E-consults and Apps in India...Why they haven't worked yet!

There seem to be a whole host of new service providers on the internet targeting the medical community. The path breaking, ground shattering, myth busting, scenario changing medical e-consults or online consultations are here and pushing at us from all angles. Almost everywhere you look, there seems to be a new provider or an app that promises you the best clinical opinion online and the easiest consultation (most popular ad tag line is 'no waiting') you've ever had. 

The crux of the e-consult is this. You log on to a website or an app, put in your symptoms or queries and they connect you to a doctor of their choice to analyse what you have put it. When it just started off, it was a crude questionnaire you had to fill with a lot of basic questions sort of like the cue cards these call centre employees use when first on the job. This has become refined to a process wherein you can now upload reports and images and offer a better understanding of your illness.The Doctor choice still remains with the app or provider! In a nutshell, here is what the process is like.

Now, there is no doubt in my mind that this is where the future lies in terms of medicine and technology making it easier for the patient to connect with a doctor. However, I have a couple of reservations and most of them point out to the reason why this has not picked up at all in India.

1) There isn't one provider / app that has been able to correctly design their process to make it easy. Either getting on is too complicated or once your in, choosing the right options are confusing or lastly there are too many tedious things to do before actually getting what you want. Does this then really cut out the waiting time for your own doctor?

2) The age old objection of no physical examination being possible stays on. While this may be ok for the patients who would feel perhaps that they just have a simple illness that needs a few over the counter drugs, there are enough and more stories of serious illness being found out only on a physical exam done as a routine and not for presenting complaints. I can't begin to explain how many cancers and chronic illnesses have been caught out over a simple visit for a viral sore throat or fever.

3) The digital divide and generation gap. It's all too well to say we are living in a digital age and our population is one of the youngest in the world. The ground reality sadly is that most people are still unaware about using a smartphone / tablet to it's complete capabilities. The generation above us is still struggling to come to terms with online banking, e-commerce and online research. Getting them to trust a doctor online who doesn't see them is going to be a task. In the villages, the population is dependent on the one tech savvy person who would do this for them and make them sit in front of the webcam while they describe their most personal and intimate symptoms. Would you be open to talking about it in front of someone who may not be ethically sworn to confidentiality?  

4) It's no surprise that most of these providers that started off as medical care givers over the internet have now positioned themselves as Second Opinion providers. This makes good business sense in terms of at least getting things moving along. However, using the app for a second opinion usually leads to two outcomes: One, you're satisfied with the opinion and then look to meet this doctor (if possible) to continue treatment with him/her (has actually happened with me) and two, you're completely dissatisfied with the opinion which leaves you back to square one.

5) The main reason why I think this hasn't worked so far and still won't unless they change this main reason is this - Most Doctors on these platforms are doing this part-time. They aren't invested in it enough to provide the best possible care for the patient. The attitude is that I will see this patient once on the computer screen and that's the end of it. So, no details are taken, no real relationship is formed and the trust issue will always rear it's head at a point of conflict. 

Unless you have full time doctors invested completely in the platform, treating it's success as their success and it's failure as their own failure, the system will not take off. 

Unless, you have that consistency which is developed with the doctor seeing the patient over time and knowing the patient inside out, the accuracy will not be there. 

Unless you have developed enough trust with the users there will be no return users, no long term subscribers. The ones that do subscribe will be driven away if there are frequent doctor changes.

Unless you obtain the privacy required and tackle the ethical dilemmas involved it will not take off.

All of these are doable. Unfortunately, no one seems to be thinking in this direction. The idea of converting health records to digital formats seems to have blocked everyone's minds away from the actual ideas that can help them grow. I do hope this changes quickly because the potential is enormous, especially here in India. I see a future, how bright it turns out depends on how quickly we realize which way the light is!

Radiologists and the PCPNDT. What to protest against?

There is a strike that started today by Radiologists to protest against the Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT Act). This is by no means a strike to be taken lightly as it is happening on a Nationwide level and seems to have garnered the support of almost all the radiologists. The strike is said to be indefinite and will halt almost all radiology services but specially Ultrasound or Ultrasonography which is where all this started.

The act itself was enacted 22 years with a view of saving the girl child from female foeticide. A noble cause indeed but perhaps not thought through well enough. In a very basic understanding, it wants to stop sex determination at Ultrasound and thereby stop the murders of girl children by forcing radiologists to register their machines, put up banners and posters all over their clinic denouncing sex determination and not even venturing towards the bottom half of the baby while doing a routine ultrasound, lest they err and have a look at the sex of the child!

 According to reports, it has failed miserably in its aims and now become a harassment for honest doctors. At least 95% of the convictions under the Act have been for clerical errors. In the few cases where the perpetrators of sex determination were actually trapped red-handed, the culprits turned out to be quacks and non-qualified doctors using unregistered machines.

“All clerical errors like not filling up forms, incomplete forms, missing signatures should not be equated with sex-selective abortion. The doctor cannot be held culpable only because of record-keeping errors. We want decriminalisation of paper work deficiencies,” These are the words of the Doctors involved in the strike!

This is the only part of the strike I have a problem with. Record keeping errors and paperwork take such a back seat in our country that we might as well have a separate room for them. In my opinion, paperwork, documentation and records are paramount for any Doctor. The fact that the radiologists in our country are so overworked that they cannot read their own reports once typed, leave alone, typing it themselves is a  grave concern. Record keeping is compulsory for all Doctors and it is done to avoid any medico legal issues. Incomplete forms and missing signatures are vital in any pre procedure checklist and avoids many many serious complications and issue.

What bothers me is that all the radiologists seem to think that paperwork is not their problem and is the work of clerks employed by them. Well, in that case, the least you could do is read up, check and correct any errors that they make because surely they aren't doctors themselves. 

I have personally seem many many radiology reports with gross errors, spelling mistakes, completely erroneous measurements, even reports of other patients transcribed to mine. All attributed to clerical errors and all not a problem of the radiologist?

I understand that it may not be possible to physically type out each report yourself, but surely, you could read each one before lending your signature on the final report which is going out with the patient. 

What is the purpose of pre procedure forms if they are incomplete and you still go ahead with the procedure blaming the clerks for not completing it. You must make sure the form is complete and reaffirm the contents with the patient. I know of many patients who would lie on the form but wouldn't do it to the face of their Doctor (do share any experiences if you agree).

Missing signatures are a criminal offense and should continue to be so because it is squarely the responsibility of the Doctor to assure the consent for the procedure has been taken before beginning. I have seen surgery been performed and the consent signature taken after the procedure. What if something would have happened intra op?

My radiologist friends, please take this in the right spirit. Yes, there are many things wrong with the Act and it merits a revision. Yes we need a review panel before sealing machines and arresting doctors. But, we also need to get our act together and streamline the process before we point fingers and find faults.

Introspect and be honest to yourself when you ask if you are doing the best possible job you can do! Get into the habit of checking all paperwork even if it means seeing 2 less patients per session. Perhaps then, the law will not look so threatening!

Trust your doctor. However....

1st July is Doctor's day. You would probably be sending out happy doctors day messages to any doctor you've visited and been satisfied with.

That satisfaction comes from a level of trust between you and your Doctor. This trust is, today, at it's most fragile state. There are reports everywhere of Doctors betraying their patients' trust, their own Hippocratic oath, their own conscience and more importantly their livelihood.

However....

These reports are like a lot of the other media sensations carried out by the ratings syndicate. They do sensationalize just a wee bit, dramatize for effect so you would read the article and of course zing it up with a bit of creative writing.

However.....

I do confess, there are a couple of rotten apples (ok may be a couple hundred) amongst my brethren. They do things that make me sick to my stomach, like, scaring the heebeejeebees out of patients for small, minor ailments, which could use just an aspirin or a paracetamol (no pharma affiliations here).

However....

This post is not about that. This post is about the way forward in this current scenario. Here is my tuppence on the matter.

The family physician is dying out. The good old GP who knew everything about your family, your children, your great grandparents, your maid, is today, no longer your first point of recourse if someone falls ill in the household. It's all gone bonkers with specialists and consultants running straight in for trivial matters.

You really do not need a specialist for about 80% of the problems that generally come up health wise. The remaining 20% can also be effectively handled by a good recommendation by your primary physician.

However....

There is no trust, no faith, no motivation to go to your GP anymore. There are a few reasons for this, primary of which, is the easy availability of specialists. They are no longer only at the major hospitals with a waiting period of 2 months. Secondly, the elite breed of Family Physician is just not being produced any more (the reasons for this wound need another post). Lastly, every distant relative that's never even seen you before has the best doctor to recommend to you (doesn't matter what the specialization is in this case).

However....

There is a way forward. Find a Doctor, one you think you can trust. Let him/her be from any field of medicine/surgery. Pick them because they are the ones you know you can trust. Then trust them for everything they say. Most specialist Doctors will probably know more about any disease more that your relative staying two countries over or that nosy neighbour who just happened to hear what was wrong or even that person you occasionally say hi to in the office parking lot!

Once you find a Doctor you can trust, place that trust completely and know that they will only do what is best for you. If they know they can't treat the condition at hand, they will refer you to someone else who is more capable to do so. Keep the trust and do not think it's because of a cut back or referral fee (here is a tip - the fee does not change whether there is a referral fee involved or not. You're going to have to pay what you're going to have to pay). Follow up back with your primary doctor after the referral. Trust him/her to now maintain your health ahead!

However....

To do so, the Doctor has to be able to trust you too. This is something that is not spoken about at all (primarily because it's a non media issue). Your trustworthy Doctor has to be able to trust you to do as he says, take his prescriptions exactly as they are supposed to be taken, go back when asked and rest when advised so. Any deviation from the plan of treatment is on your head not the Doctors. Something to think about isn't it? How many times have we felt better and stopped medication or started work because we just had to go back before the advised duration of rest, not do those silly breathing exercises because really it's just brainwashing isn't it?

However...

When we then relapse, it's the fault of the Doctor of course! He must have not given me the right medication. He wasn't reassuring enough, he wasn't clear enough in his instructions. He didn't specifically say we couldn't go back to work! Excuses flow fast and thick in order to justify our actions.

Trust is a two way street. Put in that little effort and be a model patient and you will automatically have a model trustworthy Doctor.

However...

Find one you can trust first. Once you figure you are happy with him/her, stick to them like superglue!

However.... Don't take my word for it, let me know what you think!!

Those evil hospitals and their vampire doctors

Seemed like an apt title for this post. Now that everyone is climbing on the doctor bashing bandwagon in India, the surefire way to get people to read on would be to toe the line and badmouth the hospitals and doctors.

Reality Check: Most of what is written is true!

A corporate hospital is one run by a corporation who intends to expand the hospital chain like it had expanded itself into a corporate entity. By virtue of this simple statement, it is understood that they will run the entity like a business, and why not?

We consumers are a fickle minded people. We want the best hospital every time, with the cleanest floors and the best service with the best staff and the best care with possibly the best food ever tasted in a hospital along with possibly the best views on offer along with the best amenities with of course the best possible and cheapest tariff known to mankind!

Let's take a pause here since at this point a whole bunch of you are saying, hang on, we don't mind paying for quality!! Sure you don't, but you aren't the one's complaining are you?? Also, that's kind of not the point is it? 

Everyone seems up in arms about hospitals pushing doctors to make a profit and how unethical it is! 

Reality Check: There is nothing unethical about hospitals pushing their doctors!

The thing is, every business out there, is out to make a profit. You would be lying to yourself if you thought otherwise. Anyone who thinks hospitals and doctors should be more charitable, please head on over to the number of government and municipal run hospitals there are. Even better, move to the UK and face the NHS!

Even today, India continues to be at the top of the healthcare chain and is one of the cheapest destinations for quick healthcare the world over. We must be doing something right!

Coming back to the point of this post, corporate hospital management is correct to push it's doctors. The only problem is that they seem to be pushing without direction. This could be attributed to people in high places with no healthcare experience whatsoever. Which is where the need for trained post medicine admins come in, but that is another post.

The ethics debate which is where this is blowing up, lies and should lie solely with the Doctors! It is up to them to decide whether they do what the management asks without regard to their medical training or continue ethical practice of medicine and be the best doctor that they can be!

If the Doctor is as good as he/she should be, the patient load and revenue will come in anyway. Once the doctor has a roaring practice, the management will have no choice but the accept the terms he works with, otherwise, there are enough private hospitals out there poaching good doctors.

The ethical dilemma, in my opinion, is only with those Doctors, who either can't bring in patients on their own merit, or the newbies who were drafted into the big hospitals, and want to prove themselves. Either way, the load of ethics still stays on the doctors shoulders.

An illustration to help understand this better. A recent newspaper article cited a hospital as suggestion to its cardiologist to perform angioplasties on at least 40% of his out patient visitors. A negative look on this suggests the hospital deciding for the doctor how many procedures his patients should undergo. A positive outlook is that the management is informing the Doctor about the average turnover of cardiac patients that a busy established cardiologist may have as industry standard.  

At the end of the day, every doctor gives the patient a choice. If you choose to believe in your Doctor, you would undergo a procedure. If you have less faith, you would get a second opinion. Either way, the doctor is acutely aware that he/she is being scrutinized, more by the patients than the management. Believe me, we doctors care more about what our patients think than what anyone else does.

The Doctors who do push patients for uncalled for surgeries and procedures are few and far between and must be pulled up. However, writing articles in the newspaper about the entire healthcare system being bad isn't cutting it. The book dissenting diagnosis is getting a lot of publicity with this and I wouldn't be surprised if the doctors who wrote the book aren't laughing all the way to the bank about this, but I wonder.....

The crux of the matter is, the book interviews a couple of hundred doctors. They got a few positive answers. They haven't mentioned all the others that they did not interview or those who gave them negative responses to what they were looking for.

Bottom line. Find a Doctor you can trust and stick with them until given reason not to. If you can't find one you can trust, always take a second opinion. The best way to do this is not Google, but going to a second doctor without telling him about visiting one before hand. This gets you the best unbiased consult. Once you are convinced about your condition, decide where you want to go by reading about the hospitals suggested. I'm in the process of launching a website that gives honest, first hand user related ratings and reviews of hospitals. Visit the site at Best Hospital Reviews and learn about the place. Then make your decision on an informed basis. You would never need to criticise a doctor or hospital again since you'll have done your due diligence. Yes YOUR due diligence. You play a part in this as much as the ethical doctor you want does!! Any views and critique are welcome and will be replied to in the same tone as this post!