iRADiX

After going through the wonderful blog of Dr. Alok's "Cut practice" and the intelligent responses , I started wondering , about Medicine, Medical Profession and Professionalism, in context with present day of economics driven and economics controlled crazy world and its dominant living occupants known as Human beings and their 'Next only to God' physicians.

Profession

Webster’s Dictionary says "Profession is an occupational group of people who have learned specialized skills that allows them to serve the public need".

Examples given include Medicine, Law enforcement and Architecture.

Please note the definition. The skills acquired are to be used only for the purpose of serving the public need.

Medical profession

Free Dictionary says "Medical profession is a body of individual who are qualified to practice Medicine"

Now it is clear that anybody taking Medicine as a profession by virtue of definition of 'Profession" automatically allows himself/herself to serve the public need.

And one should remember that one is subject to obligations and values

The practice of fee-sharing or cut practice is regularly condemned by the medical fraternity and general public. Patients are waking up to this reality, making it one of the major reasons of declining doctor-patient relationship. Almost every discussion about cut practice results in loud cries of moral indignation. Despite this, such practices flourish and have now enveloped much of the modern medical practice.

Forms of Cut Practice

We radiologists tend to think that we are the most affected by this ‘affliction’ but it is much more diffuse and pervasive in the medical field. It takes many forms (1):

• Giving a share of fees to the referring doctor.
• Referring patients for unnecessary consultations or tests to ensure a kickback from the consultant or laboratory.
• Giving expensive gifts periodically to the referring doctor.
• Appointing junior specialists to a super specialty hospital so that procedural work is always referred by them to you.
• Unnecessary admissions in nursing homes/hospitals.
• Sponsoring of a conference or payment of travel expenses by a company in return for the use of its equipment or prescription of its drugs.

Role of Apology in Practice

One of the things the average doctor doesn’t have time to do is

catch up with the things he didn’t learn in school, and one of the

things he didn’t learn in school is the nature of the human society,

its purpose, its history, and its needs….If medicine is necessarily

a mystery to the average man, nearly everything else is necessarily

a mystery to the average doctor.

Milton Mayer

“Would you accept an apology” the senior doctor asked the relative.

Later, he asked the resident whether he would like to apologize.

The three of them then met and a face-to-face discussion led to restoration of harmony.

“We are all human” the relative said after it was all over, accepting the factthat mistakes can occur.

How will you disclose unanticipated unfavorable outcomes? To whom will you disclose? How much will you tell?

Mammogram Errors
In “Disclosing Harmful Mammography Errors to Patients” Thomas H. Gallagher et al(2) tried to assess the attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient’s mammogram leading to a delayed diagnosis. This study was based on a survey which included items on demographics, practice characteristics, and experience in radiology and breast imaging. A copy of the survey is available online (http://breastscreening.cancer.gov)

To assess radiologists’ attitudes about disclosing errors to patients, the survey contained a vignette involving an error interpreting a patient’s mammogram, leading to a delayed cancer diagnosis:

“A diagnostic mammogram for a new palpable lump shows an obvious malignant lesion. You realize a mistake was made in your prior interpretation of this woman’s last screening mammogram. Prior films had apparently been put up in reverse order, and you mistakenly concluded that the calcifications were decreasing in number when they were actually increasing. Your prior incorrect interpretation has resulted in a delayed diagnosis”(2)

While examining the “Impartial spectators” one can try to see what other games are being played.

Game Theory
This is a branch of economics useful to study business behavior, concerned with representing economic interactions in a highly stylized form, with players, pay-offs and strategies.

For those esteemed readers who subscribe to “I-follow-Adam-Smith-not-Marx” (money-at-any-cost) Amartya Sen’s recently published book “The Idea of Justice” should be a must read. In this he teases out the confusions arising from the most famous and widely quoted passage from the Adam Smith’s The Wealth of Nations.

It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest. We address ourselves, not to their humanity but to their self-love, and never talk to them of our own necessities but of their advantages.

So we appointed ourselves as “Impartial Spectators”?!

Open and Closed Impartiality
The editors of the first edition of Harrison’s Principle of Medicine wrote “To the physician, as to the anthropologist, nothing human is strange or repulsive.”

And yet when one examines some of our current trends of practice, one does not feel comfortable at times.

There is a basic distinction of different ways of invoking impartiality, and that contrast needs more investigation. Who will be an impartial spectator in the context of a small child who comes for repeated follow-up CT scans ordered indiscriminately by the referring physician just because the patient is insured?

The state of our medical practice as has been illustrated in the previous blogs and the comments following speaks for itself.

Can there be Science without conscience? How do we work towards preservation of the patient-physician relationship in this milieu?

Indiscrete Jewels

There could be no better hook upon which to hang a contemplation of our milieu of practice than the fictional dream recounted by Denis Diderot (1) in his novel Les bijoux Indiscrets (1748;The Indiscrete Jewels). In this work Diderot describes a building without foundations, whose pillars, among which deformed and crippled men loiter about, soar upwards into swirling mists. The building is the Palace of Hypothesis and the old men are theologians and metaphysicians. Then an energetic little child appears, and as he approaches the building he grows into a giant; his name is Experiment, and when he arrives at the Palace of Hypothesis he gives it a mighty blow which smashes it into ruins. Thus science shatters the systems of Theology.

Evidence based work

A search for common values in a rational scientific context centered on preserving the patient-physician relationship can be found in the approach of “Evidence Based Radiology”(EBR).Why this debate and discussion, some friends may ask. It is in ‘enlightened self-interest’ to prevent burn-out, lack of interest in work as one finds the key decisions relating to one’s practice slipping out of one’s hands. Evidence based Radiology is a method inspired from the analytic process. It emphasizes autonomous reflection, systematic identification of roles, motives, and consequences of current actions and organizations, clarification of aims and means; selection of principles and values, and equilibrium, application and validation. This method entails constant vigilance and repeated revisions, but the allowance of time to think about ethical matters and decrease confusion and moral perplexity. The result is a stronger moral personal identity and a brighter horizon for a satisfying professional life. ”. (2, 3)

In acquiring one’s conception of the world one

always belongs to a particular grouping which

is that of all the social elements which share

the same mode of thinking and acting. We are

all conformists of some conformism or other,

always man-in-the-mass or collective man

Letters from Prison

Antonio Gramsci (1)

In developing a language and discourse of the possibility of a “Radiology Utilization Committee” there were some interesting thought provoking comments and links. From the link provided by

Dr.V.Sridhar(http://www.sfrnet.org/data/upload/files/a7e7222e420ac736c1256b6c0044cb07/euratom-anglais.pdf) it is clear that there has been a lot of detailed scientific discussion on these aspects.

And still I find myself bowing in front of the Urologist who is indiscriminately ordering follow-up CT scans. As was briefly mentioned in the previous blog-whatever happened to the patient’s right to information. How much Fairness and Justice is there in the milieu of our medical practice?

 

From passionate reformers, ethical scientist torch bearers, to grumbling egoists, and degenerate commission seekers, they come in all shades of grey.

Here are some conversations with Neurosurgeons.

 

Does a poor man not have neurological illness?

He was the best singer of us all. The strains of the sitar played by him on the 12th floor as we would feel the breeze flow from the Arabian Sea and watch Parel and Worli Sea face are still with us-deep inside. We would go to Gloria restaurant in the evenings and have Mangalorian food while he confided the nuances of his courtship. Gloria also serves liquor on the sly. He would take us through the Ragas and also gave us a window into the social reform movements of Maharashtra in the tradition of Jyotiba Phule and Bhimrao Ambedkar.

 

Hippocratic Oath has lost relevance due to ever changing religious, political and social milieu. I faintly remember a line 'you can not advertise yourself, though you can advertise your hospital'. Taking into account a large number of physicians doesn't it sound absurd? In your daily life and during your practice have you not been asked by the public or a fellow doctor as to which hospital or doctor would be better for a particular patient. Do we not enquire where to send a patient for X-Ray, C.T. or MRI and do we not know whose report is reliable and whenever the report appears unsatisfactory do we not look for the name of the doctor signing it. Some institutions have developed a name for themselves, like AIIMS in Delhi, KEM, TATA memorial hospitals in Mumbai to name just a few. These hospitals are very large many with over 2000 beds and a large number of satisfied patients go home talking good about them. These hospitals need no further advertisement.