The way health care operates at public hospitals in Nepal offers very little opportunity for outcomes based improvement. We do episodic cares. If the patient is admitted to the hospital, care is targeted to the acute illness. Once the patient leaves hospital, fate alone determines if you will see this patient ever again. On the outpatient care, where a long-term patient follow-up should be the rule, our clinics are so disorganized, patient hardly ever sees the same doctor on subsequent follow ups. In essence, our outpatient care is also episodic. So our doctors rarely get to see the outcomes of their deeds. While it deprives the doctors an opportunity to improve based on outcomes, provide continuity of care to the patient, I think it also contributes to an epidemic of of cocksure, megalomaniac doctors with god complex in our society.
Unfortunately, heroic enunciation of a well-read doctor does not seem to be enough for a good patient outcome. Well-written prescription alone does not suffice. Small detail can make a huge difference. I am witness to these differences as I see patients everyday at the outpatient clinic.
I so often see patients with heart failure who come to the clinic bloated and breathless. They have been off medications for several days to weeks. When asked why they were off medications for so long, they say they ran out of medications they got at the last visit and they were not due for next visit until now. I am surprised by how often they think medications outside Patan Hospital don't work and that they can get medications at local pharmacies by showing their current medications without a prescription. A simple conversation would have perhaps helped.
This demands of a thoughtful doctor. But that might be the next level. More concerning is the plethora of medication error. Sometimes a medication is missing. At others, a medication that was started for short-term is being continued indefinitely for no good reason. Unable to trust what is written in the charts, these days I have made a habit of asking patients to pull out their medications and tell me what they are doing with each of them. Some of what comes out of this exercise, while exasperating, is also heart-wrenching.
For a large number of patients with breathing problems we use medications that are inhaled. The types we commonly use in Nepal come in hard capsules. Patient has to put the capsule in a device which twists and breaks them releasing medications to inhale. The patient I had the other day was from somewhere remote. She was breathless and cachectic. As I unpacked her plastic bag with medications, the twisting device was nowhere to be found. But she did have those breathing capsules.
Are you taking these medications? Yes. How? I am eating them in the morning and the evening.
She had no idea that these medications were to be inhaled using a separate device. It is not just errors that I have encountered during these bag inspections, some are moving improvisations family do trying to help their loved ones.
A mother-daughter duo from remote Nepal came to me a few days back. The mother had liver failure from excessive alcohol use. In addition to medications, we had instructed her to absolutely abstain from alcohol. As I was going through her medications one by one, at the end, her daughter also pulled out a Mountain Dew bottle. She was boiling Mountain Dew and giving it to her mother in hopes that it will satisfy her cravings for alcohol.
The simplicity of our patients begs for aggressive meticulousness from our doctors.
Unfortunately, heroic enunciation of a well-read doctor does not seem to be enough for a good patient outcome. Well-written prescription alone does not suffice. Small detail can make a huge difference. I am witness to these differences as I see patients everyday at the outpatient clinic.
I so often see patients with heart failure who come to the clinic bloated and breathless. They have been off medications for several days to weeks. When asked why they were off medications for so long, they say they ran out of medications they got at the last visit and they were not due for next visit until now. I am surprised by how often they think medications outside Patan Hospital don't work and that they can get medications at local pharmacies by showing their current medications without a prescription. A simple conversation would have perhaps helped.
This demands of a thoughtful doctor. But that might be the next level. More concerning is the plethora of medication error. Sometimes a medication is missing. At others, a medication that was started for short-term is being continued indefinitely for no good reason. Unable to trust what is written in the charts, these days I have made a habit of asking patients to pull out their medications and tell me what they are doing with each of them. Some of what comes out of this exercise, while exasperating, is also heart-wrenching.
For a large number of patients with breathing problems we use medications that are inhaled. The types we commonly use in Nepal come in hard capsules. Patient has to put the capsule in a device which twists and breaks them releasing medications to inhale. The patient I had the other day was from somewhere remote. She was breathless and cachectic. As I unpacked her plastic bag with medications, the twisting device was nowhere to be found. But she did have those breathing capsules.
Are you taking these medications? Yes. How? I am eating them in the morning and the evening.
She had no idea that these medications were to be inhaled using a separate device. It is not just errors that I have encountered during these bag inspections, some are moving improvisations family do trying to help their loved ones.
A mother-daughter duo from remote Nepal came to me a few days back. The mother had liver failure from excessive alcohol use. In addition to medications, we had instructed her to absolutely abstain from alcohol. As I was going through her medications one by one, at the end, her daughter also pulled out a Mountain Dew bottle. She was boiling Mountain Dew and giving it to her mother in hopes that it will satisfy her cravings for alcohol.
The simplicity of our patients begs for aggressive meticulousness from our doctors.
Its real sad, the lady had been chewing medications that are to be inhaled. Communication is so easily overlooked, All we need is some effort on our part to identify and avoid barriers to effective communication to make our lives and the lives of those around us better.
ReplyDeleteYou are absolutely right, neeti. A little time spent explaining and exploring patient's understanding goes a long way.
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