Praxis

A dear friend had gifted me a book “A Theology of Liberation” by Gustavo Gutierrez. From it, I learned a new word praxis. It was at the time I was working at Patan Hospital. It was also a time when every day was laced with empty high-sounding words. My vocation was slowly blending into the garbage of verbiage. Amidst that despair, the word praxis hit me hard. In the book, Reverend Gutierrez further elaborates on his emphasis on praxis in the context of his theology:

"This is a theology which does not stop with reflecting on the world, but rather tries to be part of the process through which the world is transformed. It is a theology which is open-in the protest against trampled human dignity, in the struggle against the plunder of the vast majority of humankind, in liberating love, and in the building of a new, just, and comradely society-to the gift of the Kingdom of God. "

How profound! Especially in the context of a vocation that dwells on transcending the worldly matters. 

I had observed several issues at the hospital immediately after joining it. And accordingly voiced my concerns and worked on plans to rectify those. But I was not succeeding. The praxis was not happening, just talk and empty promises. I knew the relationship had to stop. But I also carried an obligation to the issues I had thought so compelled to talk about. At the least I needed to try.

Coaxed by a moral duty to this profound notion of praxis, I decided to try working on these issues at a separate setup. I negotiated with an institution called Biomed to establish a practice that focused on diabetes. The institution agreed to running this practice by certain

principles (see the picture). For over a year now, we have been working based on these principles. We have guaranteed everyone access to a doctor regardless of their ability to pay (those with financial difficulties choose how much they want to pay instead of the regular doctor's fees-- no questions asked). We have protocolized care wherever possible, including the workflow of the office and clinical care of diabetes. Pharmaceutical representatives are not allowed in the patient care area, we interact with industry only as a group if we need to. We have pledged not to receive commission for ordering tests, imaging, prescriptions (which is quite rampant in Nepali healthcare). A strict scheduling system is maintained to ensure fairness. We have trained a diabetes educator (based on curriculum by American Association of Diabetes Educators). Two junior endocrinologists have joined me. We have tried running a horizontal power structure with open communication among us, avoiding hierarchical rituals ("sir", "sister") and encouraging patient advocacy. Our diabetes educator does not hesitate to pick up the phone and remind me to reply a patient email or phone call if I slack. We emphasize on educating patients on lifestyle changes, rigorously adhering to scientific evidence base, using only medications with strong evidence of benefits (and lowest cost with most benefits), treating diabetes comprehensively (not just looking at the blood sugar levels and adjusting medications). 

Now that it has been over a year of our work, we decided to see how we were doing for our diabetic patients. Were we doing the things that we needed to do? Were we changing the outcomes by having those measures in place? Here is the outcome (you might have to click it open to have a better resolution):

In summary, we were seeing older patients with long-standing diabetes and significant co-morbidities. Our adherence to the stuff we needed to do was quite robust. The patients' blood sugars were much better after joining our practice (we generally aim for HbA1c <7% which reflects on longer-term blood sugar control). Most of them had their blood pressures and cholesterol levels at where we wanted them to be. When needed, we were using more medications that are known to reduce certain complications in diabetes patients besides controlling blood sugars. And we were doing this by cutting their cost of diabetes medications to almost half, seeing them only once every 3 months on average (we encouraged more telephone communications/emails when possible to reduce their cost of doctor visits). 

Objectively, I would like to think these are quite good results. Our grumbling was that we needed systemic and structural processes in place to insure that diabetes care is done comprehensively (not based on whims of physicians, their memories and moods). The processes we put in place seem to be paying off. At least at a small scale, at least for the time being. And the results are substantially better than what we found when looking at outcomes at my previous workplace with few foreign students on an elective rotation. 

We didn't objectively evaluate patient perception of our services. Well, several of them have offered me marriage of their daughters/granddaughters (one recently sent an intermediary to check my interest!). I don't know if that qualifies as an indicator of patient satisfaction!