How to Make Health Care Delivery a Better One
General practitioners have become an endangered species. Specialists are being bypassed and the patients are directly seeking medical advice of Super (sub) specialists. One person clinics have given way to ‘Polyclinics’ and ‘Corporate’ hospitals have ‘swallowed’ nursing homes, in the last 25 years. Health awareness has increased and some educated middle class have health insurance cover to afford comprehensive but expensive care. Govt. hospitals are busy with Primary and secondary care only. There is a mismatch between expectations and the service provided, and lack of ethics and compassion in the health care industry, in general patient care is delivered by ‘Health care team’ consisting of Doctors, Nurses, Ward boys, Ayahs, House Keepers, Administrators, Public Relation officers and Hospital office staff.
Quality of Health Care
Individuals do not simply want affordable access to Health care but also demand high quality. This requires system approaches that prevent medical errors and institutionalize patient safety, systems of training, monitoring, research, oversight, and accountability to improve quality. The quality goals include: Patient privacy, dignity and confidentiality, Safety1, drug Prescriptions/Monitoring Administration, Hand Hygiene/Biomedical Waste Management, Documentation of Medical Records, Vulnerable patients handling, Judicious use of Restraints, Lab request form filling, “Code Blue” preparedness, Safe Transfer of Patients and Informed Consent.
Role of Govt. vs Private Health Care Provider's Role
Ideally, the Govt. must provide Health and Education free. Both are expensive, unfortunately. We can provide Health education free!. Deficiencies in Govt. policies are the delight of the market forces whose slogan is to ‘serve’ but profit is the ‘motive’. Ultimately, the medical ethics takes a beating.
Cost of Health Care
When it comes to health care, “the mentality is treat me now, bill me later” and the result is that when the patients are stuck with bills and, whatever may be the amount, are always surprised and people react and create unpleasant scenes, more so, in death cases.
A break up of Hospital bills actually reveal that the doctor's share is only about one fifth of the total cost. (Doctor's fee 20%, Investigations 30%, Drugs 30% and Devices 20%.) Drug price, control and quality should be controlled by the Government. Prices of stents and Prosthesis have been brought down. However, Generic drugs are not available everywhere. Yes, the doctors work hard for their share of the amount and the same may not be commensurate with the cost of professional education and a decade of toil, after getting selected through tough National Eligibility cum Entrance Test (NEET). The fact is, less than 2% of the students succeed to get into MBBS and out of them, about half get into Post Graduate courses.
The cost of unnecessary Health care also has to be considered because of ‘defensive’ practice. Today's patients (consumers) are potentially tomorrow's litigants in the consumer's court. According to an estimate, 20 % of overall Medical care was not needed (1/4 of Tests, 1/5 of prescription, 1/10 of procedures), 85% attributed to defensive Medicine and 70% of physicians believe, they perform unnecessary procedures when they profit from them. Unnecessary care is expensive2 (2013 $ 210 Billion- USA) Low-value care is a matter of choosing wisely. Insurance reforms are required to refuse payment for the care that is not needed.
The Role of Govt.
“When the Govt. becomes the largest buyer of health care services, it can lead to standardisation of medical procedures and prices. This will bring down the overall prices of health care services, help improve services and prevent frivolous tests and procedures, for even the middle class3.
A Relook at Medical Education
“The purpose of Medical education (is predominantly public good rather than a private one) is to improve the health of communities and to decrease the burden of illness and disease”. The need of 21st century is high quality evidence – based and patient – centered care. The profession has to agree on its collective purpose, aims and standards. People are much more than a collection of symptoms and signs – they have preferences, priorities, fears and hopes. Doctors too are much more than interpreters of symptoms and signs – Ethics is part of practice; it is a practical pursuit. Medical education has to evolve into giving medical students a holistic view of the patient and not the current narrow horse shield view. We need medical colleges to be honest with students and teach them about how things really are. We need to provide medical students with that most powerful and dangerous of life forces-reality.
Medical Council of India /National Medical Commission Measures 2018 at MBBS level
The national medical council has already adopted the Attitude, Ethics and Communication Module (AETCOM). It is a competency based curriculum to train medical students to become competent primary care clinicians, thorough professionals, lifelong learners, leaders and excellent communicators. If we improve primary care, the secondary, tertiary and quaternary care will improve further.
Assessment for a Pass
Right now, the medical graduates are ‘50%’ doctors! Raise the bar. The students need to score not less than 60% in every theory paper, which may be 75 percentile if multiple choice questions are used for evaluation. In clinical/Practicals the student shall score not less than 60% for a pass, questions should be more practical/case oriented rather than theory oriented.
Role of Patient's Family in Improving Healthcare Outcomes
Patient care systems and processes should involve the family as extended care providers. The local culture and beliefs need to be considered for effective patient and family engagement. And this will also prevent avoidable litigations, poor patient satisfaction and sub optimum health outcomes.
Unrealistic Patient Expectations (UPEs)
“In an imperfect world, patients expect you to be perfect”. The patients and their families are under the impression that doctors are to be correct 100% of the time, all surgeries will be without complications, all infections require an antibiotic, all conditions need medications/investigations, life should be pain free and that all diseases have a cure !, doctors can fix them despite their lack of self care in the form of smoking cigarettes, alcohol consumption, sedentary behavior and obesity, doctors can and should prolong life regardless of how sick the patients are. All the above have led to practice of “defensive medicine” and growing patient disrespect toward physicians. What is critical for both the doctor and the patient is basic human respect and compassion. In urban practice, patients today often come to the examination room convinced that they know what ails them and what should be done about it, meanwhile doctors are spending less time with the patients and thus can not get to know them as well as they used to do. The net result of this mismatch is patient dissatisfaction.
Resurrection of Image of Profession and Restoration of ‘Nobility’
The doctors also need to take care of their families but the total shift from service to only profit is not acceptable and this has lead to wrong perception among the public. Compassion and empathy are most important attributes of a physician and these qualities must be perceptible to the concerned. Empathy builds trust and the right attitude. Doctors are vulnerable, in fact ‘sitting ducks’ and easy targets for the public ire. Even a minor lapse is blown out of proportion, cancelling out the enormous amount of good work one might have done silently. Apart from knowledge, skills, effective and efficient communication efforts are required to earn public faith, trust, confidence and patient satisfaction. The future of the medical profession in our country depends not on legislation or medical audit but on inculcation of propriety and dedication in one's medical practice.
Role of Media and Press
For happiness, harmony and a healthy life in the society, medicine and media must be in cohesion. Media has to be pragmatic, and positive in its approach to medicine. With prudence, pragmatism and professional blend of sincerity as well as courage of conviction, we, together can provide the medical consumer with useful and accurate information that they can use to make important medical decisions about themselves and their near and dear ones. Seniors should be involved to educate the patients, their families and deal with media appropriately.
Behaviors Influencing Litigation
Patients are less likely to sue when clinicians orientate patients, e.g. ‘We are going to do this first and then go on to that’, use facilitative comments, e.g. ‘Uh huh, I see’, use active listening, Check understanding, ask patients their opinions, use humour and laughter appropriately and the doctor-patient encounter may last3 15-20 minutes, wherever time and space permits.
The knowledgeable shops for health care and these, Patients Attitude “How do you know you are right doctor?” can irritate the provider and disturb the focus. People can doubt the wisdom of the medical field!, Society has changed, people spend more time with electronic devices and don't relate to one another with the same compassion, as in the past. It has lead to erosion of respect. Aligning actions with our personal values of caring for the patients hopefully will improve things.
Do not promise more than what you can give/deliver. Make every clinical encounter a pleasant one. Spend quality time to know your patient. Focus on Geriatrics is required since longevity has increased. Counsel your patient with chronic and incurable diseases to ‘live’ with the disease as best as they can and modify their life style as per treating doctor's advice. ‘Crash carts’ will save the patients and you as well. Provide them even in non-critical areas also.
Solutions to Rising Health Care Demands
Vitally important soft skills need to acquired during professional training and they are
- Strong work ethic Problem solving ability
- Professional demeanor Self confidence
- Critical thinking Ability to learn from criticism
- Positive attitude Flexibility and adaptability
- Good time management Ability to work well under pressure
- Being a team player
Safety of Health care workers at Emergency, Casualty and critical areas has to be ensured by providing CCTV cameras, police outpost and Bouncers. Improvement of infrastructure to handle critically ill patients has to be provided in every hospital. Hospital medical council has to be established to address the complaints of the patients and suggest appropriate steps of action.
All said and done a doctor's role is challenging and demanding. Live up to it. Good luck.
Dr Visweswara Reddy
Emeritus Professor, PESIMSR, Kuppam, Andhra Pradesh
1. International patient safety goals (IPSGs). The targeted solutions tool (TST) can help JCI-accredited organizations meet IPSG requirements. Joint commission international. JCIIPSGFN0517.
2. Aaron E. Carroll, MD, MS. The JAMA Forum The High Costs of Unnecessary Care. JAMA November 14, 2017 Volume 318, Number 18.
3. Yatish Rajwat, The New Ind. Exp 402.18.
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.