Yesterday morning, on my out patient day, I was prescribing a medication to a gastritis patient.The patient was a 40 something thin built man who had quit alcohol some time ago, but still continued having severe burning pain in the upper part of his abdomen. Just after I finished instructing him on the usage of the medication, a young medical representative lady came to me and requested me to prescribe the drugs her company manufactured.The drug was a commonly used medication sold in liquid form for wound cleansing.I told her that the drug was a very useful product which we had found comparitively cheap and very effective during our daily surgical practice,I would prescribe the medication as and when feasible. I also requested her to leave a sample with one of my postgraduates so that we can use the sample on some poor patient. The lady smiled as she said 'Sir, our product is very cheap and affordable, it only costs Rs 54 for a 50ml bottle'. Well, it was my turn to smile back at her as I said 'Look lady, your brand may be the cheapest and the best in the market but sometimes even that is not affordable for some of my patients!'. She left a sample, rather reluctantly, with my junior and left.
The same afternoon the gastritis patient came back to me and requested me to prescribe a drug which was available in the hospital. I told him frankly that he had a severe variety of the condition and as our hospital had no such 'strong' drugs in stock, I would still advice him to buy it from outside. He was embarassed a bit when he told me that he could not afford the medication (about Rs 19 for 10 tabs) as he had just enough money to get back to his home in Doddaballapur taluk.I told him to buy the medicine as soon as he gets some money and gave few samples of the drug my postgraduates had.Reluctantly, I wrote him some 'weaker' medications (not very effective and which would take more time to act too) which he could use and (more importantly) which were available with the hospital pharmacy.
There was no other way. Even though the drugs which I prescribed produced less than the desired effect I had to give those drugs.Apparently, getting the patient back home was more important than the correct treatment in the present situation.I had followed the Social Indication (rather than the Medical Indication) rule to give a less effective drug for a disease condition.
Indication,in medicine, is defined as the basis for initiation of a treatment for a disease or of a diagnostic test;may be furnished by a knowledge of the cause(causal i.),by the symptoms present (symptomatic i.)or by the nature of the disease (specific i.).(Stedman's Medical Dictionary, 28th Ed).In simpler terms,an indication is a term describing a valid reason to use a certain test, medication , procedure or surgery.
All throughout my undergraduation and postgraduation days (MMC, Mysore and KIMS, Hubli respectively,both Govt hospitals) I have been lucky enough to work under professors and teachers who had a penchant for social indications.I have seen them use their authority and intelligence to employ it at various situations.I have seen patients not being discharged from the hospital just because they did'nt have the money to go home, old people being admitted to the hospital just because there was nobody in the house to care for them, prolonging the placebo tablet treatment just to keep the lady from being beaten by her husband,admitting dying patients because the immediate relatives were not bold enough to give a satisfactory end of the patient and so on.I believe I have learnt from them as well as from my own mistakes and interest to fit social indications wherever they might feel right.
In the same way as we doctors and surgeons respect the ethics of our sacred practice(to be correct and accurate always) we should also respect the situations people are in, or are going through, which is most of the times, quite a big challenge.
The same afternoon the gastritis patient came back to me and requested me to prescribe a drug which was available in the hospital. I told him frankly that he had a severe variety of the condition and as our hospital had no such 'strong' drugs in stock, I would still advice him to buy it from outside. He was embarassed a bit when he told me that he could not afford the medication (about Rs 19 for 10 tabs) as he had just enough money to get back to his home in Doddaballapur taluk.I told him to buy the medicine as soon as he gets some money and gave few samples of the drug my postgraduates had.Reluctantly, I wrote him some 'weaker' medications (not very effective and which would take more time to act too) which he could use and (more importantly) which were available with the hospital pharmacy.
There was no other way. Even though the drugs which I prescribed produced less than the desired effect I had to give those drugs.Apparently, getting the patient back home was more important than the correct treatment in the present situation.I had followed the Social Indication (rather than the Medical Indication) rule to give a less effective drug for a disease condition.
Indication,in medicine, is defined as the basis for initiation of a treatment for a disease or of a diagnostic test;may be furnished by a knowledge of the cause(causal i.),by the symptoms present (symptomatic i.)or by the nature of the disease (specific i.).(Stedman's Medical Dictionary, 28th Ed).In simpler terms,an indication is a term describing a valid reason to use a certain test, medication , procedure or surgery.
All throughout my undergraduation and postgraduation days (MMC, Mysore and KIMS, Hubli respectively,both Govt hospitals) I have been lucky enough to work under professors and teachers who had a penchant for social indications.I have seen them use their authority and intelligence to employ it at various situations.I have seen patients not being discharged from the hospital just because they did'nt have the money to go home, old people being admitted to the hospital just because there was nobody in the house to care for them, prolonging the placebo tablet treatment just to keep the lady from being beaten by her husband,admitting dying patients because the immediate relatives were not bold enough to give a satisfactory end of the patient and so on.I believe I have learnt from them as well as from my own mistakes and interest to fit social indications wherever they might feel right.
In the same way as we doctors and surgeons respect the ethics of our sacred practice(to be correct and accurate always) we should also respect the situations people are in, or are going through, which is most of the times, quite a big challenge.
It is a deeply moving story of your experience. You have stated it so well.
ReplyDeleteSocial indicators are just as important as physiological indicators in assuring total health of a person. Your last but one paragraph is just wonderful.
Twentieth century has seen medicalization of human health to the detriment of total health. It is heartwarming to see qualified young people like you restoring the correct balance. More power to you.
Although I agree to you on the Social Indication. I have a major disbelief in accepting the fact that Social Indication can be replaced with the Medical Indication. In what way can it help achieving the end result compromising on the right thing to do?
ReplyDeleteSecondly, In this case, can you not, by all your knowledge and influence being a in house surgeon, ask the hospital pharmacy to procure the right medicines and hand it over to the patient? I know it may not be possible, but would it not be the better social indicator?
Hi Srik,
ReplyDeleteSorry for the delay in responding.
Firstly, we are not trying to replace social indication(SI) with medical indication(MI) or the vice versa.SI and MI have to go hand in hand.
In medical colleges we are taught to do things correctly in a medical sense, we are not taught to do good things in a social sense.Example;-A patient CANNOT be kept in the hospital after his treatment, whatever the social reasons.A doctor is RIGHT medically to send him after the treatment completion as keeping him for more time in the hospital causes more harm medically(like secondary infections, decreased nutrition, even complications like bed sores, etc.And obviously a home is always a better place than a hospital).But, we should also worry about the social circumstances (which are not taught to us syllabus wise or which are not mentioned in textbooks, these can only be learnt if the doctor has interest in it).We have a situation here where we will have to balance between the medical and the social complications.Narasim has said this in a simple way 'medicalisation of human health to the detriment of total health'...we may have done the RIGHT thing by treating(and discharging) the patient, but have we done any GOOD to the patient and the society?The question is between doing RIGHT things and doing GOOD things.We may be right (by definition) in many instances but if it is bad to the patient and society, I dont think the purpose will be served.By giving more importance to doing things in a 'right' way we should not forget the 'bad' things which may follow.
By employing SI we are shifting a bit more towards doing good than just doing the right things.
To answer your second question;- To get new drugs to our hospital pharmacy, first a professor(not a lesser ranked surgeon) has to give a written request to the superintendent, which will be placed in front of a ethical committee comprising a team of decision makers.The meeting is called once every couple of months(emergency meetings will take days), maybe a month once.It has to get through the meeting to come to the pharmacy.My guess is it will take a minimum of 2 months(excluding the time taken to call the tenders, processing them and purchasing them) to transfer them to the patient.And of course a pharmacy cant have all the drugs at all the times as there are so many drugs with various combinations and with different concentrations too.Besides talking in a social sense, better than asking the patient to come to the hospital next time(and spending for the bus) I think he can buy them at his place for the amount which he is spending for the bus.As you know this is simple thinking with a sense of doing good rather than doing the right thing.
I think I have made some points clear.As always, comments and queries are welcome.Feel free to ask questions as we are trying to be 'good' rather than 'right'. :)
Thank you for clarifying the questions raised by Srikanth. Your explanation helped me to understand your value system better.
ReplyDeleteThanks Doc! for the clarification. However, your first part of the answer gives the distinction between the good and the right thing. And what 'you' chose to follow. Like Narasim said - your value system. Good for you! But my question was completely different and was with respect to the end result.
ReplyDeleteSecond part of the answer was known to me. If not why will people in India compromise over what they get from the government?
In both your responses the strong feeling that I get is that poor people living in India will need to be always 'Compromising' on what they do not get!