Relationship of doctor and patient is the most delicate and yet the most trustworthy. But they do have to go by the rule book. A few things need to be followed during the term of their relationship.
The patient has a right to be informed of what is going to be done, why it needs to be done, anticipated complications, possible alternatives and consequences of delaying or refusing treatment. Some of the consent is implied, like raising a shirt up for an abdominal examination or holding out a hand for a needle prick. Some consents for internal examination, surgery have to be specific and clear. The ground situation is that most patients prefer to let the doctor take the decision for them.
There are a number of patients who rightly attempt to locate information (from Internet) and understand their disease. However their opinions may be tarnished by personal anecdotes and experiences of their friends, blogs or comments by untrained people. In the Indian scenario, patients are usually afraid to question their doctors.
On the other side, most doctors are over-worked and do not seem to find the time to settle all the queries raised by patients. They also deal with a different set of relatives every now and then who need information about the patient. Technically, doctors are required to discuss the medical condition only with the patient and their legal next of kin.
Patient participation in Decision Making
There are times when multiple treatment options are available or sub-optimal outcomes are expected. These are situations where patients need to make an informed choice about the treatment they are willing to undergo. This choice may become mandatory due to issues about the patients general condition, concurrent illnesses, mental incapacitation, cost considerations. This needs to be addressed jointly by the treating team and the patient.
Prognosis and end of life issues
Often, unfortunately, doctors and their patients have to deal with end of life issues. This requires sensitive handling by the treating team as the patients and their relatives go through phases of denial, anger, bargaining, depression and acceptance. Bad news is received poorly and most doctors receive little or no training in discussing end of life issues.
Further, relatives do need someone (rather than something) to blame for the death of their near and dear ones. The most likely candidate is a member of the treating team especially when associated with a perceived or actual mishap just before death. This is part of coping.
Further, in India, there is a tendency for relatives to urge the treating team to continue aggressive (rather than supportive) treatment till the very end. It is a noble thought and finally the relatives have to deal with the loss in the long term. Yet it is the patient who may be suffering despite the treating team explaining the consequences. This is not to be confused with euthanasia which deals with ending life support in hopeless situations.
Complications in medical care
Complications are unfortunate outcomes of medical intervention. These are not unknown or unexpected. All descriptions of medical or surgical treatment do list a series of complications that may occur.
The doctors are trained in reducing, recognising and managing complications. Yet the smallest medical intervention may result in death of a patient. If the entire list of possible complications is explained to every patient, probably no one will undergo surgery. And if every doctor is punished for complications, no one would ever become a doctor. Hence, the international yardstick of reasonableness.
Briefly it means that did the doctor possess reasonable skill or take reasonable decisions in the care of the patient. Hence, would another doctor with reasonable similar training and in a similar situation done the same thing? This is why complications remain a tenuous subject of doctor patient relationship.
Patients have a right to expect reasonable care hence, they should ask their doctor about possible complications. The treating team has a duty to explain possible complications beforehand and to keep the patient or next of kin informed about complications that have occurred.
What can patients do
- Take a close relative (preferably the same person) for every interaction with the doctor or paramedic.
- Jot down questions to be asked.
- Ask lots of questions. There is no need to be afraid of the doctor. However, do schedule an appointment for taking the doctor’s time.
- Take active part in decision making.
- Understand that medical care is all about reasonableness. Anyone who offers a guarantee of any kind of cure is best avoided.
- Be open to discussing end of life issues.
How to say what to say
This is not a medical topic. It pertains to the service industry at large. Medical care is a service purchased by the patient. Patients have every right to be treated in a courteous and honourable manner by everyone in the hospital.
Problems arise when doctors and their subordinates speak to patients in a manner that is perceived by the patient as condescending, brusque or dismissive. The number one cause of complaints in a hospital is not what was said, but how it was said. Unfortunately this is where the parallel with service industry ends. In a hospital setting, the patient is the weakest link in terms of medical knowledge and is the weakest person in terms of health.
Combined, it makes for a person who needs and deserves more compassion and care than a customer ordering a meal in a restaurant. Hence medical and paramedical students are now being trained in soft skills and dealing with difficult situations.