How long should a doctor listen and converse with his patients to understand the malady, and clinch a momentary diagnosis, before body examination?
Most lay people would agree that a doctor should listen to the complaint and converse by giving more time, so that the patient will feel more comfortable and develop faith and confidence in the doctor. That is how the relationship between the doctor and the patient should start. Hippocratic Oath is clear on this.
A few decades back the doctors listened wisely before examining their patients physically and make a tentative diagnosis, as there were only the basic investigations available to confirm a diagnosis. Basic blood tests, plain X rays, barium meal studies and other radiological investigations were the only ones available, then. I remember the well-known clinician in the fifties Dr. Cyril Fernando would look at the phlegm closely and sniff-put on his thinking cap and come out with a spot diagnosis like tuberculosis or pneumonia and so on and how right he was.
“It must be emphasized that doctors did further investigations only to confirm the diagnosis they have already reached – rather than to diagnose the condition”.
In spite the advances in drugs, surgery, scans and other complex investigations a good relationship should start with a conversation.
Am I right by saying that the present day doctors have lost the clinical sense the past doctors had? I know of a case of Dengue the doctor initially did a blood test to check the platelet count. After that the doctor visited the patient, without clinically assessing the situation orders another blood test and this goes on repeatedly. The pathology laboratories are making hey whilst the sun shines. Doctor’s order too many tests in most situations, possibly the progress of the disease is assessed on laboratory tests and others, without paying much attention to clinical judgment and assessment. Health costs seem to steam up and the standard of practice of medicine deteriorates.
Medical schools train the students to take proper histories of the illnesses of the patients and spend more time in examining and asking more questions. Invariably, after qualifying they seem to bypass this phase and focus more on investigations and easing on clinical judgment.
I remember, when the first CT scan machine was invested in a popular private hospital in Colombo, the specialists were requested to order plenty of CT scans to cover the costs of the investment. One neurophysican related the story that every patient having a chronic headache was ordered a CT scan of the head. Most ignorant patients then thought that was part of the treatment going through the tunnel of a impressive machine. Three months later when the same patients were reviewed and those who complained of the same headache were ordered another head scan. People were then happy to pay rupees ten thousand for the scan as most believed that it was part of the treatment and not an investigation.
The present day doctors don’t seem to follow such basic practices in their craft anymore according to the training they received, and for convenience and expediency request investigations, may be the quickest way to see the next patient in waiting. After all, listening to the patient and noting down patient’s past and present, about the symptoms and signs make 75 per cent of the diagnosis.
There was a famous eye specialist in Kandy government hospital that would see 60 patients in the morning and evening outside his office hours in hospital. Especially, an eye doctor should spend at least 15 minutes with a patient to converse and examine the eyes through the equipment before a diagnosis is made. It surprises how a specialist can become so popular when such little time was spent on each patient.
The inconvenience that ill patients go through is nobody’s business. Just imagine, a patient to make an appointment to see a specialist in Colombo, need to get up and take the earliest bus to reach the respective hospital. Then, you need to wait a while till your turn comes to make an appointment at the desk, and then wait in another queue to pay the consultation fee, to the cashier.
Invariably, you could see the specialist after 5pm when the specialist rushes in to the clinic of the respective private hospital. There would be at least a minimum of 30 patients in waiting to see him.
If the specialist allocates 5 minutes for each consultation, he would have to spend a good three hours to clear the lot.
In most situations the specialist gets delayed and the first patient may be seen after hours and he or she may need to work till late to clear the lot. Can any human being work like that day and night? One would get exhausted and tired by the time a few patients are seen and the efficiency may deteriorate which will affect patient management. Visiting private hospitals after working hours also takes hours due to the heavy traffic on the roads, and that would be exhausting and frustrating, too.
Next problem could be that the patient may have to stay overnight to get those necessary investigations done requested by the specialist. The results may take days. Invariably, the patients need to make another appointment to see the same specialist subsequently and meanwhile he or she lingers with the disease.
You could just imagine how you would feel being a patient in such a system. Most specialists have no time to explain the disorder and details of management. They don’t like been questioned regarding your condition. I know of a situation, where the healthy brother of the patient made an appointment with the ill-brother to see the specialist simultaneously. When his turn came he most politely confessed that he made an appointment too, to discuss the brothers illness. The specialist got annoyed but he did explain the situation with the brother.
It is advisable that the patient making an appointment to see a specialist to make good communication to plan ahead and write down:
• Your symptoms, your personal history and relevant past and family history.
• Write down a list of all medications you take from previous doctors
• Also take copies of all investigation done previously.
Also take a relative as a support person. Such planning may help the specialist to organize a better regime for your illness within that short period of time.
Cardiologists should be equipped with treadmill facilities with ECG monitoring for stress cardio graphing in their rooms. They should stay with the patients whilst being on the treadmill, and keep an eye on the monitoring screen: check on BP at the onset and immediately after the exercise. Echography facility should be available for the cardiologist to check on the heart functions immediately after the treadmill work-out.
Unfortunately, most cardiologists in Sri Lanka are not equipped with such a system to give an opinion and assessment to the patient promptly.
So, there are many holes in the system, and streamlining is required to provide a more efficient and better service to the public.
This article does not blame the specialists- notoriously known for not spending sufficient time with their patients. They are sucked into a system that they are compelled to practice bad medicine.
For a better health care system we need to check on other models in more developed countries. The US spends more money on healthcare than any other wealthy nation. But it hasn’t resulted in better health. That model would not suit a poor country like Sri Lanka.
The Australian system of ‘Medicare’ universal health system considered as one of the best, where doctor and specialist consultations and most investigations are covered by a universal system and the tax payer to pay 3 per cent income annually. The system has survived since 1976 and working quite smoothly and efficiently.
This system encourages people to get far too many unnecessary investigations done because you don’t pay for your services. It is a system that most people become hypochondriacs and some keep on going from State to State checking their cholesterol levels and others. Expat Sri Lankans and those others who live in Sri Lanka, when they pay their compulsory annual pilgrimage to Australia to sustain their citizenship rights were notorious for such practices. Such a system will lead to malpractices, overservicing and corruption in our dear island.
It is important to bring in a system where all island-wide GPs’ are assimilated to ease the burden on the specialists.
Today, in Sri Lanka the people have the choice to choose a specialist without consulting his GP for a referral. The GP wouldn’t know that the patient has seen a specialist and the specialist is not obliged to send a follow up note to the respective GP.
People must be registered with the local GP like the British NHS, where patient records are filed with the GP and the GP will refer to specialists as required.
A patient should consult his GP and he would be in the best position to decide whether the condition needs specialist referral.
Such a system will preclude over-crowding in the outpatients in public and private hospitals wasting the specialists’ time on conditions that could have been handled by his or her own private practitioner.
A special committee appointed by the government with invited health experts, representatives from the local specialist and GPs’ would be the best proposition for planning a better health care system for the people. The Trade unions should be excluded.
Hope this article will help our health administrators to plan a better health system which is long overdue.
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Dr Gunatillake-Health editor is a member of the Academy of Medicine, Singapore. Member of the Australian Association of Cosmetic Surgery. Fellow of the Royal College of Surgeons (UK), Corresponding Fellow of the American Academy of Cosmetic Surgery, Member of the International Societies of Cosmetic surgery, Fellow of the International College of Surgery (US), Australian diplomat for the International Society of Plastic, Aesthetic & Reconstructive Surgery, Board member of the International Society of Aesthetic Surgery, Member of the American Academy of Aesthetic & restorative Surgery, Life Member of the College of Surgeons, Sri Lanka, Bachelor of Medicine & Surgery (Cey)