Why are patients dissatisfied with medical care ?

 

Papers are full of news and headlines of the dissatisfaction of patients with health care. Why does this happen? I am not being judgemental on any one issue, but want to share a fundamental truth about modern medical care.

It is really worth listening to a TED talk by Kevin Jones .

We all assume that medicine is an “exact science”. Even science itself is not “exact and always true”. Some of the biggest principles of science like Newtonian physics had to give way ;to Einstein’s theory of relativity and then later on to quantum physics. So nothing is an absolute truth even in pure sciences like physics and medicine is far from perfect.

In actual practice, we treat based on some evidence. Most robust evidence is by a clinical trial or trying a therapy or a procedure ,which would be useful in a majority of patients. The important word here is “majority”. Typically a bell shaped curve in which the middle segment of majority would benefit from the treatment. But within the same population are those who are outliers and who are not part of the majority and this number can be as high as 30% or sometimes even more. So the benefit is limited only to those who are within the median.

So every medical treatment in some way, as the author says, is an experiment. It may be tough for any patient to accept that he is part of an experiment but it is a journey undertaken both by the doctor and the patient. So actually it is a contract, a contract between a doctor and the patient. The doctor explains the limitations of the treatment he is proposing and the patient also understands and accepts the limitations.

In our field of cancer surgery, almost every patient asks me “Can you guarantee me that the disease will never come back?”

Of course I can’t guarantee. Most of the time we don’t even know why it has happened for the first time. So one has to understand that while in a particular stage, like stage 1 or stage 2 there can be survival of 80-90% but still there is a 20% who will have an adverse outcome. As on today we may not be able to predict which patient is going to remain well and which patient will have problems. This is true of every single cancer treatment.

Now coming to other surgical procedures. Yes, surgical procedures do have their risks. There is no surgical procedure which can be done with zero risk. One has to balance what is the risk of the disease versus the risk of surgery. Modern surgery has a risk of 5% or less in most of the major procedures and it is a lot more safer than before of a lot more complex surgeries which includes not only major cancer surgery, cardiac surgery and transplants and even complicated bariatric surgery but none of the surgeries can be 100% risk free.

Many times the patient expects the answer that “no, there will be no risk and yes, he will be 100% free of the disease” . That is what he wants to hear. Even when the explanation is to the contrary he will go from pillar to post. Today I had a lady who had already seen three doctors, two of them advised that she will need a procedure with a stoma and one surgeon said he will not do a stoma. So obviously the patient is a bit confused.

We have to tell what is a realistic expectation. I think most of the time the patient partly understands it or does not want to understand.

In all the situations, there is obviously a huge gap between the expectation and the result.

One may say that after bariatric surgery, losing 300 kgs. is a remarkable achievement, but one may even argue but that does not solve the problem of other issues, like inability to walk, etc.

What is the real answer? The real answer is that every single treatment is a contract between a doctor and the patient and each of the parties should take a decision based on certain facts and will accept that there are likely to be deviations from the norm. They have to be accepted as part and parcel of the treatment.

Till then, adverse news in headlines will continue.