Disgruntled Relatives Push a Young Doctor to Suicide

The tragic death of a young female doctor by suicide last week due to coercion by angry relatives of a patient who had died under her care, has stunned the medical profession and society.

From press reports I gathered that Dr Archana Sharma was attending to a female patient who had bled massively from the uterus following childbirth, and whom she was unable to save.

Agitated relatives had accused her of negligence, had barged into the local police station, and then gone on to filed a charge of “murder”. The police had obligingly cooperated, leaving the female doctor helplessly alone and deeply hurt.

In her desperation and as a vindication of her innocence she chose to end her life, leaving behind two children and her husband. In her suicide note she stated that she had done no wrong, but had been unable to save the patient.

Post-partum bleeding can sometimes be very massive and kill within minutes despite transfusion of large amounts of blood and medicines, uterine packing and rarely sometimes requiring emergency surgery. Few patients do die from this terrible unpredictable condition, in the best of hospitals even today.

This unfortunate event is a reflection of several social beliefs and practices that we need to face up to.

For one, we are getting increasingly intolerant and unaccepting of the fact that death can indeed occur in critical conditions despite the best of interventions.

Second: whenever a patient dies, our society believes that it has to be somebody’s fault! We seem obsessed to ascribe culpability and hound someone till punishment is meted out.

It is amusing to see the CCTV footage of road traffic accidents for instance; the relative is often seen running after the offending vehicle rather than attending to the victim lying on the road.

There is no space for doctors to fail in their human efforts. I wish members of the society in other walks of life, of say a place like Dausa in Rajasthan, hold themselves to such unreasonably high standards too.

Even more shocking was the role of the police who seemed be saving their backs from an unreasonable agitated mob, rather than defending a helpless female doctor being victimized and coerced.

The reason why young doctors choose not to settle in small towns and villages, should be evident by now. They flock to big towns and cities, not just for money, but for better living conditions, and better security.

I shuddered to think what I could have done had I been in her place.

The government machinery needs to take urgent corrective steps and instill confidence in young medicos if they want doctors to serve in smaller places.

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Do Patients’ Expectations and Attitudes vary? East vs West

One may argue that if body organs and illnesses have common patterns of afflicting the human race, why should responses, reactions, expectations and attitudes between Indian and Western patients be so different.

• In the West, particularly in Western Europe, patients fiercely uphold their right to know the diagnosis. If it is a cancer, the patient is often the first and only one to acquire that information. They often demand to be told explicitly what he is suffering from, the stage, the treatment options and the likely options. The doctor is bound to share this with the patient directly in most instances.

In Oriental cultures, such as India and Japan, the family often assumes the role of the guardian cum care-giver and very often requests the doctor not to divulge the “C” word or break the bad news to the patient, fearing that he may be unable to bear the blow.

The patient’s right to information and decision making all too commonly shifts from the patient to the “responsible” relatives, the doctor often finding himself trapped in an awkward position of having to lie to the patient if he is asked a straight question.

In a survey conducted in Japan several years ago, 80 % of respondents did not want a “bad” diagnosis or poor chances of survival to be told to their elderly relatives…something quite like India. While the figures may have moved marginally, responses in India have remained similar.

• Confidentiality about a patient’s clinical details is often a very strictly guarded and valued aspect of care in the West. The French president Francois Mitterrand was solely privy to his diagnosis of prostate cancer that he hid from the public and family for over 10 years. His  long-time personal physician kept it a secret too , but provoked a furore a decade later by revealing in public, and got sued for violating professional ethics.

India is quite a contrast: the doctor is bombarded by questions or phone calls about the diagnosis, status and details of reports, not just by a “care-giver” relative, but friends, in-laws, office colleagues, bosses and even neighbors!

Assuming that these questions sprout from genuine concern, most doctors usually do share some updates. But “confidentiality” is usually not on top of the list of our virtues.

Marking the door with a red cross of those who had tested positive during COVID times might have served public health, but plunged an individual’s sense of privacy and confidentiality to very low levels!

Several colleagues who have practiced medicine in developed Western countries find the transition back to India difficult. What makes it so, are not the diseases, but our social and cultural responses. Will discuss some more next week.

“Scapegoating” : a common defence mechanism of our minds

If you are one of those who direct your angst against a domestic help, staff, spouse or even Fate, you are not alone. Many of us are just too uncomfortable accepting set-backs or bad times, and resort to holding someone responsible if something goes wrong.

When 45 year old Siddharth (name changed) who had collapsed at home after vomiting two litres of blood, and had been rushed to a nearby hospital where he died within 2 hours, the family blamed the doctors and the hospital for delay and mismanagement.

Rahul had died of a complication of liver cirrhosis, a disease that had developed from 20 years of heavy drinking.  It must have been frustrating for the parents to helplessly watch their son drift away despite their urgings, and fall into the company of delinquent friends and a bad habit. The parents however did not blame themselves or their son or his friends for the habit.

By picking on one external scapegoat, the doctor, the family members had unconsciously found a way of remaining united emotionally.Scapegoating, therefore, is the perpetrator’s defense mechanism against unacceptable emotions such as shame and guilt.

Scapegoating or blame transfer is something we do almost everyday without quite realizing. When a smoker develops lung cancer after years of heavy smoking, it is the tobacco lobby at fault. If the cancer, when detected is at an advanced stage, the fault is of the 1^st doctor who ignored that nagging cough and did not ask for a bronchoscopy. If he finally succumbs to his disease, then the cancer specialist and hospital are guilty for not being able to achieve a cure. Everyone is guilty, except the smoker himself or his family, or the people who really allowed all this to happen.

In another interesting case, a 29 year old man, who seemed frustrated and angry, came to consult me for constipation. He had consulted 5 doctors in a year, who had all prescribed mild fibre-based laxatives by various names. These had provided him relief too, but now he blamed the doctors for getting him “hooked” to a natural fibre like “Isabgol”.

Happiness has become our right and if we are prevented from achieving it, someone must be responsible. Doctors, who have become the favourite scapegoats of these times, need to understand this unique need of desperately distressed patients and their relatives to want to paradoxically blame them instead of thanking them for their efforts.

Superhuman Nurses

Although one cannot imagine a hospital without nurses, their importance in the delivery of care often goes unrecognized.

It is not uncommon to hear of instances when a very critical patient with little hope of survival, has been successfully operated upon by a team of highly specialized doctors, brought back to life as it were by a group of intensivists in the ICU, and then, after several weeks in hospital when hope has mounted, suddenly dies due a wrong injection or infection from a catheter due to nursing lapse. What relatives experience at such times is a deep sense of betrayal and anger, that soon replaces the gratitude and appreciation that the previous few weeks of heroic achievement had earned.

And what compounds matters in busy hospitals is that nurses neither have the time nor the training to provide emotional support to grieving relatives at this stage, ensuring that they go back with permanent bitter memories and impressions of this hospital.

To be fair to nurses, just too much is expected of them and just too little effort goes into looking after them. Most hospitals run woefully short of nursing staff, resulting in overburdening the few.

Consider their case. A regular eveing or night nursing shift comprises 2 nurses who are expected to look afte 30 (in some 60)  sick patients over 6 to 8 hours. At first sight it may look simple, but here is the list of what they are expected to do in this period: take over the stock of medicines and details of patients from their colleagues of the previous shift (30 min), check each patient’s vitals (pulse rate, BP, respiration and temperature 4 to 6 hourly (@ 10 mins x 30 patients = 300 minutes), distribute medicines ( highly individualized) to 30 patients 2-6 hourly (90 mi), give injections (to 20 odd patients), draw blood samples for tests (from around 10 patients), start IV fluids or change IV bottles ( around 15 patients), shift patients for procedures such as surgery, endoscopy or radiology (10 patients), assist doctors in minor procedures such as ascitic or pleural taps (10 patients), supervise diet, complete discharge formalities and expalin instructions to those who are leaving, and the list goes on. On top of all this, every time a patient’s condition deteriorates, they have to assist with resiscitation (30 mins) and respond to SOS calls (quite frequent as 50% of the ward consistes of very sick patients).

If you calculate what they actually achieve during their shift, you will be surprised how they indeed manage. Where then is the time to administer TLC (acronym for tender loving care), talk and establish rapport with patients and relatives, sponge and clean them, and do all that good nursing is all about?

It is unfair to expect nurses to perform as super-humans all through their careers. While the complexity of medical care has increased several fold over the last 5 decades, the ratio of nurses to patients have hardly changed. Strengthening this pillar is essential if hospital care has to improve to the next level.

Scapegoating: The new solace

Of the many roles such as healer, soother, guide and teacher that a doctor dons for his patients, one important one that often goes unrecognised is that of serving as a scapegoat to provide emotional comfort and solace to those who have been through bad times.

When 45 year old Rahul (name changed) who had collapsed at home after vomiting two litres of blood, and had been rushed to a nearby hospital where he died within 2 hours, the family blamed the doctors and the hospital for delay and mismanagement.

Rahul had died of a complication of liver cirrhosis, a disease that had developed from 20 years of heavy drinking.  It must have been frustrating for the parents to helplessly watch their son drift away despite their urgings, and fall into the company of delinquent friends and a bad habit. The parents however did not blame themselves or their son or his friends for the habit.

For them it was the doctors and the hospital that had snatched their son and happiness! By picking on one external scapegoat, the family members had unconsciously found a way of remaining united emotionally. Scapegoating, therefore, is the perpetrator’s defense mechanism against unacceptable emotions such as shame and guilt.

Scapegoating or blame transfer is something we do almost everyday without quite realizing. When a smoker develops lung cancer after years of heavy smoking, it is the tobacco lobby at fault. If the cancer, when detected is at an advanced stage, the fault is of the first doctor who ignored that nagging cough and did not ask for a bronchoscopy. If he finally succumbs to his disease, then the cancer specialist and hospital are guilty for not being able to achieve a cure. Everyone is guilty, except the smoker himself or his family, or the people who really allowed all this to happen.

In another interesting case, a 29 year old man, who seemed frustrated and angry, came to consult me for constipation. He had consulted 5 doctors in a year, who had all prescribed mild fibre-based laxatives by various names. These had provided him releif too, but now he blamed the doctors for getting him “hooked” to “Isabgol”.

I learnt that he had quit a stable job 2 years ago to follow his dream of becoming an officer of the Indian Administrative Service. When I asked him if he had a back up plan, he broke down and said if that happened he would hold the doctors and the laxatives responsible for his failure!

Happiness has become our right and if we are prevented from achieving it, someone must be responsible. And as often happens in matters of health and life, doctors are the favoured scapegoats.

Doctors need to understand this unique need of desperately distressed patients and their relatives to want to paradoxically blame them instead of thanking them for their efforts. It is distressing to doctors to see their patients react this way, but they need to understand their “special need” and be kind and generous to them.

How Doctors Think

Doctors may not be the brainiest in society; yet the fascinating ways in which they think and make decisions has been the subject of interesting research. A book by Dr Jerome Groopman that deals with the subject has hit the best-seller list.

There are some parts of the brain that a doctor uses preferentially over others, memory being the most important to start with.  It begins from the time a youngster thinks of taking the entrance exam to medical school – he is required to read, retain and reproduce a large number of factual information and names of body parts and functions. Unlike the engineering, management, or law students, medical aspirants are hardly required to use mathematical problem solving, creative thinking, logic or thinking out of the box. But ask them, names and profiles of thousands of organs, tissues, cells and drugs, and they will have it on their fingertips!

As they progress to the next phase of clinical work, doctors learn to recognize “patterns” of symptoms and signs in patients, and try to fit these into the puzzle board of diagnosis.  Chest pain accompanied by sweating would suggest a heart attack, or jaundice with loss of appetite would fit the pattern of “hepatitis”, for instance.

When the doctor starts maturing as a clinician, he starts to pick up a feature called “probabilistic” thinking, wherein the patient’s profile starts becoming a key factor rather than the symptoms alone. To take the example of chest pain again, he starts recognizing that the same symptom in a young 20-year-old girl is almost always of neuro-muscular origin and hardly ever from the heart, while in a 50-year-old overweight smoker with high BP, it is very likely to be a heart attack, requiring immediate referral to a cardiac ICU.

With further development in his career, he starts factoring in several aspects of his patient in the process of decision-making.  In other words, it is at this stage that he starts incorporating the “art” of decision making to the text-bookish science that he has crammed.  Does the vegetable vendor who has come down with cough and fever for two days after getting wet in the rain require to be subjected to a CT scan of the chest or would an antibiotic suffice?  Does the 16-year-old schoolgirl with recent onset vomiting prior to the board exams require an endoscopic examination right away? What if she had had these symptoms last year too when she was stressed before her final exams?

The mature doctor then is not just a repository of facts, information and knowledge. It is the unconscious assimilation of years of experience, marinated with a sensitive understanding of his patient’s concerns and constraints, and with an iota of intuition thrown in, that make him take decisions that posterity usually seems to approve. 

Good clinical decision making, like good wine, matures over time. Knowledge alone does not make a good doctor; the flavor matters!

How Doctors Talk to Patients

How a doctor speaks to a frightened patient or his anxious relatives is often the course changer in a person’s disease process, and sometimes, for the rest of his life. It is therefore not surprising that eight of every ten patients who visit a doctor would have researched not only about his clinical competence but also about his “temperament”.

Unfortunately, a doctor’s communication skills or ability to empathize do not find a place either on the website or on the hospital’s promotional profiles as they are not measurable. And who would be stupid enough to broadcast that the surgeon is foul mouthed, arrogant or is in the habit of throwing tantrums?

The onus of finding out the doctor’s personality is therefore left entirely to the patient and his family, using a powerful tool that we frequently use unconsciously called word-of-mouth.

Word-of-mouth is a indeed very useful in several settings. Be it for fixing your daughter’s marriage, choosing a tenant, or surrendering your body to a doctor for surgery, it usually stands dependable.

Most intelligent physicians realize that what draws patients to their clinic is the word-of-mouth of satisfied patients! Hence doctors keen on building their practice pay due attention to “patient satisfaction”. Corporate hospitals seek feedback from patients about their “experience” so that they may improve their performance.

This component of a medic’s overall competence that constitutes a defining component of a doctor’s career is funnily absent from his official curriculum. The five years of his “graduate” training is largely spent on gathering facts, learning about disease states, memorizing tongue-twisting names of medicines, interpreting symptoms and signs, and developing psycho-motor skills. Patients, for them and their teachers, are often “clinical material” to learn on, with scant regard to their feelings and perceptions.

Medical education in developed countries was no different 50 years ago, but has undergone an upheaval in recent years, thanks to improved literacy, awareness of individual’s rights, financial security and the demand by patients for accountability by doctors. Communication and ethics, using real life scenarios, are now essential components of their course.

The MRCP examinations conducted by the Royal College of Physicians of England or Ireland place a great degree of importance on this aesthetic and humane aspect of medical care. My recent experience as an examiner for MRCP part 2 was an eye-opener. Marks were almost equally distributed for knowledge as for bed-side manners and communication skills. If the candidate was seen to be disregarding of the patient’s dignity, privacy or comfort while examining him, had to be failed.

Medical consultation is tricky business. It is not just about asking for symptoms, eliciting signs, ordering investigations and scribbling a prescription. If well done, it should meet a larger expectation of being a transformational experience for a distressed patient visiting a true healer!

How Doctors Die

Unlike the perception of most relatives that doctors treat critical patients callously, they in fact often “over-do” than what may be reasonable.

Says a intensivist “Rescusciation or CPR (cardio-pulmonary resuscitation) looks nothing like what we see on TV. In real life, ribs often break and few survive the ordeal.

“I felt like I was beating up people at the end of their life. I would be doing the CPR with tears coming down sometimes, and saying, ‘I’m sorry, I’m sorry, goodbye.’ Because I knew that it was very likely not going to be successful. It just seemed a terrible way to end someone’s life.”

Doctors fall ill and die just as others in society do. Interestingly in spite of all their knowledge about the body, its ailments and cures, they life expectancy is not much different than the general population.

What is indeed different is what they choose to go through themselves compared to what they do to others. In a revealing article “How Doctors Choose to Die”, Dr Ken Murray points out that doctors more often shun ‘advanced’ and ‘intensive’ therapy.

They more often refuse chemotherapy when diagnosed with advanced cancer, prefering to spend quality time at home. Their decision is perhaps based on their first hand experience of having witnessed the unpleasant adverse effects and futility of these treatments.

Doctors also more often choose to refuse aggressive terminal care treatment. They have seen what is going to happen, and they generally have access to any medical care they could want. They know enough about death to understand what all people fear most: dying in pain and dying alone.

They know modern medicine’s limits. Almost all medical professionals have seen “futile care” performed. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs.

In a way doctors can be accused of double standards, applying one set of advice to patients and one to themselves, but the important variable here is the expectation of relatives. If a patient becomes critical, even if he is 85 and is known to be suffering from a termical disease, the wish of relatives is usually “Do whatever is possible”.

In the litigant and finger pointing times such as ours, doctors therefore prefer not to leave any stone unturned. Relatives, many of whom may have flown in that day, may derive solace from having gone “all the way” in the care of their dad or mom.

It is this fear of guilt of “not having done enough” that makes relatives agree to submit their loved ones to the dehumanising terminal treatment: surrounded by strangers, hooked to machines, body punctured at sevral places and not a familiar loving face to see before they close their eyes.

Food Fetish in Medical Descriptions

Strange as it may sound, doctors have an obsession for food items when describing body parts, organs or even human excrements.

It often starts with the relatively innocuous description of kidneys as bean-shaped organs and the human brain as walnut shaped, that most students of biology are familiar with.

But they soon go on to use “café-au-lait” marks, salmon patches, and cherry red spots to describe different types of skin lesions that tell tales of diseases from a brown nevus or angioma or bleeding spots.

And when doctors, who by the way derive their professional origin from butchers, delve inside the human body while cutting up corpses during autopsy, they resort to food items to describe what they see. If the liver shows alternating red and white stripes as in early cirrhosis the description goes as “nut meg liver”. If the intestine shows a central narrowing due to a cancerous tumor, an “apple core lesion” seems to depict it best.

Familiar fruits are most commonly used to describe the size and shape of tumors and swellings: from “berry like” small ones, to “lemon” sized bigger ones, to “orange” shaped yet bigger ones and then on to “melon” shaped large tumors. References to our familiar fruits mango and coconut are however conspicuously absent as most writers of modern medicine have been of British or American origin.

When doctors start peeping into the stomach or other organs through the endoscope, this food-based description takes yet another turn. Scattered erosions of the stomach are described as “salt and pepper”, polyps as “pea-like” and a gastric antral vascular ectasiaas as “water melon” stomach.

“Bunch of grapes” is a common descriptive term used for large varices (dilated blood vessels) located in the stomach or rectum, while “cherry red spots” help depict if they are in imminent risk of bleeding. “Curd like” or “cheese like”white patches suggest fungal infections of the food pipe while “cauliflower” lesionsdepict large cancerous growths in the gut.

When an abscess forms in the liver as often happens in amoebic infection, the reddish brown liquefied content is described as “anchovy sauce”.

Radiologists are not far behind in this race. Apart from the “apple core” lesions of luminal cancers, the swollen pancreas in auto-immune pancreatitis is likened to a “sausage” and shadows in the lungs to seeds of millet to castor, depending on their size.

But the most nauseating description is of human excrements. It is “rice water” stools in cholera, “pea-soup” stools in typhoid and “currant jelly” stools in intussusception.

It could be hazardous to have a doctor over for dinner. If you see him getting too chatty with guests, make sure you keep him well away from this topic the entire evening, should you want your guests to eat well rather than retch and scamper to the wash-room when food is served.

“Fatherly” or “Salesman-like” or A Bit of Both

Why a patient feels comfortable with one doctor and not with another depends on whether the attitudes and expectations of the two match well.

In the conventional “Paternalistic attitude that doctors have sported over the centuries, it is he who decided what was best for the patient and ordered only one line of treatment that the patient  followed  unquestioningly and faithfully. Assuming a father-like role, he assessed his patient’s need, tolerance and affordabilility and “told” him what to do. Many patients still prefer this simple apprach and ask “Doctor, please tell me what I should do”.

This “paternalistic” attitude prevailed when treatments were few or none, and the doctor-patient relationship was hinged on blind faith. In present times, when treatment options are exploding and patient’s expectations escalating to dizzy heights, this appraoch is heading towards obsolescence.

In the current age of “Cafeteria Appraoch” doctors are required to place all the treatment options on the table, each with its risks and benefits, and facilitate the patient to choose from the “menu”. A typical example is to discuss with a patient of heart disease the risks and benefits of 3 treatment strategies; continuing medications alone, undergoing coronary angioplast, or a “bypass” heart surgery. Each has its unique advantages and risks, the perspective often varying from severity of disease, age, and the patient’s ability to endure the invasive procedure. A frank discussion on cost of therapy and expertice of the doctor helps the patient make a well informed choice.

Although a mathematical answer is what many doctors and patients grope for, it is often not easy to come by. How, for instance, does one weigh the small risk of death of 2 percent for a 60 year old man contemplating heart surgery against a 5-year survival of 85 percent if it goes well, when his daughter’s wedding is scheduled 6 months later?  

The onus of a decision whose outcome has gone awry is therefore now shifting from the doctor to the patient himself. As the society gets more litigant, requiring doctors to become defensive, many are finding it more comfortable, albe it time-consuming, to quote appropriate facts and figures, and leave patients to decide their own fates. However, as surgeries and procedures fetch in the moolah, doctors do inject their biases. Watch the laparoscopic surgeon deftly mention the “slight” but tangible risk of cancer developing in your gall bladder should the silent stones not be removed, or the cardiolist tell the anecdote of one of his patients who refused angioplasty last month and collpased on the golf course a week later.

Highlighting the features of a new product is easy but customer feed back, that could critically tilt the scale, is not often easily forthcoming. Appealing to the “fatherly” sentiment of the modern doctor with the question “What would you do if you were in my shoes, doctor?” often makes it easier for Indian patients to decide.