Medical Practice Should be Organized around Medical Conditions & Patient Expectations

By:?Rajiv Tewari,?based on a conversation with?Dr. Shafiq Ahmed

Medical conditions-based approach is critical for early diagnosis and treatment instead of a narrow specialty wise approach.

A specialty wise narrow focus can cause delay in diagnosing critical diseases like cancer. As a director in one of the hospital chains, I had carried out research on this factor and the findings were scary. A large number of patients, under treatment in the Gastroenterology department for stomachache and constipation over a long period, were found to be having advanced stages of cancer. Precious lives could have been saved if these cases had been diagnosed early through an internal referral system based on medical condition of the patient instead of focusing on a single specialty.?Similar were the findings in several other specialties.?

Dr Shafiq Ahmed, a strong believer in the medical condition-based approach says that in his early days he used to get angry if a doctor did not collaborate with others in cases where the clinical results were not clear after a week or so.?With many years of experience behind him, he says that now he uses many polite ways of collaborating with other specialties. He believes in reaching out to fellow specialists and encourages them to work as a team.?Fortunately for him the work culture nurtured by Dr Devi Shetty at Narayana Health, where is currently working, is not driven by maximization of share of profit on surgeries so the environment is conducive for collaboration.?

Due to his medical condition-based approach, Dr Shafiq has been very successful in saving many lives by diagnosing diseases at an early stage. I experienced it for my elder brother who is a patient of Dr Shafiq and had come in with multiple issues which included kidney stones, cancer in the urinary bladder and a botched-up surgery. Dr Shafiq’s quick diagnosis prevented Septicaemia due to botched up surgery, followed by removal of kidney stones and then the treatment of cancer. Before beginning the treatment due to the patient profile at the age of 71 years, Dr. Shafiq ensured that all the major specialities were consulted for any other possible complication in record time as this was an emergency.?

Managing patient expectations

Making the patient comfortable with a smile and empathy-based listening is critical in understanding the symptoms, early diagnosis & better outcomes. This can be very challenging in the case of emergency patients but plays a very important role in reducing stress levels and in improving outcomes even in emergency cases. Dr. Shafiq calls it Value Based Care.?This kind of approach adds a lot of value to the overall treatment from a patient as well as clinical perspectives.

Setting right expectations by listening to the patient and giving an appropriate brief on the line of treatment sets realistic expectations due to increased awareness and thereby reduces a lot of anxiety and disappointment especially if the treatment is a prolonged one. Dr Shafiq uses a stage wise approach as a lot of issues may be discovered as the treatment progresses.?Jumping the stages can create reduced levels of trust in the line of treatment as the line of treatment may need adjustments if new facts are revealed. Sometimes these are discovered during the surgical procedure and sometimes during the medication stage so if the patient is aware then the collaboration from his or her side is highly positive.?Once the patient becomes a part of the process then he or she shares a lot of information which may have been left out earlier. For example, many a times the laboratory tests may throw up infections which may be asymptomatic and may not require any medication so in such cases patient’s feedback is very important. Another example is that the patient may have forgotten to share his earlier ailments or diseases in the family tree.?

Several studies have revealed that a lot of litigation and angry responses from the patient and attendants are avoided if the expectations are set correctly from stage one by briefing the patient in an easy-to-understand language. In my brother’s case Dr. Shafiq had fully explained his stage wise approach from day one. Due to his clear brief, we could visualize the steps we were to go through at each stage and could mentally prepare well for the long treatment a cancer patient has to go through.?

Managing unrealistic expectations of the patients

The basic reason for unrealistic expectations from the patient side is lack of listening and lack of appropriate briefing by the treating doctor. Other reasons may include wrong information from social media and several other sources.?This can be sorted out during the first stage itself by giving correct information about the disease and the basis of the clinical approach & treatment line.?A lot of times Google search even from good sources may confuse the patient due to its language and generalizations.?Stage wise briefing approach of Dr. Shafiq not only saves time but also sets right expectations at each stage.?

The treating doctor cannot be available on a 24x7 basis so creation of a communication line and explaining the communication points to the patient helps a lot, particularly during emergencies in the night when the attendant may feel a bit helpless. Though all hospitals have emergency switches and telephone lines connected to the patient’s bed yet keeping an eye on the process and briefing the patient as to how the treating doctor would be informed by the team if the situation needs him at any?point of time reduces anxiety levels.?This too should be treated as an essential part of the brief.

During the treatment of my brother by Dr Shafiq, one of the nursing staff members did not put the canola correctly and there was some delay in rectifying the mistake. Dr Shafiq Ahmed on his visit to the patient apologized for this mistake and made sure that the attendant understood the right procedure and did not repeat the mistake. My experience in another hospital was quite the opposite as the Surgeon was not much concerned about the patient post -surgery other than taking a routine round with no feedback on what was happening during the night shift.

Managing human error and mistakes during patient care

In India a bigger challenge comes from the quality and quantity of support staff particularly due to shortage of experienced nursing staff. Indian nurses are poached by developed nation by the time they have two to three years of experience.?One study shows the poaching to be approximately 60% in cases of good institution trained nursing staff.?Dr. Shafiq says that the leadership teams including the doctors should have a double check system and a direct line of communication with the patient in cases of staff related issues instead of only focusing on the treatment.?If the leadership is too harsh then complaints related to staff areas may never reach them which can be disastrous for patient doctor relationship so it’s very important to bridge the comfort levels between the doctors and the support staff so that mistakes are shared instead of being put under the carpet due to fear.

At the Narayana Hospitals, such issues are raised in a WhatsApp Group which can be seen by others too and prompt action is taken if one of the team members fails to respond in time. This is something I had experienced during the night shift while my brother was admitted in the Gurgaon Unit of Narayana Health.?The response from the highest levels of leadership was prompt and there was a follow up to have full feedback by a bigger team early morning on next day.?Dr. Shafiq says that mistakes are bound to happen but the important thing is to have a culture where people are encouraged to ask for help and at the same time?learn from mistakes instead of hiding the mistakes at the cost of the patients.?According to Dr Shafiq managing mistakes is as important as setting the right expectations and managing unrealistic expectations.???

Tracking & learning from patient feedback for improving outcomes

Patients may not complain about a doctor, but they react in several ways. One clear sign is that the patient does not come again for on-going and follow up care. We have to understand that the days of absolute trust in the doctor have gone.?And if the patient is not briefed adequately then he or she may try to gather right or wrong information through google search and reach conclusions which may be harmful for the patient as well as to the reputation of the doctor. By simply trying to read the patient well and by setting right expectations the trust factor is strengthened which benefits the patient as well as the doctor.

Dr Shafiq not only takes direct patient feedback but also checks patients’ feedback regularly on digital media platforms to improve his patient management skills. He has a 4.7 rating on a scale of 5 on most of the platforms, yet he is cautious about the feedback factor.?Before choosing Dr Shafiq as the treating doctor for my brother I had done a lot of research through google on several doctors and had also talked to some of the patients and approached Dr Shafiq only after we were satisfied with the feedback. At Narayana Hospital, I was told that Dr Shafiq primes all stations one day early for his patients to be admitted in IPD so that the waiting time is reduced and the team members from reception till billing are already aware of the expected number of patients.?Fortunately, the billing department at Narayana is superfast compared to most of the other hospitals so that also helps a lot in meeting the patient’s expectations at all stages of interaction.?

About Dr. Shafiq Ahmed

Dr. Shafiq Ahmed?is Director and Senior Consultant, Urology & Renal Transplant at the Narayana Super-speciality Hospital, Gurugram though he visits all the centers of the group hospitals across North India. He is an US credentialed robotic uro-oncologist and specializes in robotic radical prostatectomy, robotic radical cystectomy and robotic partial nephrectomy for treatment of patients suffering from prostate, urinary bladder and kidney cancers in addition to general urologic problems in men and women. An MBBS, MS (Surgery), DNB (Urology), MNAMS with 15 publications, including 3 book chapters, to his credit in leading medical journals and with work experience at some of the most respected hospitals in India.