Manufactured Success

"Kidney transplantation at Bir Hospital is world-class," declared an article in Kantipur. Perhaps elated by this apparent achievement, it even published an editorial praising the success. 

Great!

It sounded like something to celebrate. Especially when we are working in such resource-poor setting with several limitations. Such success should be morale-lifting for anyone working in the field. 

But the news sounded too good to be true to me. Primarily because of extremely sloppy care my patients had received when I sent few with advanced kidney disease to the same folks that tout these results. My earlier sympathy for a fellow public institution has faded and I have stopped sending them patients.

Are they doing such superb job? Maybe I had misunderstood them. I do not have access to their original data. But going by what data have been given in these newspaper articles, it does not actually look very celebratory. 

The only data that I could make sense of was transplant rejection rate. It says Bir's kidney transplant rejection rate is 11% compared to global average of 20%.  I assume this is annual graft rejection (the transplant program seems to be just 4 years old to give a longer-term outcome. And 20% global outcome data is for 1 year graft rejection rate based on my non-expert search of web. The range was actually 10-20%). 

All these transplants are living donor kidney transplants. So the 1 year graft survival rate is 89% for Bir's program. Corresponding data for whole of the US is 96%. This seems to be a huge difference from a claim of world-class outcomes. Perhaps it could be claimed that Bir's outcomes approach that of global average. But being closer to global average does not mean being a "world-class" in the usual sense of the word. All this hoo-ha appears to be self-congratulatory chest-thumping from statistical white lies. 

While it may be very healthy to celebrate success, however small, this propensity to manufacture delusions to feel good might be rather detrimental. From what I see everyday working at a public hospital, humility and self-reflection to rectify and improve our dismal healthcare delivery system is more important than ego quenching from such manufactured successes.  

Bags of Medications

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. 

Patan Hospital Protests Updates: A Mess

The Prime Minister, also the chancellor of Patan Academy of Health Sciences (PAHS), decided to suspend the newly appointed vice-chancellor of PAHS. He reversed his decision [ultimately he is the one who appointed this controversial vice-chancellor (VC)].

But the tale does not find its coup de grace there.  This VC has decided she wants to fight back legally. We are told she is taking help of some star lawyers. The court has given a stay order. So the sacked VC is officially still our VC. 

With this, we have officially joined the typical mess our larger political system is in. In this mess, a rich philosophical discourse can be conducted in purely technical/philosophical terms about what is right and what is wrong. 

In the court, perhaps an intense debate will happen. Who is right? Who is wrong? What is right? What is wrong? What are the evidences?

But for a novice physician like me, who saw an overnight transformation in energy and work ethics of care providers in the hospital from a political appointment, fundamental questions will be: Why did it happen? What did it do? 

High-Rises

High-rise buildings like the one in the middle of the picture are growing in this city. Amid the shabby concrete houses of this city, their grandeur stands out. When the darkness of the night wraps the valley, unruffled by our perpetual load shedding, these buildings glow with lights perhaps generated by backup power systems. The contrast at night is sharper. They are the survivors in this city where night favors darkness.

They must be the lucky ones who get to live in these buildings: ones who do not have to depend on the electricity that the national power grid supplies. The power grid that is raped by scarcity, incompetence, corruption and ruthlessness. I hear you have to pay millions of rupees to buy these apartments. But if you own that fortune, you do get a chance to escape the darkness of this city.

These glowing buildings at night are the epitome of power structures in Nepal.

If you have enough money, you get uninterrupted electricity (fair enough) and water . If you know somebody at a public hospital, you do not have to wait in line to be seen. But be prepared to let those people in front of you, even if you have waited in line since early morning, if you are a nobody. Hospital beds can be emptied if you hold some power (political office, connections,... you know it). But be prepared to be shoved out to another hospital if you are a nobody. Even if you are paying a substantial sum, do not expect to get a reciprocal quality of care if you are a nobody, either at public hospital or private ones. Be prepared for endless tomorrows to meet the government regulatory requirements if you are a nobody but everything can be done from home if you are in the power structure. 

Let me give you an example: our government gives a subsidy for hemodialysis to patients who have kidney failure. For that, they ask you to get photocopies of citizenship certificate, few passsport-sized photographs and a statement from VDC stating that you need financial assistance. If you are an illiterate peasant from Sankhuwasava, imagine your ordeal. Do you have a citizenship certificate at the first place? How are you going to go to Sankhuwasava to get a VDC statement while you are lying breathless in a public hospital floor? But if you are a local political somebody, you will make a call to the VDC secretary on his mobile phone and have a villager hand-carry the letter to you the next day.  

I get a sense that the plight of powerless is growing. Our government is growing and so are the ones with access to power. Our intellectuals have run out of imagination, their only solution to all of our woes is additional regulation. Our oligarchs are ecstatic about bringing any new regulation. It creates an opportunity to exercise power and extort money. In this game, ease for those with power is still secured but life for the regular folks becomes tougher. 

It seems to me incompetence of our institutions is a bigger issue than a lack of elaborate regulation. Unfortunately, our incompetence and corruption is growing and these institutions are getting larger.

Stones

In my relatively rare taxi rides, I have found our taxi drivers chatty, in a good way: an unusual attribute for our service providers. This might be just a coincidence or perhaps they are primed by potential return in tips by this exhalational exercise of vocal cords.

Today's was a master of them all. His oration that spanned a ride from Tripureshwor to Maharajgunj would have convinced a novice that this bloke was the most knowledgeable person in the area of kidney stones.  Let me summarize:

Our conversation started with me pointing out dust in the air that was made more apparent by the bright car lights at night. You know, he began, the dust can make kidney stones. It makes 10% stones. If you live in Kathmandu enough, with all this dust, you are bound to have kidney stones. The smoke, chewing tobacco, all of them get deposited slowly and make kidney stones. Tomato is the most notorious one, it makes 50% stones. Another one is palung (spinach) that makes 20% stones. I learned all of this from a book that a bideshi (foreigner) gave. 

Was it in English? I ask. 

Yes, he says, it was both in English and Nepali. 

You need to drink 5 liters of water after each meal not to have kidney stones. Stone is a huge, huge problem he perseveres. 

Have you had a kidney stone? I ask. 

Yes, he says, himself and his wife. His wife got operated 2 days back for a kidney stone. It was this big, he shows me with his fingers. I used this same taxi to bring her back home from Dhulikhel Hospital yesterday, he declares. Then he veers off to a lengthy praise of Dhulikhel hospital; how they did operation with a total cost of Rs. 23,404 when at private hospitals they were estimating Rs. 150,000........

Risks, Benefits and Trust

In a heart condition called atrial fibrillation, electrical activity in the upper chamber of the heart goes haywire. The squiggly muscle contraction generated does not pump blood effectively. Resulting blood stasis predisposes these patients to blood clots which can break off and reach the brain causing stroke. In these patients with atrial fibrillation, you may be able to prevent stroke by using blood thinning medications. One of these, aspirin, does so by reducing stickiness of platelets which have a major role in clot formation. It generally has low risk of bleeding and does not need monitoring blood tests. Another medication, warfarin, does so by reducing chemical substances involved in clot formation. Warfarin carries a significant risk of bleeding, especially with injuries, and a blood test has to be done regularly to ensure a safe dose of warfarin. Warfarin is more effective than aspirin for reducing the chances of clot (and stroke) while there is a higher risk of bleeding. 

Which one do you choose?

It is a complicated decision. Not everyone has the same risk of stroke with atrial fibrillation. So a risk-benefit assessment is employed. In lower risk patients aspirin is preferred while warfarin is used in higher risk patients. It turns out age and certain comorbidities accurately determine risk. In clinical practice, there is a scoring system called CHADS2 which gives certain points for these characteristics and overall score is used for treatment decision:
    Score 0: Give nothing or aspirin
    Score 1: Use aspirin or warfarin
    Score 2-6: Use warfarin
Let's say my patient scores 2. Untreated, the annual risk of stroke is 4%. Aspirin use reduces annual risk to 2.5% and warfarin to 2%. Is warfarin use a risk worth taking for 0.5% risk reduction? Does the study that came up with these results take into consideration peculiar circumstances of my patients: bumpy roads where you routinely levitate few inches out of your seats stretching blood vessels in the brain, need to climb trees to fetch fodder for cattles, availability of money to do blood tests, availability of blood tests nearby,...the list goes on. All these factors make warfarin a risky choice because of increased likelihood of life threatening bleeds. But is the risk justified for the benefits? 

If this exercise has been confusing, it indeed is. You hope and pray your doctor has done this exercise for you. 

I do routinely see atrial fibrillation patients taking warfarin at my hospital's outpatient clinic. When I ask them why they are on it, many of them answer their doctor asked them to take it or they were discharged with this medication after the hospital admission. They faithfully do blood test (which is required every 2 weeks many a time) and come for warfarin dose adjustment. If you allow, I would venture a guess that my patients have no idea about above risk-benefit calculation (if it has ever been done). But they are doing it because their doctor told them to, that it may be good for their well-being and longevity. 

This is just an example. Our clinics abound with patients suffering from non-communicable chronic illnesses. The treatment decisions entail risk-benefit calculations. What is the potential long-term benefit? What are the potential risks? These are more or less abstract notions both for patients and doctors but especially for patients. A patient with high blood pressures is treated to reduce the risk of heart attack, stroke, in future. Why should one agree to take medications daily for something that one cannot feel? What are these patients actually taking medications for? Are they calculating their risks? Many of my patients don't even know that high blood pressures can increase the risk of heart attack. They have been taking medications because they reduce the blood pressures to normal values. How did these abstract notions about benefits of normalizing blood pressures come? Is it a transmitted knowledge from others experiences? Is it a transmitted notion of benefits of their doctors?

Whatever it is, it expresses as a faith  in doctor's recommendation in my day-to-day patients. However much we hear about increasing lack of trust between doctor and patient in our debates,  in daily doctor-patient interactions, most of the decisions are done by reflexive trust of patients to their doctors. When I think about it, as a doctor, it is an overwhelming responsibility, to deliver to that trust. 

Especially humbling in the setup I work is the fact that our power structure is oblivious about this responsibility. Rather, I sense a feeling of entitlement among us doctors and administrators who hold the power. It is not uncommon to hear, in one of our grand eloquence, that the root of the problem in several of our disorganized institutions is illiterate, irresponsible janata (people) behaving haphazardly. We can elaborate on every solution that does not involve ourselves.  As I see a swathe of patients navigating the torturous disorganization of a public hospital just to see a doctor who will tweak their cholesterol medications, I have been increasingly disillusioned about the idea that our patients are illiterate. It is time that our doctors be literate.  

Article

This article might be of interest regarding emigration/retention of Nepalese doctors: 
http://www.bmj.com/content/345/bmj.e4826