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Dear doctor, look before you leap!

Dr.Tandava Krishnan

Couple of years ago, I sat through a presentation by a doctor. His topic was, “Importance of sterilisation process in an operation theatre”. He started his presentation by putting up a picture of road traffic accident and said,” We all are good at driving vehicles but it just takes one accident for people to lose their lives. Sterilisation is also similar! A small slip here, a little laxity there and we all end up with a big catastrophe of post-operative infection.”
As doctors, we strive to keep our patients happy. We read newer books and journals, attend conferences and participate in hands on refresher courses to familiarise ourselves with the latest developments in the medical field so that we may do what is best for our patients. Sometimes we go beyond the call of our duty to ensure that the patient is not inconvenienced. This could be in the form of working extra hours or on holidays or working without charging the patient. These measures might sometimes be at the cost of sacrificing one’s personal life. One might call it the “call of duty”! But how far should we be going in this pursuance of keeping the patient happy. This was the question that came to my mind when I heard a friend narrate an incident he faced.
An elderly gentleman presented to an eye hospital with complaints of decreased vision. Examination revealed that he had a cataract which was impeding his vision. He also had a history of stroke and of having undergone a coronary artery bypass grafting (cardiac bypass surgery) recently and was on blood thinners. The usual protocol would be to request for a clearance for surgery by a cardiologist with specific instructions about how to modify the medications in the period before and immediately after surgery. This is done for various reasons. Firstly, to assess whether the patient can safely undergo the surgery and to grade the risk if any of any life threatening complication during the surgery. This would ensure that the anaesthetist who is monitoring the case is well prepared for any eventuality. Secondly, as the patient would be on blood thinners, a systematic approach to temporarily put on hold these medications would ensure that there is no excessive intra operative bleeding. And finally, such an approach keeps the doctor on a firm footing medico legally. Coming back to the case, the doctor explained to the patient about his eye condition, the need for surgery as well as the need for the cardiologist clearance prior to the surgery. The patient’s attendant immediately produced a clearance which was taken 6 months prior at which point the doctor requested them for a fresh cardiologist assessment as the old opinion was irrelevant for the current condition. The doctor saw them again after 5 days. To his utter surprise, the patient had stopped the blood thinners on his own without visiting his cardiologist and was insisting on being operated at the earliest possible date. The doctor patiently explained to the patient and the attendant that a cataract surgery barring some exceptions was never an emergency and that the patient had put him selves into a grave risk by stopping blood thinners without any medical advice and hence requested them to first visit their cardiologist so that no harm may come their way. The patient picked up an argument with the doctor and accused him of harassing innocent patients by unnecessarily delaying surgery on one pretext or the other. The doctor patiently listened to all the accusations but did not relent and the patient eventually went away. The patient came back after a week. He had been operated upon by another doctor who did not insist on cardiologist fitness. The operating doctor apparently told the patient that seeking cardiologist fitness was a method employed by doctors trained at “big institutes” just to harass the patients and throw their weight around and there was absolutely no need for anything like that for cataract surgeries. Needless to say the operating surgeon wanted to look large hearted and patient friendly. Moreover, the opportunity to score points over a fellow surgeon by painting them as rigid/dogmatic and therefore unfriendly to the patient was something too good to have let gone. However, one shudders to think of all the wrong things that could have happened. Who would be blamed in the event of a mishap? To use a clichéd phrase, you don’t need to be a brain surgeon to figure that out!
One of the arguments put forth, while justifying cutting corners in patient management is that, if we insist too much, the patient may just walk to the next available surgeon. While, there is some truth to this statement, if the trade-off is between losing a patient and doing a risky procedure which might end up in a medico legal litigation what would the doctor choose. Another issue is that the patients can be very belligerent. I have seen patients boasting that their sugar levels are never below 300 mg/dl with a pride one would usually associate with someone who has topped the IIT or civil services exam! There is also one tribe of patients who are ready to take the risk personally. “Sir, you please operate. After all it is my life which is at stake. Why are you worrying so much?!” With the little experience I have gained, I can tell that these are the sort of patients who could cause maximum trouble at the slightest of the pretext. Similarly, the pressure to cut corners and operate on cases that are systemically unstable might come from the management. A doctor once confided in me as to how he was pressurised by the chairman of his hospital to operate on a case with blood glucose level of 300 mg/dl. The chairman wanted the patient to be operated so that beds may be cleared to admit newer patients. He (the chairman) claimed that he will be losing money if patients are made to wait for surgery. When asked as to who would take responsibility if something went wrong, he initially volunteered but relented once the doctor requested for a written assurance. Every time a doctor tries to take a chance and operate a case without proper precautions, he/she might console themselves by believing that they are being accommodative/ magnanimous/ brave or daring but in reality they are just exposing themselves to undue risk. And once a doctor dilutes his/her standards by giving in to weak arguments, they are painting themselves into a corner. The supporting staff and the management of the hospital might take the exceptions made by the doctor as a rule and compel them to operate on cases which may not be suitable for surgeries I would like to quote a conversation I overheard in an OT after a case was cancelled due to high blood pressure. One of the doctors said that it was very difficult to convince people that a case needs to be postponed due to high blood pressure and all the measures taken are for the patient’s good only, to which another doctor replied, “You will be able to convince the patient about the importance of some measures only if you yourselves are fully convinced!”.
I have seen the pulse rate of premature kids racing to alarming levels because a nurse inadvertently applied dilatation drops of the wrong concentration. I have seen patient collapsing on table and succumbing to their systemic ailments despite taking all the precautions pre operatively. I know of doctors who were subjected to media trial for ending up with post operative infection despite maintaining strict asepsis in the operation theatre. Let us be frank.  Most seasoned doctors would agree that treating cases is all about odds. There is no formula for guaranteed 100% success rate. Every doctor endeavours to ensure that odds of success are enhanced and the odds of failure or complications are minimised to a negligible number. The now familiar efforts by various hospitals to get themselves accredited by NABH or QCI are a step in that direction. It ensures that we assimilate in to our work culture, all the efforts which are needed to ensure that our patients get the best possible treatment with the least possible risk of complication. And if a complication does occur, we are well prepared to deal with it.  
We may not always succeed but we must leave no stone unturned to ensure that our patients get the best possible treatment. If it means that the patient has to pay an additional visit to his or her physician, so be it! Moreover, issues as serious as this must not be exploited to score brownie points against our colleagues. Because in an attempt to upstage our competition, we ourselves might end up in a complication which was best avoided and might threaten our career.

 

 

 

TK

 

 

Dr. Krishnan is a Vitreo-retinal consultant at Neoretina, Hyderabad.