The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

The Chinese Doctor

Fascinated by the Chinese culture, I had researched what it was like to be a doctor in China. My thinking was that if my Chinese was good enough, I could go to China to practice for a few months to a year or so, and develop more of my Chinese, as well as see how healthcare works in another country. I didn’t mind if my wages would be much lower, but it was the experience that would make the decreased wages worth it.

My research led me to see how fractured and weak the healthcare system in China was.

Doctors are overworked, and underpaid. A lot of doctors provided substandard health care as a result of an overwhelming number of patient demand that could not be met by the health care system. With a country that has over a billion people, it’s no wonder. Coupled with the fact that there has been a net migration of rural residents flooding into the cities, and this will burden the health care system a lot.

Last year, my grandma needed to pay a visit to the hospital as a result of what was likely an asthma attack. In the hospital, everything is based around the almighty dollar. A deposit of around 5000 yuan was required upon being admitted as a patient, just so that you will be able to pay for your medical fees. And what should happen if you end up spending all that 5000 yuan? You get refused medical service. My aunty managed to bargain with the doctor’s in hospital and was able to bargain the deposit down to 2000 yuan. But a couple of days as a patient, my grandma was not given her morning medications. When asked why, the nurse advised that her 2000 yuan deposit was all spent, and no medications would be provided until this amount was topped up.

Other things that seem to be wrong with the health system there, is the encouragement of the “hong bao” or red envelope. In China, a red envelope contains money, and is often given as a token of goodwill. For the rich in China, giving a red envelope gives them a sense that things can be accomplished more quickly, that the doctor will spend more quality time with the patient. My mum who had been to one of the hospitals had clearly seen a Chinese sign that states “No red envelopes allowed”, yet I’ve heard that this gets curtailed by the use of credit cards given instead that are loaded with money.

The way that the doctor gets paid is also shocking. Doctors seem to get paid for prescribing things. In that way, this ends up to a lot of unnecessary prescribing for the sake of earning extra money. My father who had gone to one of the hospitals because of an upset tummy and 1 or 2 episodes of diarrhoea was offered IV fluids. He wasn’t dehydrated or anything, and didn’t need the IV fluids. Why give someone something when the risks of infection from the cannula etc outweighed the benefits? Perhaps by giving IV fluids, it is relatively “safe” and makes good money as well, and in the minds of other patients, they think something is being done.

Finally, perhaps the most disheartening thing I’ve read, have been doctor killings from patients. A times article sums up this perfectly here.

It’s quite sad actually, but I’ve been told that being a doctor in China is not what people aspire to, given the great responsibility and little financial reward given. I don’t blame them given the way doctors are being treated there.

 

 

Paediatrics – It Made Me Sick

I remember having done paediatrics as a student and as an intern. Both times, I got sick. Probably for only about a week or so, but then I got better, so I could enjoy the rest of the rotation.

I’ve been doing paediatrics now for about 6 weeks. And I hate it. Well, that’s probably not entirely true. I like managing and diagnosing paediatric conditions, but I hate the germs and bugs that comes with the patient group.

Every second or third child is a febrile, coughing, runny nosed kid. With such a high exposure rate of flu viruses and bacterial infections, it was only a matter of time before I became sick. And sick I became. In fact, for a total of 3 weeks! Yes 3 miserable weeks of suffering!

Thinking back to it, the first time I got sick, I had to cancel dinner plans with a friend. I started feeling better over the next few days, but had to do a 4 day stretch of nights. And on the last night shift… I got a sore throat. So I get sick some more, with some laryngitis, hoarse voice and the like. Just as it’s improving …. I get unilateral throat soreness. I don’t think much of it, thinking it’s viral. But over the next 2 days, I become febrile, I get chills, I have extremely painful lymph nodes, and I think I can see some exudate in the back of my throat.

I only just started some antibiotics today, and it’s already helping a bit. My throat doesn’t feel so sore anymore. I just hope I don’t spike fevers again tonight.

I must be extremely unlucky with 3 successive episodes of throat infections. I think I’ll be extremely glad to leave paediatrics behind and to leave a miserable few weeks of illness behind as well.

On Being Genuine

The other day, my consultant saw me as we were about to do ward rounds and said “Hey doctor, how would you like to do a mental state exam on our next patient while we give you feedback later on?”

That was not a question at all I must say, in firstly, saying something like “no thanks!” would reflect badly on me. So I ended up saying “yea sure!”, and then felt the fear build up inside of me.

So in to the interview room we went, where there were two consultants, my colleague, one medical student, one nurse, one student nurse, and finally the patient himself. The patient himself was a man I had done the admission work for, so I knew his history.He is a man in his 50’s, who was brought in by police from his flatmate in regards to suicidal intent, and alcohol intoxication.

What happened next, was that I proceeded to establish rapport with him, asking basic things like “how have you been feeling lately?”, through a nervous bodily sensation. As I asked a few more questions, I felt more comfortable, and followed up on important cues such as his recent nightmares.

On closing, the consultant told me I did pretty well. He followed up with a few questions, such as “what specifically in hospital has contributed to your mood improvement?”. I wish I had asked that.

What surprised me next, was the consultant’s feedback that I was genuine in my interview with the patient. My interview persona was a reflection of how I interacted with others normally, and in a way, I brought my personality with me as the doctor, to how I am as a colleague.

In a way, it’s something I never really considered, but it’s something I feel is actually quite important. Being genuine with patients is a way of building rapport, and of being sincere to the patient. It helps to establish trust, in that in a way, it lets the patient know a little about the doctor’s true self. And I guess that being doctors, we don’t share our personal life stories, so the patient has very little knowledge about us as a person, other than their first impressions and the personality/persona we display to them. In that sense, to put forth a fake persona to patients, is really in a way distancing ourselves from the patient, in that a mask is worn so that patient’s don’t get to know the person behind the mask.

In a way, I guess my consultant has seen the fair share of other doctors who wear a mask, and adopt a different persona to patients compared to how they are normally. In my view, it isn’t authentic, and it would be difficult to maintain. Perhaps some feel the need to hide their true character between a persona to patients because of the fear of revealing too much? Maybe some try and adopt a more confident persona, or try and tailor themselves as a person similar to the patient to try and build rapport?

Now that I’ve come to it, I think I’d prefer a doctor who showed their personality through in a consult over someone who tried to be someone they are not. Eventually, it’ll show through that they are trying to be someone else.

But it’s definitely something I didn’t consider until now. From now on, I’m going to continue being genuine in my patient interactions.

On Perceptions

Delusions and hallucinations have been something that always puzzled me.

A delusion can be defined as “a fixed false belief that is resistant to reasoning with actual facts”, whereas a hallucination can be defined as “a distortion in a person’s perception of reality”.

For the past two weeks, I’ve been encountering patients who have delusions and hallucinations. For delusions, the puzzling thing is that I don’t understand how any person can have such conviction in their beliefs about something, that almost anyone can see is absurd. But then again, I guess with psychiatric illnesses, such distortion of realities is something that those unwell experience. It’s something that I’ve never experienced before, so I don’t know what it’s like to have such absurdly false beliefs.

The other day for instance, one of the patients (let’s call him Mr A) was seen shadow boxing in the courtyard. When asked about his actions, Mr A explained that he was practicing boxing, because he believed (a delusion) that a “fat man” will be coming in a helicopter to have a fight with him, and if the “fat man” loses, he’ll take Mr A’s spot in the hospital, while Mr A himself can take the helicopter to escape from the hospital.

In dealing with such patients, my consultant gave me a very important word of advice; rather than dismissing or directly challenging such delusions, we should neither accept or dismiss their delusions, but ask them about it. It was explained to me, that the patient lives in a reality completely different to the treating doctor, and any pertubation of such reality by challenging or dismissing it, could possibly lead the patient to close themĀ  self off, or destroy the rapport already built. In a way, it reminds me of a physics principle known as the “observer effect” which asserts that in trying to measure an event or outcome, the measurement itself has the potential to disrupt such an event or outcome.

What the patient believed seemed like absolute reality to him, enough for him to do some shadow boxing in preparation for the supposed “fat man” fight. I pondered about Mr A’s reaction to the non-event of the “fat man” turning up for a fight. Would Mr A think to himself that maybe his belief was wrong? Would Mr A continue to have further delusions that would feed into his primary belief, (for instance, the “fat man” was training as well, so would come in a few days time)? I suspect that it’s more likely the latter option that Mr A would continue the line of thinking for.

I don’t live in Mr A’s reality, so his belief seems absurd to me. He would probably contend that I’m absurd to point out that these are delusions, and that he is unwell with a psychiatric illness, for indeed his illness has probably affected his insight into his illness.

In a way however, I think I have my own delusions at times. There have been times I thought that I would make a fatal error in judgement, and that the medical governing bodies will come and deregister my medical registration. Well, it’s not as much a delusion, as it is probably negative thinking, and a lack of self esteem and confidence on my part.

What I’ve learned from patient’s like Mr A, is that to me and other doctors and health professionals, a psychiatric patient’s delusions are completely absurd. But to them and their reality, they live in a different reality where it makes sense to them, just as much as it makes sense for us to believe that the sun would come up the very next morning after night time.

On many levels, psychiatry in a way is like the movie Shutter Island (if you haven’t seen it, I recommend watching it). Reality can seem to be so engrained to a patient, that they seem to have a distorted reality in which everything to them makes sense and seems normal, whereas to other people, it is highly abnormal.