I was reminded of these words written over a hundred years ago when I heard the following on a recent visit to India.

A friend’s experience

A friend’s wife took her young married daughter for prenatal care to a husband- and-wifeno-hyphen team of obstetricians practising near their house in north Bombay. The couple belonged to the same community as my friend (an assurance of competency and personal attention?) and were highly regarded as they had trained in Germany. Shortly into the consultation the lady doctor exclaimed that this was obviously a tumour, not a pregnancy at all. My friend and her daughter were shattered. The lady doctor spoke to her husband in German, the conversation being completely unintelligible to these two ladies, scaring them even more. She turned to the patient saying prompt surgery was essential.

On returning home from work, my friend found his wife and daughter in tears. When he heard the details he accompanied them the next day to the nursing home and despite pressure from the doctor-couple to reserve a room for the impending surgery, entreated them to wait. Intending to get a second opinion, he requested a copy of the consultation report but the doctor refused to give it, angrily saying he did not have to seek their care if he did not trust them. My friend pacified the doctors promising to return the next day with the necessary funds for surgery. Instead he made a frantic phone call to an obstetrician in central Bombay who had taken care of several of his friends and relatives. A normal pregnancy was diagnosed and, sure enough, six months later his daughter delivered a healthy baby girl.

Elementary, my dear Watson!

The doctor’s errors are glaring in this incident. Should the doctor have pronounced a definitive diagnosis without considering other diagnoses particularly in a situation where the pronouncement was likely to be so traumatic? Should she/he not have ascertained the diagnosis by appropriate tests before recommending surgery? Clearly, a written report of the consultation should have been made available to the patient as the patient has the right to a copy of her/his medical record which includes all notes made by the physician and results of all tests. Finally, the patient should not have been discouraged from getting a second opinion because a patient has the right to consult other professionals and has the right to question the correctness of the diagnosis and treatment plan advised by a doctor. Perhaps my friend and his family’s mistakes are less obvious. They never informed the first doctor that the diagnosis of tumour had been questioned by the second doctor. Later they never sent even a letter to the first doctor saying that the daughter had delivered a normal baby. How can doctors be made to adhere to a high standard of ethical behaviour?

In the USA the doctor’s code of conduct is enforced by the regional medical societies, similar to our Maharashtra Medical Council. This has evolved over the years to its present form due to legal and societal pressures. Perhaps that will eventually happen in India too. Until then or as an alternative, one could have a panel composed of experts (preferably retired doctors who would be willing to donate their time) and representatives from the lay public under the aegis of a neutral, respected non-governmental organisation.

This panel could investigate complaints quickly and render a public opinion. Public scrutiny would result in loss of face for the doctor and affect his/her practice through negative word-of-mouth advertising.

Perhaps this will act as a greater deterrent than lawsuits as in India, the judicial process is excruciatingly slow and prohibitively expensive as lawyers don’t yet have a contingency fee system. Finally, in this day of privatisation, a for-profit business could employ medical professionals to assess a situation and recommend a course of action, for a fee.

How can patients correct doctors?

Why was my friend so reluctant to confront the first doctor? There are many things that stand in the way of patients bringing about a change in the way medicine is practised in India. Firstly, the attitude of hero-worship of the doctor that is prevalent in the society. Secondly, the paternalistic way in which all doctors treat their patients, ‘We know what is best for you. ‘ Thirdly, the very idea that one can challenge authority is discouraged from childhood onwards. Finally, the fatalistic attitude that after all complaining is not going to redress the injury or loss, and, after all, one might need the help of the same people tomorrow so why antagonise them today. The middle class will have to learn to demand accountability from the system. Recognising their common interest, the middle class will have to organise, across castes and religions, to fight for their rights and not wait for the government or some other body to solve all their problems.

Signs of change

People are beginning to demand compassionate and competent care from their doctors. What often holds people back is the lack of knowledge- what are their rights in a given scenario? How do they go about exercising those rights? One way to encourage awareness of patients rights is through consumer organisations dedicated to health care who can publish brochures on standards of care and mechanisms of seeking redress when those standards are violated. Patient support groups can promote exchange of information about care given by specific doctors and hospitals. Since the public does not read specialised journals like Issues in Medical Ethics, newspaper articles based on real cases of misconduct, showing step by step how a patient can get complaints addressed, would be invaluable. Finally, the great medium of TV could be utilised to reach even the illiterate

Health care in India has become a nightmare for not only the poor but also the well-to-do. Where the medical professional is not held accountable, the government lacks the political will to mandate and enforce the necessary reforms, the medical councils only too happy to let things remain the way they are, the patients alone are going to be the engines of change.