Few weeks back, my brother Manish posted a blog post titled “Is Paternalistic Model of Healthcare effective in Modern India” wherein he touches upon the aspects of doctor-patient relationship which he believes exist in India at present. If you are keen in understanding what paternalistic model in doctor-patient relationship means – I would encourage you read Manish’s blog. He has done a good job in explaining that and so I wouldn’t repeat it here. In my blog post today I wanted to focus on my personal views on the same – needless to say that it would be more from doctor’s view point.
When Manish was in process of writing his blog post, I recollect him asking me about my view points. It was a brief conversation, we agreed on few points and disagreed on some others, but could not conclude. After few days he forwarded me the link of his blog post after he had already published it. After reading his post, I felt that it was the quintessential Manish I have known for years. Manish has always had a bottoms-up and inclusive approach towards looking at any problem statement. While I respect this ability of his, however my dear brother should also know by now that there are always two sides of any given thing in the whole world. This is what I think Manish missed to bring out in his argument on this topic.
Let me make it clear – I am not here trying to advocate use of paternalism in doctors-patients relationship as many may implicitly assume that doctors like me would traditionally prefer to do that to our benefit. In fact my argument against Manish’s hypothesis of Paternalistic Model being prevalent in India is that it is fast becoming inconsequent based on my experience of practicing medicine in India for more than decade and half now. And I am saying this even in a private setup as mine. Even if we were to assume that ‘we‘ doctors are keen in practicing this model, medical consumers a.k.a. patients themselves are changing in their ways and are in some ways providing us an implicit framework to provide them the services. Personal preferences, growing awareness, peer experiences, costs, and the easily available option of walking over to another provider are driving patients in India to force their view point on what kind of services they expect from us service providers. I do not think majority of my patients are coming to me because they are seeing a ‘parent‘ in me.
Medical practice has evolved tremendously in the last 20-30 years itself. The science and technology in healthcare itself is evolving in quantum leaps as we speak. The numbers of options or procedures to manage an illness are increasing day-by-day. Just as an example – just look at the number of options available for hysterectomy which I discussed in my previous blog post. If I had been practicing about 20 years back, the only surgery option available was Abdominal. Considering the limited choices available – I would have directly prescribed my patient to go under the knife. Many may consider this as the paternalistic approach – however I don’t think I would have had any additional options to share with my patient. However, today it is a different scenario. More the options mean that I have to get my patient into a discussion wherein we jointly concur on the path-forward to be selected. As medical practitioners we have learnt that patient values are important for what is best for them. I personally also think that some of the examples given to explain paternalistic approach are very out-dated too.
Having said the above, I will also confess that part of me also believes that paternalism justifiably has a place in Healthcare even today especially in the scenarios where the patients (or their family members) are most vulnerable and may not be in the situation to make appropriate decisions for themselves. This vulnerability may be because of perceived fear of their sickness (plenty of studies have shown that patients are unable to take the proper decision for themselves especially when they are scared), prevailing social environment or simply having the inability to understand the options or implications. A paternalistic decision made by doctors in such scenarios is necessary and justifiable. I call this as Judicious Paternalism. It is also important to note that as doctors we are taught and trained in solving problems in an exploratory way. However, most of the patients in my experience are unfamiliar to decision-analysis process.
Regardless of my arguments above – many of the points which Manish mentions in his blog about reducing illiteracy; inability of one doctor to get a complete grasp of a complex machinery like human body; or the increasing incidences where doctor’s morality is getting challenged – are all very valid and well put. His coercion to medical consumers for taking responsibility in their own personal healthcare decisions because physicians cannot or do not know their complete wants, needs, interests or fears may be valid too. However, I will possibly attribute them to many a times in our weaknesses in not able to properly communicate with our patients. Trust us – and I can say this on behalf of many of my peers too – that we are continuously making efforts to improve on this aspect. Though all these points are very valid – however – do keep in mind that for a patient their safe bet at the end of the day would be their doctor’s judgement only!
I know that Manish is all for consumerism in Healthcare. And as a doctor I don’t mind it too if patients want that. However my contention is that consumerism should augment joint partnership in doctor-patient relationship rather than trying to pit one against the other.
In any regards, I am keen in hearing your view point too besides what I or Manish think. While I may not have agreed completely with Manish’s view, I enjoyed this opportunity to get into this debate with him. This certainly seems to be more enjoyable than some of the nasty fights we both have been involved in our teenage years. Hope Manish recollects those!
