Thursday, April 19, 2012

Doctor Shopping . . .

3 days back, I had a young man in Emergency with fever for a duration of 7 days. Quite an expected event with the advent of summer. Last year I had written quite a lot on the umpteen number of fever cases that we ended up managing. 

The interesting aspect was that NJH was the 5th healthcare provider his family has taken him to. The unfortunate part was that NJH was more close to his home than the rest of the other providers if you exclude the village quack to whom he had gone initially. 

He had already received almost all the common high end antibiotics that is available in the market as well as all anti-malarials except Quinine. And he was from a well to do family with some amount of education . . .

I counselled his parents and told him about the futility of getting treatment like this. I was not at all interested in taking the young man in for treatment. The family was well off, they could afford to take him to Ranchi and a continuous fever of 7 days duration was not something trivial. 

Armed with a high risk consent, we started to manage him. On examination, we got a suspicion of meningitis. But, the lumbar puncture was negative. The blood tests were negative for malaria. There was lymphocytosis with increased polymorphs with toxic changes and a shift to the left. Renal and Liver functions were within normal limits. 

I covered him with high dose antibiotics and anti-virals. For 24 hours, there was no respite of the fever. Then, I started him on intravenous quinine. His high grade fever has come down. But, he again had one spike, although a smaller one in the evening. I hope that he'll become better and I was most probably dealing with a partially treated malaria. 

Now, Doctor-Shopping is a major problem with the sort of healthcare we have in India now. 

With almost 70% of actual healthcare happening in the private sector, patients are on the run searching for the magician who will get rid of their sickness. The competition between doctors and healthcare institutions makes things more worse. . . In the modern era of evidence based medicine, there is not much of a choice in varying treatments. The impetus is on making a good diagnosis. 

Rather, by doing Doctor-Shopping, patients put themselves at a high risk of getting multiple types of antibiotics and medications. Of course, things become difficult when there is a challenge in getting investigations of your choice with assurance of good quality. 

The quality of medical education only makes things worse. 

Recently, I came across a colleague working in obstetrics in a big hospital in the city. I came to know that his department routinely prescribes intravenous Ceftriaxone for all Cesarian patients irrespective of the indication for a total of 7 days. It was pathetic. He told me that nobody wants to take any chances. It was so unfortunate. It was done so that patients would not go doctor-shopping. But, at what expense. 

Drug resistance in almost all the spheres of microbiology is a major challenge to healthcare. Doctor shopping is something which would built up drug resistance. 

Protocols for diagnosis and treatment prepared by different agencies on various disease conditions and symptoms are available for almost all major diseases. A strict adherence to the algorithm almost always helps in the correct diagnosis. It is cheaper and easier process to go through. 

Now, the question is who will adhere to protocols. This is the situation where a family practice consultant would be of benefit to the patient, especially when he/she is poor. Another point in favour of introducing family practice consultants in a big way in the Indian healthcare scenario . . . I hope the concerned people lend a ear . . .