The Aggressive Patient

Why are we intimidating and beating up our doctors ever so often these days?

Every other day one see’s newspaper headlines where doctors find themselves facing angry patients and their attendants who believe that misbehaving with hospital staff and doctors is no big deal at all. That breaking furniture and maybe a few bones will get them better service or perhaps the hospital will waive off a portion of their bills. Doctors and hospitals today are quite scared of such hooligans, who create a nuisance in the hospital demanding better treatment for their patients without realizing that their behavior is putting other patients at grave risk.

Part of the reason for this I suppose is that we are becoming a more aggressive nation. The road rage that one witnesses on the roads in Delhi everyday, the ugly fights among neighbors usually for parking spots, the crazy honking even on a red light are perhaps all a manifestation of this malaise. The medical profession too I suppose cannot escape its share of problems in a society becoming louder, more aggressive and more demanding. Everyone seems to be on a short fuse.

In hospitals, where life and death situations are routine, people are perhaps a lot more stressed and express their frustrations by mishandling the folks right in front of them. These are mostly doctors and nurses, who bear the brunt of their anger. Little do they realize that beating up the doctor won’t help them get better care. And that beating-up anyone is no solution to any problem.

The other reason that I find for all this anger in the hospital is a lack of communication between doctors and the patient’s attendants. Usually, the clinicians are very busy folks who have very little time for patient’s attendants. They believe that their primary duty is to look after the patients, without realizing that in today’s world they also have an equal duty towards addressing the attendant’s fears and concerns regarding the patients. Hospitals spectacularly fail in impressing on the clinicians that they must meet the attendants regularly and address all their queries as honestly and as transparently as possible. This must be a part of a process and not a random meeting in a corridor or when a patient’s attendant catches hold of a doctor fortuitously. Better communication will help reduce these unsavory episodes far more than more security guards manning the hospital doors.

I also look upon these incidents as reflective of a loss of respect and trust between patients and doctors. With the media awash with stories of profiteering hospitals and grasping clinicians engaged in dubious practices, no wonder that the relationship between patients and doctors have almost broken down. The noble profession has been reduced to no more than a transaction. There is no longer the old world courtesy and respect that clinicians commanded not so long ago. No longer are they the Gods of their realms. This is rather sad. The relationship between a doctor and a patient and their care givers has to be a a bond of great trust. The patient willingly allows the doctor to treat and operate upon him believing that he will do so to the very best of his skills and ability. The doctor on the other hand accepts this as a huge and crushing responsibility and does his best to ensure that the patient comes to no harm, while under his care. This is the covenant that has always existed between doctors and patients. This sacred bond is now stretched almost to the breaking point.

What is it that we can do to get back from the brink??

As hospitals and clinicians we have to understand that the patients are increasingly getting impatient and we must learn to deliver all that we commit. We must find more time to address their concerns and not just fob them off with some sarcastic remark about their limited understanding of medical matters. We must engage with them more, learn to treat them as equals and partner them in their treatment. A dialogue is essential.

As patients and their attendants we must understand the tremendous pressure and responsibilities each clinician carries. We must also have an unshakable faith in their good intent, skills and abilities. This has to be a given. We must also have the wisdom to realize that in medicine an adverse outcome is not necessarily the fault of the doctor or the hospital. Actually, at times it is no one’s fault. We must treat our doctors and nurses as fallible humans, just like ourselves.

Finally, there will always be those who believe that creating a ruckus helps get things done in the hospital. In my view the hospital must deal with them firmly and take whatever action is required to ensure orderly conduct.

Violence can not be justified, whatever the reason or the grievance. Beating up ones doctor is almost the most stupid thing imaginable that one can do.

The views expressed are personal

 

 

 

The Doctors who Communicate Better, are Better Doctors.

Communication with patients is perhaps the most important component in the overall patient experience at the hospital, yet it is a rare hospital that gets it right. The communication with patients largely involves the clinicians. The nurses, front-office executives, the house-keeping staff and even the security guard manning the elevator too can help deliver a wonderful experience by reaching out with kind words. However, it is really the doctors, whose words make the biggest difference in a patient’s life.

A few years ago, a friend’s husband needed a kidney surgery. The patient was to be wheeled into the surgery at around 10 am in the morning and the surgery was to finish in 4 hours. He was wheeled in for surgery from the hospital room at around 0930 in the morning. When I met the friend’s family a couple of hours later the attendants sat huddled together in the cafeteria, anxious and hopeful in equal measures. The time went by rather lethargically and their anxiety kept mounting. When 6 hours had gone by, the frantic family members approached the doctor’s secretary, who assured them with great panache that the surgery has gone without any hitch and they will soon be able to see the patient. Much relieved, the family members decided to have a celebratory coffee as they waited to see the patient in the recovery.

While they waited to hear from their surgeon, a couple of hours went by. The helpful doctor’s secretary by now had finished work and gone home. The surgeon was no-where to be found and there was just no one who could give them any information about the patient. Again frantic with worry the friend reached out to me to get some information about the patient’s well being and also when can they possibly see him and their surgeon.

Concerned, I made inquiries with the team in the OR and learned that the patient’s surgery had been delayed by a few hours as the previous surgery in the same OT had lasted longer than planned. The surgeon had been busy operating his scheduled cases and did not have the time to step out and explain the delay to the anxious patient’s relatives. The surgeon’s secretary had not heard anything untoward from the OT either and just assumed that everything would have gone as planned.

The patient’s surgery was uneventful and he made a full recovery. However, for the patient’s attendants, this was a harrowing experience. This is a true incident, and we know that something like this happens every day in our hospitals.

I have often pondered over the stark difference in the situation between the surgeon and the patient. Consider this for a minute. For a surgeon, a surgery is something that he does every day (maybe multiple times every day!!!), for a patient it is a frightening and hopefully once a lifetime experience. The surgeon, while operating in his theatre, surrounded by a team that he has perhaps worked with for years is usually confident of his skills and the ability to help the patient. The patient and his family are on the other hand in an alien environment. No one likes to be in a hospital and surgery is scary. The outcome in the patient’s mind is always uncertain. Given a choice, he would be anywhere but the hospital. Such is the power imbalance and asymmetry in the equation between the doctor and the patient, that it is imperative that we use clear communication to keep things on as even a keel as possible.

Patients will always see doctors who communicate well as better clinicians. Patients and their families like their doctors if they step down from their pedestals and treat them as friends. They will readily narrate stories about their interaction with their doctors and tell all their family and friends on how approachable and wonderfully transparent their doctor was. They will readily recommend the doctor to their family and friends and ultimately restore the doctor back on the pedestal!!!

It is very hard for the hospital administrators to mandate processes that define when and how should the clinicians meet their patients. Afterall, this is really a matter between a doctor and his patient and the hospital management isn’t usually welcome as a participant in this relationship.

However, hospitals must encourage their doctors to spend more time with patients and their families and not just fob them off with brusque briefings in the corridors. They must provide infrastructure, where patients and their families can meet their doctors and spend time together.

Doctors who communicate well with their patients can easily transform the hospital experience for a vast majority of patients.  Hospitals will do well to remember that.

The views expressed are personal

 

 

The Demonizing of Private Healthcare in India

The demonizing of private healthcare services providers in India seems to have reached a fever pitch. Everyday the social media is agog with how private hospitals, mostly in the quest of unhealthy profits are compromising with patient safety, recklessly using expensive medicines, over-charging and generally not treating patients well.

This is rather sad and generally a very one-sided view.

Private Hospitals in India invest heavily in hospital infrastructure. The cost in building the infrastructure, installing cutting edge medical equipment, hiring experienced and statured clinicians and managing the enterprise is high. The patients who prefer private healthcare providers also demand world-class services. There is nothing wrong in this. However, this also means that the healthcare costs are going up. Most patients do recognize the fact that a private hospital is a for-profit enterprise and the investors do need a return on their investment.

Thus, the quest for profits by the investors is legitimate. However, this must not deteriorate into blatant profiteering. This is clearly understood by most of the corporate hospitals. Even a casual glance will indicate that the EBITDA margins of most of the large healthcare chains in India are below 15%. At these levels the hospitals can hardly be accused of profiteering, particularly when the up-front investments are high and the profits emerge usually after 5-7 years of operations.

It is also a fact of life in India today that most people who can afford to pay prefer to go to private hospitals.  The subsidized government hospitals are over-crowded, filthy and callous. The accountability of the care being provided is very limited, the clinicians are over-worked and under-paid. Industrial disputes with the government are rampant and often some or the other section of the employees are on strike. The private corporate hospitals in sharp contrast to the government hospitals provide high quality care in state of the art hospitals. The clinicians are paid much better, they are also held accountable for the quality of care being provided, peer reviews are regularly done and hospitals are run on processes and systems that rival the best in the world.

Now, with this being our reality, it is rather unfair to blame private hospitals for ‘over-charging’, which is often confused with being expensive. That the hospitals use expensive branded drugs can hardly be held against them. If we expect great patient outcomes, the hospitals have to use the most appropriate and efficacious drugs and these are expensive. In India, where there are more than 30000 drug manufacturing units, some of them manufacturing spurious or barely efficacious drugs, the clinicians will tend to use drugs manufactured by large well-known drug companies and one will have to defer to their judgement. After-all, they are squarely accountable for the clinical outcomes and we can hardly ask them to produce great outcomes, while working with their hands tied behind their backs.

Pretty much the same applies for everything else that happens in a hospital. Infection control, IT system led processes to reduce medical errors, high-end diagnostic equipment and world-class OT’s all cost a lot of money.

The problem seems to be that, while the patient expectations in terms of care and outcomes has significantly gone up, they are just not reconciled to pay for these services as much as they cost to deliver.

The Role of the Media

The sad truth about media in India today is that in search of TRP’s, they have lost objectivity and even probity in what they report. The media is no more interested in facts or for that matter the truth. Most viewers want to see an individual patient, maybe a grieving father, take on the big hospital, which “killed” his daughter. This is clearly high drama and the media just loves it. The images are just too compelling and it is so easy to paint the big hospital as the ogre. The TRP’s are there to be had.

This kind of vilification and sensationalism, with very little care for truth or fairness is unfortunate but in today’s times, inevitable. While, a sustained onslaught is mounted for a few days, the hospitals run for cover, it is great spectacle for the mass viewer. And then a new story comes along and we all move on.

Sadly, while the media moves on, this kind of reporting causes long term loss of trust between patients and hospitals. This is a catastrophic and an insidious loss as trust between a doctor/hospital and their patients is usually the bedrock of  the relationship itself. In the absence of trust, things between clinicians and patients start going wrong right from the beginning.

The media must realize this and play a more non-partisan and balanced role in this dialogue. It should certainly highlight the shortcomings of the hospitals, however it should do so in a balanced and judicious manner.

The Role of Social Media

Social media has empowered patients and customers. It has given a voice to the ordinary man, who can at the push of a few buttons air his grievances to many and watch others join in, sharing in the anguish or narrating their own past woes.

However, here too rampant abuse is visible. It has become fashionable to troll service companies be it an airline or a hospital. Yes, sometimes front line service staffers may behave rudely, particularly when provoked, but is that a reflection of the organisation’s culture and ethos?

In cases involving hospitals and death, which unfortunately cannot be avoided in hospitals, it is common for the grieving relatives to take to social media airing all kinds of issues related to the quality of service and billing deficiencies. Most of these issues emerge only with hind-sight. Many of them, sadly are a matter of perception but are always aired as indisputable facts. The doctors working hard to save a life suddenly become merchants of death. While the patient is in the hospital, the usual demand is “do whatever to save my baby”, suddenly the hospital starts being accused of callous behaviour, ill-treatment and criminal negligence. In a recent case, I even heard an argument that the hospital charged so much, yet they couldn’t save the child. If only, we could buy a precious life, by spending money….

To make matters worse, we than see the proverbial mob arrive. Everyone here has a past tale to narrate about the horrors they suffered at the same or even other private hospitals. This becomes the pre-dominant narrative, and if the hospital tries to respond with facts, they are showered with the choicest and the nastiest abuse. The hospital decides to usually cop it and wait for this to blow-over.

Sadly, this too causes a serious erosion of trust between doctors and patients. It simply helps no one.

So What needs to be done

The hospitals need to acknowledge that there might be some bad eggs among their fraternity. These need to be weeded out. They also need to acknowledge that patient communication is not their strongest suite and they need to work on it more diligently. They also need to show greater empathy and take care of the “small things” that can so easily be fixed yet cause serious consternation among the patient community. They also must set up Patient Grievance Committees to help patients reach out and complain if they are not satisfied with any aspect of care or have an issue with billing.

The patients have to realize that private healthcare in India is becoming more and more expensive (while it still remains the cheapest in the world). This is only natural as Indian hospitals aim to deliver better quality healthcare across the board. If they choose to go to private hospitals in the hope of receiving world-class care, it is bound to be expensive. As responsible citizens they must have health insurance to protect themselves in medical emergencies. Running down hospitals and doctors on social media does not help in any manner. On the contrary it does immense damage. Patients and their care-givers must also realize that hospitals cannot guarantee a particular outcome, they can only try. By being dismissive of their desperate and perhaps ”expensive” efforts later on, they are only encouraging doctors and hospitals to hold their horses in their battle against disease. Let us not do this.

As far as media is concerned, they must stop playing to the galleries. Individual lapses must not be generalized to vilify hospitals and clinicians in general. While one understands their love for the TRP’s (after-all everyone needs to make a living!!!), they must carefully ponder the kind of damage they are doing to the sacred relationship between doctors and patients. Do highlight lapses as human errors, negligence as failure of an individual or a system but do not call everyone crooked and corrupt. The majority and by far the majority of clinicians try their best to cure without causing any harm.

Sadly, in the polarized, binary world that we increasingly inhabit, this is perhaps too much to ask.

The views expressed here are personal. 

Connecting Better with Patients Works Wonders

Hospital_bedside_caring2

Most doctors I know are reticent with their patients. Curiously the better they are at the work they do, the greater the reticence. They will walk over to the patient’s bed, look at the charts, confer with their colleagues, instruct the nurses, maybe inquire from the patient about how they are doing, mumble a few reassurances and then they are gone. The patient is often left pining for more information and hoping that their doctor would spend a little more time with them, maybe even share a light-hearted moment to lighten a grim day or just hold their hand for a while.

While medical outcomes do matter in the end, a doctor’s ability to connect with his patients is what matters during their stay in the hospital. I recall how Dr. Harsha Hegde a former colleague and a orthopaedics and spine surgeon would interact with his patients on his rounds. I have seen him checking on his patients, while chatting up with them on all manner of things. He would walk into a room, chat up with the patient about anything under the sun, engage with the patients as a friend, assure them that they will be out of the bed soon, crack a joke or two and in the same breath pass on the necessary instructions to the nurses or other colleagues. I even recall on many occasions, he would invite a patient out for dinner in the evening, particularly the day before the patient would be ready for discharge from the hospital!!!

Once we had a patient from the US, a school inspector if I recall correctly. He had come in pain and required a two level cervical disc replacement surgery. Dr. Hegde, duly operated on him and one evening as I was heading home, I saw him in the hospital lobby with the patient. Apparently, Dr. Hegde was taking him out for dinner !!! The patient too appeared to be in a state of shock, saying that he could hardly believe his luck. Three days back he had arrived from the US suffering from excruciating pain, and here he was heading out for a dinner with his doctor, who already seemed to have wrought a miracle.

While, what Dr. Hegde does is exceptional, most patients would be happy with a lot less. When the doctors start connecting with their patients, the patients also tend to be a lot more forgiving. A nagging unexplained pain, a sudden unexpected turn for the worse, a longer than planned stay in the hospital, and even a bigger bill are forgiven if the patient believes that their doctor was nice to them.

These patients than start spreading the good word around. They often exaggerate their experiences, the doctor turns into that wonderful knight in shining armour, who came riding on a mythical horse and saved them from the jaws of death. The doctor becomes a true saviour, capable of doing nothing wrong and the hospital too acquires a nice and warm halo. These patients are truly a healthcare marketer’s delight, they are the ones who do all the marketing and the doctor’s reputation and the number of patient’s queuing up outside their door goes up exponentially. The doctor loves it, the hospital loves it and of course the patients love it as well.

On the other hand, a very good surgeon with excellent outcomes, but with a grumpy, matter of fact style, would always be a lesser surgeon in the eyes of the patient. While, the patients would be happy with the excellent outcomes, they would always add a line saying that the doctor is rather ‘difficult’. And, here not surprisingly the patients would find many things wrong with the hospital as well. For some strange reason they will find that the nurses do not respond on time, that the food served is rather cold and bland, the pain relief offered to the patient is poor and the hospital overcharges for everything !

Life in a hospital is such. However, I do have a hunch, doctors, who connect with their patients better, also help in faster healing. The patients probably recover quicker and better, they return homes in a better and happier frame of mind and ultimately, that is really what truly matters.

Hiring Right Makes a Hospital Special

Hiring right, is at the best of times a tricky proposition, more so if one is attempting to hire people to work in a hospitals. This becomes even more difficult if one is hiring people in managerial roles in non-medical areas, folks such as the Front Office Executives, Case Managers, Service Line Managers or Sales Managers.

This is primarily because healthcare services are unlike any other service industry. The customers here are both patients and customers, they are unwell, they don’t want to be there but circumstances have forced them to seek the services of the hospital and the expenses incurred unlike say that of a restaurant or an amusement park are an unforeseen burden. Many a times, they have been compelled to travel far away from home and they are alone amongst strangers, who will have an immense amount of power over them. And to make things a lot worse is the lingering uncertainty about the medical outcomes, indeed about life and death.

People working in hospitals must understand these factors well. Medical folks because of the virtue of their training and  knowledge comprehend these facts instinctively. However service personnel, who have moved to healthcare services from say the hospitality sector are often caught by surprise and are left wondering about the interplay between patients, customers and hospital staff.

Thus, a hospital must be very careful in hiring the right people and then training them in handling customers and patients. Here is a small checklist of what I look for when hiring people in a hospital.

Empathy:

This is the single most important characteristic that I look for in an individual. It is absolutely essential that those who work in hospitals have empathy for patients and their attendants. Many years ago I heard a doctor say that she always tries to remember that it is not a tumour that she is treating, but a human being. Anyone who works in the hospital would do well to remember that. In a hospital I would like to hire people, who can connect with those in distress and interact with a measure of understanding and compassion.They must treat every patient and his problems as the only one that they have to handle that day.

Patience and Maturity:

It is imperative that a hospital hires mature people with loads of patience. This will help in managing patients, who are generally impatient-to see the doctor, get the tests done, lay their hands on that elusive report and get the hell out of the hospital. Since most people find it hard to understand matters related to their illnesses and treatment options, it is best that we have people who can explain these things patiently, without losing their cool and without showing the slightest signs of indifference.

Hunger for Knowledge:

It is a myth that in a hospital, medical knowledge should remain restricted to the medical folks and it is only they who need it. I have seen patients asking questions from patient care executives about arcane surgical procedures, about diagnostic tests prescribed by the doctors and even about their prognosis. To my mind, every individual working in a hospital should aim to acquire and benefit from basic medical knowledge. For me, part of the charm of working in a hospital has always been the immense amount of knowledge I gain by interacting with medical colleagues. In conversation with doctor colleagues, if I find myself lost, I never hesitate to ask them to stop and explain things to me in terms that I can understand. It always helps, when I am required to explain a procedure to let us say a foreign patient contemplating travel to our hospitals in Delhi.

Ability to Get Along with Doctors

It takes a special kind of skill to work with busy doctors, who are always short on time and stressed out. One needs to adapt to their work schedules and understand their pressures to put things in the right perspective. Also, one must remember that they are trained as doctors and not as professional managers, thus often their understanding of a manager’s world is not the same as that of another professional manager. In my experience it is best to always try to understand, where they might be coming from rather than articulating management dogma, which they may not understand well or may find obnoxious.

Optimistic and Cheerful Disposition:

Those blessed with an optimistic and cheerful world view do well in a hospital. A hospital needs loads of people with a sunny disposition, who always look at the brighter side of things and who are hard to put down. These are individuals, who are eager to help, who go out of their way, do that bit extra to make someone happy, because that is what makes them happy.

Rigorous training and an organisational culture based on openness and trust helps these people become good to great and transform the hospital into a wonderful place of healing and caring.

Why some of our doctors have such poor bedside manners?

I have often wondered, why some of our doctors have such poor bedside manners and never more so since my father’s surgery.

My father underwent an urgent Prostate Surgery earlier this week. The surgery was conducted at one of the most well-known and if I may add, sought after hospitals in South Delhi. The hospital and the surgeon are familiar to me from many years and yet this is what happened one evening.

The surgery in the morning had been uneventful and the surgeon was happy with my father’s progress. In the evening as my wife and I sat in his room in the hospital, two gentlemen barged in and started examining my father. They lowered his pyjamas for the examination, chatted with each other, assured him that all was well and walked off. As they were leaving I asked them who they were and one of them introduced himself as an associate of my father’s surgeon and left.

Now here is my problem.

I have no idea who these people were. They wore no surgeon’s gowns, they had no telltale stethoscope around their necks. They marched into our room without a knock and proceeded to examine a patient, without his permission. They removed his pyjamas for an examination, with two people sitting in the room and the door wide open. I was shocked to witness this humiliation and I could feel my father’s acute discomfort.

To the doctors, strangely nothing appeared to be amiss! When I stepped out to have a word with these gentlemen and pointed out their completely unacceptable behaviour, they appeared surprised that a patient’s attendant has the gall to question them and arrogantly dismissed me saying that if I had any complaints I needed to address those to my surgeon! They did not deem it fit to utter a word of apology for their appalling conduct.

All this at as I said earlier  at one of  Delhi’s finest and most expensive hospital.

Why do some doctor’s treat their patients as if they do not exist or matter? I believe this is primarily because we patients allow them to. In India, a career in medicine enjoys tremendous social prestige and doctors are treated with enormous amount of respect. We bestow on our doctors God like powers of life and death and since in our eyes they are Gods, we refuse to see their shortcomings and failings. Gods afterall can treat us, the mere mortals, as they please.

To make matters worse, most of our doctors receive their training in government hospitals, where the poor and the uneducated see these doctors in their shiny white coats and stethoscopes as people from another world. In these hospitals overflowing with people from ‘darkness’ (to borrow a word from Arvind Adiga’s ‘The White Tiger’) they are treated as the lords and the masters of all whom they survey. These doctors  from an early stage in their training imbibe these behavioural patterns and one assumes that in later life, in different hospitals and while treating educated folks, the old habits refuse to die.

Lastly I also believe, that parental and peer pressure force many a youngster to choose medicine as a career, while they just do not have the calling. The admission procedures are also flawed as they test knowledge but not aptitude. Thus we have doctors, who have no business being doctors. They are trapped in a glorified profession from which there truly is no escape. Can we really blame them for (mis)treating patients the way they do?

How do we cope with such arrogant and errant doctors? Well, I see no reason why we cannot simply ask them to treat us better. Their ego may stand in the way of apologising or showing contrition, but I am sure they will think twice about being discourteous the next time around.

And that should be a good enough start.

PS:Lest this sounds like a diatribe against doctors I hasten to add that I also know many very competent doctors who treat patients with great courtesy and professionalism. They are warm individuals, love their work, have great compassion for the sick and look upon their profession as nothing less than a calling. They not only treat but heal and that is where the real difference lies.

PicCourtesy: http://thyroid.about.com/b/2008/08/19/six-rules-doctors-need-to-know-and-six-ways-to-be-a-better-patient.htm

So much for my ‘Indian Hospital Experience’

Doctor WhoWhile trawling the net I came across a blog (http://www.travelblog.org/Asia/India/National-Capital-Territory/Delhi/blog-440604.html) about the travails of an American, getting treated for a mole/wart/skin cancer in New Delhi. The experience narrated in this post is exactly the kind of stuff we do not want. I am amazed at some of the narration and the stereotyping this does of the Indian doctors and medical system.

The blog has a semi mad sardarji (sikh) as a doctor who speaks and understands no English, laughs at his own jokes in Hindi and does not understand the difference between a mole and a pimple. The doctor has never heard of the United States and knows America, a country whose citizens are rich and ripe for fleecing. The doctor prescribes lotions and creams for treating the mole, which are not available at his own pharmacy and the patient (the author) walks out, having parted with Rs. 500 and nothing to show for it. Astoundingly, this gentleman returns to the clinic of the mad sardarji, encounters a ‘wildeyed’ patient on a wheelchair, and asks the doctor to burn off the offending mole in the emergency room next door.   Continue reading