How to Visit
a Doctor’s Office (If You Must)
By Zulfiqar Rana, MD,
MPH
Mobile, AL
In the US, when patients talk
about wanting to avoid physicians they usually
mean that they do not like the long waits, the
extensive paperwork or the insurance hassles.
However back home, when people talk about not
wanting to go to a doctor’s office they
are usually dreading doctors per se (apart from
financial reasons). However, doctors are a necessary
evil. We need them in urgent and emergent situations
and seeing them actually seems to help (sometimes).
I remember once one of my friends talked to me
about his harrowing experience about going to
a doctor back home. The ailment started as a simple
backache but soon culminated into a recalcitrant
pain syndrome that just would not go away. It
got to the point where it was affecting his quality
of life. Thereafter started his ordeal entailing
doctor visits, a plethora of tests that yielded
nothing except cash and kick-backs for physicians
and a host of failed therapies. After a few visits
my friend had a flash of brilliance. He was going
to this joint specialist and nothing had worked
so far. Moreover, the rheumatologist’s explanations
about the diagnosis and treatment left much to
be desired not to mention the hefty bills that
were accumulating for those five-minute consultations.
So he gathered the courage and asked the specialist
if he could get a second opinion. Let me pause
here for a moment and explain to you the rationale
behind my friend’s move. In the US (and
I am sure elsewhere in the Western world as well)
it is quite common to ask for second opinions
in difficult cases and physicians really do not
mind this practice. My friend had lived in the
US for some time and probably had a little spell
of amnesia that day as well. Needless to say,
the consultant took quite an affront to that and
as they say the rest is history. The patient was
summarily discharged from the doctor’s care
and was eventually left stranded.
This story is by no means an exception or an outlier
– it is the norm back home. The question
is why are doctors the way they are? Why are doctors
rude, perfunctory and dismissive to their patients
back home? The answer to the problem is complex.
The transformation starts at medical school (or
as some would contend much before that). A starry
eyed teenager enters the medical school with a
resolve to find cure for cancer and a few years
later he is transformed into an incurable cynic
and a skeptic. However, this is a topic for another
day. For now I am going to focus more on immediate
causes instead of long-term theories. As far as
I am concerned this behavior can be explained
on the basis of three things (I am sure there
is a myriad other causes one can think of as well).
First, the way the health care system is financially
structured in South Asia. Second, the way mechanisms
for accountability, regulation and legislation
are in place for physicians and hospitals in South
Asia. Last but not least the way the public in
South Asia perceives physician roles and duties
has a bearing on this matter as well.
In South Asia like the rest of the Third World
the health care system is still overwhelmingly
fee-for-service. This means that unless you pay
the physician you do not get treated. Admittedly,
government hospitals do a respectable job of taking
care of the indigent population; the out-of-pocket
expenses are still sizable. Just to give you an
example. If a patient needs surgery the OR, physician
and hospital charges are more or less waived.
However, the patient is still responsible for
the antibiotics, intravenous drips, dressings,
suture material and so on. All this can pile up
to a pretty hefty sum in the end. The downside
of this set-up is that it gives the physicians
an unfair advantage in terms of their bargaining
power. This is manifest in the type of patients
they see, the fee structuring and scaling and
the quality of care they impart to their patients.
Due to this, health care access, cost and quality
all suffer. Part of this has to do with the overall
condition of the judicial bodies in this region
the discussion of which is beyond the scope of
this article.
Second, the state of bioethics and its implementation
is still in a deplorable condition in South Asia.
It is a fact that medical counsels and physician
organizations in South Asia have not been proactive
in nurturing this oft neglected but extremely
important medical discipline. To be fair it should
be admitted that this field is relatively new
in the Western world as well. (1) Moreover, the
principles of bioethics that emanated from the
West may not be wholly cognate with Eastern values.
For example in Eastern setups that are more parochial
and family oriented the concept of privacy does
not have the same implications as in the West
and is often more difficult to implement.
If in this case the physicians are to be blamed
for the most part then the society does not go
scot-free either. Doctors are esteemed so highly
that the public is willing to overlook any shade
of deviancy on their part – from frequent
gaffes to overt criminal behavior in certain instances.
Therefore, you rarely see doctors go on trial
for malpractice in this part of the world. I remember
once when I was in medical school we were attending
an Ear, Nose and Throat outpatient clinic run
by a senior doctor. This gentleman was not only
at the pinnacle of his career but had authored
some kind of book of poetry in English as well.
With this impressive dual qualification he was
really the king of his little hole. He was seeing
a lady with a sore throat and after he was done
the patient meekly asked him what she should eat.
This was a perfectly legitimate question but our
attending thought it otherwise. In a rather irate
tone tinged with haughtiness he exclaimed, “chicken-a-la-Kiev”.
He then looked triumphantly at us. The sad part
is that back then we thought that his retort was
quite impressive and funny. The patient left quietly
after that reply. This rather forgettable incident
is just another example underlining the fact that
doctors are routinely involved in unconscionable
bioethical practices ranging from verbal to even
sexual abuse without any serious repercussions.
The doctors however choose their victims carefully
from among the indigent population, people without
power base, retired and elderly people etc –
which incidentally is the majority of the patients.
What is equally surprising is that most patients
would take this abuse without any recourse - verbal,
physical (not recommended of course!), legal or
otherwise.
So in the end what options are we left with? Not
many I would confess. Just go see the physician
(if you must), tell him your symptoms, get the
prescriptions, pay his fee and get out of his
clinic. If you know an MNA call him first. However,
next time you see a physician and he seems a little
paternalistic or slightly dismissive or a tad
bit hasty and irate at least you would know why
he or she is like that. Knowing the diagnosis
is half the cure - sometimes.
---------------------
Notes:
(1) It was only as recently as 1978 when in the
Belmont Report an outline of three most important
ethical principles was delineated. (Those were
respect for persons, beneficence and justice).
