A letter to the ST Forum today allows me to illustrate a point about judging doctors:
H1N1: Family doctor did what hospital did not
ON JULY 21 at 11pm, we sent our 10-year-old son to KK Women's and Children's Hospital (KKH) with symptoms typical of a flu. He had a high fever of 38.6 deg C, sore throat and persistent cough.
He had seen a GP that evening and the day before and was prescribed antibiotics and a cough mixture. It was his worsening condition that prompted us to take him to KKH.
The doctor did a chest and throat X-ray and confirmed that it was not H1N1 as she claimed that the symptoms were not typical of the illness. The X-ray showed a narrowing of the trachea.
Note that my child is asthmatic and therefore belongs to the "high-risk" group for H1N1 infections.
She prescribed a cough mixture and fever medicine and advised that he be referred to an Ear, Nose and Throat specialist for follow-up at a later date.
The next afternoon, we took him to our family physician and after reviewing his case, he immediately ordered a swab and sent it to the lab to test for H1N1.
The next day, the results came through positive for H1N1.
I don't understand why the doctor at KKH did not order that same test.
The lack of initiative by the doctor might have led to unnecessary risk of exposure to the disease for a whole lot of people if we had accepted her diagnosis and carried on with life as normal without taking any precautions.
After receiving the test results from our GP, we stopped work and immediately returned home for quarantine.
How many people could we have infected during the two days?
I thank my GP, Dr Fadzil from Al Barakah Clinic and Surgery in Hougang, for his professionalism and foresight.
I strongly urge the Health Ministry to implement a policy that all doctors order compulsory
H1N1 tests for all patients displaying flu symptoms.
I agree we should not panic but we should all learn to be responsible - doctors and patients alike.
Steven Seow
Now Mr Seow, presumably a layman, obviously thinks his assessment of the situation is correct - in fact he is so sure of it he wrote a letter to the newspaper to admonish the doctor at KKH, to praise his GP, and to urge the Ministry of Health to implement a policy on his recommendation.
In Mr Seow's point of view, the first doctor was obviously wrong, the second one a paragon of "professionalism", and he, a layman who had been aggrieved, is qualified to tell us what the correct policy should be, never mind all those people who examine data and evidence and work all day on our policies to combat the epidemic. He presumes to judge doctors and policy makers based on his personal experience of three clinical episodes.
Is it any wonder why doctors resist the inclusion of laymen on the disciplinary committee?
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9 comments:
Very often, patients/parents have their own view point of what is "correct" and what is "correct" in their minds may not be actually correct. In this case, the testing for H1N1 is actually moot because it is already so prevalent in the community that testing for it is not going to help in the management of the patient's condition but the parent kept on insisting that it was wrong not to have done the test.
I find the line written by the parent, "I strongly urge the Health Ministry to implement a policy that all doctors order compulsory
H1N1 tests for all patients displaying flu symptoms." especially amusing.
In this case, the patient had symptoms of influenza since there was fever, cough and sore throat. The patient also has increased risk of influenza complications because of history of asthma, I would have offered a course of Tamiflu to the patient (assuming that the patient was seen within 48 hrs of onset of symptoms). The parent in the article did not specifically mention about this so we will not be able to know if the KKH doctor had offered Tamiflu to the patient.
So yeah, to repeat the point I made earlier, a lot of patients have in their own minds what is correct to them, eg. giving of injections (when not clinically indicated), fever myths, myths about food, belief that chronic hypertension or diabetic meds will cause liver/kidney damage, belief that eczema/urticaria is caused by 'toxins' in the blood etc etc. It's a really long list and very often I find it quite futile to change their mindset.
All arrogance of ignorance, Vince - people with little knowledge who presume that they know all that there is to know about a subject and seriously under-estimate what real professionals know, and are at the same time so cock-sure of themselves they presume to tell the nation what policies to implement and how to judge professionals.
I get a feeling Mr Seow is under the impression that being in the "high risk group" for H1N1 means one had a higher risk of catching it, rather than a higher risk of getting complications from it.
Mr Seow obviously is an example of a customer who believes that the "customer is always right".
An age old debate ......is a patient a customer?
I would like to think that there are very gray areas all over. Especially so in the realms of general practice (GPs).
GPs often see patients who have non-life threatening conditions. Where the patient is not really in a serious condition that requires a very definitive management plan. Often it falls into the "wait and see", "therapeutic and diagnostic" sort of approach.
In Mr Seow's case, his agenda for seeing a doctor was to determine definitively whether his son had H1N1 or not. This was based on his own idea that anyone with H1N1 should be immediately quarantined because of his concern that H1N1 was a serious disease that must not be allowed to spread by any means. This was Mr Seow's ideas, concerns and expectations. And these were not addressed totally by KKH, despite KKH merely following MOH's guidelines albeit correct from a scientifically epidemiological standpoint.
Hence Mr Seow's outrage from his perspective.
I can also imagine someone may write in a complaint letter against a GP in this manner :
"I recently visited my GP as I had high fever, cough, runny nose and a sore throat.
My GP ordered a H1N1 swab test and prescribed Tamiflu for me. The bill came up to over $200.
I returned home and read the MOH website and found that it was unnecessary to do H1N1 confirmatory tests as the prevalence of the disease is very high, and the confirmation makes no difference to my management given that we are now in the mitigation phase of controlling the spread of the disease. I also confirmed this with the Polyclinic doctor when I visited the Polyclinic again to extend my medical leave.
I feel that the GP might have ordered the tests merely to profit from me, as it adds no value to me. It is also not recommended by MOH.
I would like MOH to give private GPs stricter guidelines on ordering unnecessary H1N1 tests that serve nothing except increase profits for their clinics."
So as a doctor, often we have to determine what the patient's agenda for visiting the doctor is, and address it appropriately. In some instances, what the patient wants is also what the doctor wants to do for the patient (for different reasons). In some instances it may not.
My personal view is that if the decision is not one that determines mortality or morbidity and merely an issue of procedure and/or cost, then some leeway be given to the "patient is a customer" adage and let the patient have what he wants. It saves a lot more trouble for everyone and to a certain extent is a "win-win" situation on a small personal doctor-patient scale.
The downside of course is that this does nothing to "educate" the public on the "right" thing to do and merely perpetuates this problem.
However, looking at the way society has progressed and is progressing, this is a trend that cannot be stopped and will continue to grow. In situations where patients complain, doctors will always be at the losing end. The focus should be on preventing complaints from happening in the first place.
Just my two cents
Just wondering ... is the H1N1 being tested for the H1N1 - 2009 of the Swine Flu, or just any H1N1 Influenza A virus?
blur
First, in response to the Forum Page letter, my main grouse is the Straits Times' repeat offence of printing the complaint first, then the institution's reply ( usually a few days later ).
I notice that this practice is preferred to a more logical and useful method of printing BOTH complaint and reply on the same day, which would allow readers to see for themselves how nonsensical the complaint really is.
Guess the ST staff just find it too bothersome to alert the appropriate respondents and wait 24-48 hours, or just want the maximum "hantam" factor, rather than do what's right.
About swabs - depending on which test the doctor orders, you can test for either the generic "influenza" ( not specifically swine flu, can be just the seasonal bug ), or target H1N1 only.
I don't think this is a good example of judging doctors. Firstly, you are taking a case where the father is obviously writing about a treatment grouse of his daughter and thus much more personally involved than a layperson who is reviewing it.
Secondly, I think the credentials of the layperson candidate would be interesting point to pay attention to. I don't think the layperson needs to be completely immersed in a profession in order to be effective in that role. Case in point, many lawyers have an in depth understanding of their industry of specialization as there is a need to understand inner workings in order to deal with the legalities.
Distinguishing between moral and ethical behavior is necessary because people have a wider array of value obligations when functioning as professionals than when resolving value dilemmas in their personal lives. A professional has specialized knowledge that must be applied to serve four entities: the employer, the client of the employer, the profession, and, most importantly, society. A professional also has legitimate moral obligations. In addition to the application of technical knowledge and the proper consideration of economic factors, the professional must properly balance the value obligations to each of the four entities. In light of this, it might serve the medical community better to be more open to other views other than their own.
Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof. ~John Kenneth Galbraith
Thank you for calling me out on my post, anon.
The letter is of course a rather blatant example of how arrogant an ignorant layman can be, and while we can probably be sure that a senior lawyer or ex-judge appointed to the DC will not display a similar arrogance, I dare say that a large number of laymen who support the idea of the proposed amendment are of the same mindset.
Your argument of including laymen into the DC to bring in 'external' points of view is a good and valid one, but this is neither the stated reason nor the desired result of the purpose which drives the current proposal to change - the first is supposedly a lack of legal expertise on the part of the medical council, and the second (as mentioned in my earlier post) is merely to give the public an impression that we are not partial to our own.
In any case, an 'external' point of view is already provided by a 'mandated' layman on the DC - the current proposal will have a legal professional displace that layman, making the DC less 'varied' than it is in its current form. More importantly, the legal professional is not just to provided a point of view, but to chair the DC (see my earlier post).
The medical profession do not just oppose the change out of a knee-jerk reflex - if you examine the arguments provided by the ministry you will realise that the stated aim and the methods are not always congruent.
Does Tamiflu even really work ?. Where are the RCTs ?. Nonsence imo
Hi I am a layman as well, but it seems to me that the simple fact that the KKH doctor confirmed that it was not H1N1 when it turned out to be H1N1 shows the doctor was *incorrect*.
I admit I too would question the doctor's competence if her diagnosis is decisively incorrect.
Can you explain why Mr Seow did not have the right to be upset that his doctor "confirmed" it was not H1N1 when it turned out to be just that?
For now I accept your position that it may have been pointless to test for H1N1, but this does not exempt the doctor from explaining that it was not necessary because it did not matter whether the child had H1N1 or not, instead of making the incorrect diagnosis of decisively "not H1N1". You may also claim that practically speaking the result is unimportant, but I do not think that means Mr Seow had no right to feel aggrieved in this situation...
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