the disease before someone else mangles it in a botched surgery. It’s not exactly about pride at not being consulted first, not being the first choice so to say. The real reason, I would say is that doctors keep score. Just like any other professionals, they worry about their success rates. The higher they rise, the more they worry about their success rates. Their reputation demands that every single patient they treat turn out to be a success. To achieve that kind of consistency they turn down cases which in their opinion have even a marginal risk of failure. It’s like a batsman cutting down all risky shots to make sure that he scores a century every match And that means they stick to only safe cases and turn down the demanding ones, the difficult ones and also the interesting ones. I guess they have a right to, but sometimes this is carried to the extreme. If every single doctor decides only to treat those patients he can guarantee a success, what will happen to others who need it as bad but are also risky to treat. This is what I used to think myself and this was what brought me a lot of trouble in my younger days.
For instance, in my younger days when I was just dipping my feet in the profession (at Tanjore Medical college hospital) and had absolutely no clue to what I was doing, I was caught in a bind once because of my over enthusiastic (plus compassionate) mindset. Once during a late night duty period (when the mind is half asleep) a colleague from the ENT department managed to pass on a terminal cancer patient (someone who is at the end stage of the disease and about to die) to me with the improbable story of their wards being full and no place for the patient (plus the seductive story that this was something which was in our specialty and we could treat better) and as our beds were free could I shift the patient over to our ward? It shows just how much of an innocent babe (greenhorn) I was that I managed to swallow this story hook, line and sinker and admitted the patient in our wards. Until the next day, when my chief came for the ward rounds and caught on to the swindle immediately. After a barrage of bad words at high pitch delivered at me (must have gone on for atleast half an hour non-stop), my chief asked me what the hell will we say at the 3-M? And that’s when it struck me what a fool I had been.
The 3-M for those who don’t know is the Monthly Mortality Meeting where the death cases from each department are discussed every month. Every single department has to explain about patients they lost that month and what they learned from the experience to prevent it from happening again. This self flagellation will not prevent the other departments from pitching in with their own expert analysis of the in-competencies of the doctors and about what they did wrong. It sometimes degenerated into all-out slugfests where insults were traded openly based on what the other group had said at the last meet. And my chief was sure that the sanctimonious ent doc who had cleverly passed on the patient to us, would be the first one to roast us alive when the patient died despite him knowing very well that there was nothing we could do at this stage (the last stage) for the patient. But hey, he had got it off his hands didn’t he? So he could have a go at us with clear conscience. Anyway, the story ended with my being given a punishment posting at the fracture clinic – re-fracturing improperly set (half healed) fractures for re-setting properly, in other words a bone breaking job, plus a job which meant that I would always be delayed for lunch, which meant that the mess would have just empty vessels being washed when I turned up for lunch. Even after all this time, I still remember that month I survived majorly on bananas and biscuits. And I remember that my chief somehow passed on the patient to general surgery and got me off the hook.
The lesson I learned from that episode was that people will be merciless in taking advantage of you if you are innocent. And also that I was too young and inexperienced to take risks without proper guidance. But after all these years I have learnt to trust my own judgment rather than others opinions. To take a risk or two, if I judge I can pull it off. And I have also made it a habit of predominantly picking up revision surgeries (which is not as grotesque as it sounds) but which means doing a second surgery to correct any surgery which did not come out right the first time (for whatever reason). I have learned to work within the limitations, I have learned to lower my expectations (and the patients) and I am not fazed by the occasional failure. It is kind of liberating to treat patients when I don’t have targets to maintain and for whom I can do my best without worrying about my success rates or about doing something spectacular all the time. Sometimes not having a big reputation, being junior, does have its perks, doesn’t it?
So tell me, do you think that doctors should be always infallible and have 100% success rates? Or do you think that doctors should be ready to do the best they can, even if the results are not going to be spectacular? Which kind of doctor would you prefer to be treated by?
(P.S. I really enjoyed the wedding as I got to hear for the first time certain native musical instruments like daalaku, dhol and dappi which are never played by mainstream orchestras)