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How to Recognize a Trustworthy Doctor


Dr Abhay Shukla and Dr Arun Gadre |July 5, 2017|15:14

PHOTO ILLUSTRATION By NILANJAN DAS


PHOTO ILLUSTRATION By NILANJAN DAS
The
difference
between a
rational,
ethical
doctor and
one who is
not can be
the crucial
difference
between
good health
outcomes
and bad
health
outcomes,
and
sometimes
even
between life
and death.
As doctors who have practised and interacted with many other
doctors, we share clues about how to spot a good physician, not
just by looking at technical qualifications, but based on their mode
of interacting with patients.
The most important asymmetry between a doctor and patient is
the asymmetry of knowledge. The doctor generally knows much
more about what is going on in the patient's body, what needs to
be done and what is the likely outcome than what most patients
will ever know. Given this context, the doctor has a duty to share a
small portion of his or her vast pool of knowledge with the patient-
-at the very least by carefully addressing the questions and doubts
of the patient and caregivers; and by allowing them the autonomy
of choosing appropriate treatment options, wherever possible.
One case from Dr Arun Gadre's experience is illustrative of the
importance of these attributes in a doctor. A 90-year-old man was
admitted at midnight to a reputed nursing home with heart failure
and severe breathlessness. The relatives were anxious- even
though they knew that age was catching up with grandpa, his
present suffering was unbearable. The physician came and
prescribed something; he was not ready to entertain any
questions. His blunt response was: "What can we do for a person
at the age of 90 with such severe heart failure?" When the patient's
son tried to inquire about how to alleviate the old man's suffering,
the rude answer came, "Do not argue with me, I have no time to
answer silly questions."
Grandpa was shifted to another hospital. The new physician
patiently answered all the questions and elaborated upon the
nearly hopeless long-term prognosis for the elderly man, but
agreed to perform a small procedure to remove the liquid that had
collected around his lungs to relieve him of his acute suffering.
The simple process of dialogue between the patient's caregivers
and the doctor made a huge difference.
The message is simple--whenever there is a choice between two
doctors with similar years of experience and qualifications, opt for
the doctor who is willing to talk and explain things. The practice of
medicine is not just about good technical skills, to a great extent it
is also about good communication. The very word 'doctor' is
derived from the Latin word for 'teacher'. In brief, whenever we
are in the role of a patient or caregiver, we should try to choose
providers who are willing and able to communicate--every patient
deserves to be spoken to decently and given an explanation about
their illness and the treatment that they are undergoing.

A rational, ethical doctor does not create fear or panic, but


gives timely and balanced information.
It has been said that if you can make a person sufficiently fearful,
you can get him to do almost anything. And there is perhaps
nothing that induces as much fear as the apprehension of physical
suffering or loss of life. When a patient approaches a doctor, there
is a valid expectation that while the severity of the problem should
not be underplayed, the patient should not be driven to panic and
rushed into taking a major decision like undergoing an operation
(except of course in the case of genuine emergencies).
Unfortunately, nowadays instances of such 'panic-inducing
medical advice' are becoming rather common. We have not
infrequently come across situations where immediately after an
angiography, the cardiologist has told the patient, "Angioplasty
must be done immediately, within a few hours," and the patient
has been rushed into undergoing an invasive procedure, even
though the option of waiting and taking a balanced decision might
have proved to be more appropriate.

A rational, ethical doctor does not pretend to know


everything; the doctor can admit that there are aspects of the
illness that he or she cannot definitively comment upon.
Not all doctors might like to publicly admit that in a significant
number of cases, in the beginning, the doctor may be unsure of the
exact diagnosis. In these situations, the doctor is acting on
probabilities rather than certainties. The doctor may rule out
various possibilities in the course of investigations and treatment.
So when the patient or relative anxiously asks, "Doctor, what is the
illness?", in a certain proportion of cases, the fact may be that even
the doctor does not exactly know.
In these days of rapidly expanding medical knowledge, it is very
difficult for any doctor to keep up with all the developments even
in his or her own speciality, not to mention a myriad other
specialities and areas of medicine. Would we not prefer a doctor
who is aware and frank about his or her own limitations, who
does not hesitate to take another expert's opinion or refer to an
appropriate specialist, when required, in the interest of the
patient?

A rational, ethical doctor does not advise additional


investigations and procedures due to demands from the
patient.

We live in a consumerist society, where we are often conditioned


to think that 'more' is generally 'better'. Needless to say, this logic
is often inappropriate, but some well-off patients tend to think that
if some tests are necessary, then undergoing more investigations is
even better, especially if the test is more expensive. However, the
job of a physician is not to cater to each and every whim of the
patient, but rather to guide the patient towards rational
management of illness. Even though many laboratories give hefty
commissions to doctors who refer patients to them, a rational
physician would not recommend a test or procedure just because
the patient asks for it.

Doctors often have to rely on information that is incomplete,


while trying to understand what is wrong with the patient.
Doctors continuously deal with uncertainty and frequently
work their way through the patient's illness, rather than
always having an unambiguous diagnosis from day one.
The human body is an immensely complex entity, which medical
science understands only partially, and there are also tremendous
variations from patient to patient. The information available to a
doctor may be limited, and there may be unusual, unexpected or
rare manifestations of an illness that the doctor must grapple with.
Hence, sometimes it may be more logical to talk in terms of
possibilities and probabilities rather than pressurizing the doctor
to give a completely definitive answer.

Good doctors continuously manage risk--doctors who are


only interested in saving themselves may not save many
patients.
Many patients have survived and are living today because the
doctors treating them were willing to take certain risks. Especially
doctors working in remote rural and tribal areas know that
recommending a critical patient be taken away to a distant city for
treatment may be the equivalent of sending the patient home, and
maybe to certain death. If it is within their sphere of competence,
they may need to use their professional judgement and take
informed and considered risks for the benefit of the patient. Of
course, doctors must never take reckless decisions or unjustified
risks, or deal with matters that are beyond their competence. But a
small risk taken by a doctor may make a huge difference and save
a patient's life.

Doctors need to deal constantly with changing situations,


both related to medical knowledge and society. They have to
keep abreast of the rapidly changing field of medicine, and
also grapple with the changing expectations of patients.
Fortunately, today patients are on the whole better informed
about illnesses and treatments than they used to be a generation
ago; think of your overall awareness about health issues
compared to, say, your parents. This positive change should be
harnessed so that the doctor and patient/caregiver can work
together as an informed team, in dialogue with each other, and
choosing the best line of treatment that is appropriate to the
patient. However, there is also a flip side to such increased
awareness on medical issues. While Google has literally brought
us a world of information, this information may not always be of
high quality or appropriate to the patient's specific situation. In
some situations, patients may access half-baked information off
the internet and be convinced that they need to undergo a
particular line of treatment.
One of my orthopaedic surgeon friends narrated another case,
which exemplifies the changing expectations of patients and the
emerging perils of 'internetosis'. He was acquainted with an
elderly couple. The woman was in her 60s and had mild arthritis.
One day she visited him along with her husband and asked him to
talk with their engineer daughter, living in the USA, on the phone.
The daughter was aggressive with the doctor, and complained that
he was not doing his best to relieve her mother's suffering. She
asked for the his email ID, as she wanted to send him internet
links related to knee replacement surgery. The surgeon calmly and
firmly explained that the patient had mild arthritis, that
painkillers were working well and if she were to take his advice
seriously and start exercising as instructed, the painkillers could
be stopped within two months. He refused to operate and asked
them to see another doctor if they felt like. But the husband
understood his logic, and two months later the old lady visited the
him with a bright smile. She had recovered completely.
We need a doctor who would help us to interpret the complex
mass of information around us, in the light of our internal values,
to take an appropriate decision. We need a doctor who would
deliberate with us and would help to bring out the best in
ourselves, to choose the healthiest options in life, acting as a friend
and guide, not just a detached expert.
Excerpted with permission from Dissenting Diagnosis by Dr Abhay
Shukla and
Dr Arun Gadre. Published by Penguin Random House, 2016.

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