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ramblings of an unknown psychiatrist

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“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.


3 Responses to ““He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model”

  1. Augustin said

    Practice of broader model needs spending more “time” with the patient.Healthcare nowadays is greedy for “more patients” mainly to boost their ego.So more patients ——->less time for individual person——>lesser knowledge of the background of the patients——->only a medical model can be offered!

    Are the advocates of family practice model ready to embrace “limited patients ” to spend quality time with them?!If adequate “time” is there it is possible to bridge the gap between the so called “medical” and ” family practice ” model.

    If the choice of the patient is to save himself by doing whatever he can do in his capacity do we have any right to take that away from the patient in the name of saving his “future generation”?I dare not do so.As you have rightly said that “we can not assume the sentiment of “saving future generation” in every case, we need to offer him the best possible treatment and the financial implications of it and allow him to decide for after all its his family.

    Dear brother , think again will you really defer treatment for yourself to save your grandchildren?!

    • Dheeraj Kattula said

      Thanks Augustine for pointing the reason why docs do not spend time with patients- the case loads. I appreciate your veiw that it is not only greed for money but ego-boost that drives docs to take up too many cases. There is a delicate tension between quality and quantity. We can discuss that in future posts.

      Family practice advocates have a very clear inclusion and exclusion criteria for who they take up. Usually it is based on the geography and socio-economic factors that they call their “community”. This at times makes me uncomfortable. I ask them “How can you not give yourself fully to a person who has the same disease but lives 3 streets away?” They give a reason like,” One has to draw a line somewhere.It is painful. But it has to be done.” This is in line with your view of having a limit to an OP.

      I am sure that he would have told the options but also told them his choice in such a situation. He knew the family well and what it could handle and what it could not. The family could afford travel to the hospital but not the treatment. By sending the patient to the hospital the doctor feels happy and is free of any guilt as he has appropriately referred a case that he could not handle. But was the refferal handled well? Did it bring any improvement? Or was it only waste of time, money and energy leading to greater morbidity?

      In my own opinion we docs do have a management plan which we try to push…Of course in the interest of the patient. We give more information, allay anxiety regarding our treatment plan, explain risks of not going for the plan. This is usually done from a ‘medical model’. For example:- “Patient is too sick. He would cause a lot of damage.Drugs take time to act. ECT acts very fast. Why don’t you consider ECT?” If the family rejects due to practical difficulties, we get irritated. Of course we later work with the family and work out a balance. But this example is from psychiatrists, who take long term interest in patients. In many medical specialities that balancing act is not done. Patient gets lost to follow up at the same time ends up poorer both in health and finance. Don’t you think so? The doc that I spoke of in the post has 80% of his patients on regular follow up. This is pretty high for a high volume regular OPD.

      I am sure I would rather invest in my grandchildren’s education than in my own health at the age of 74, especially if I am anyway dying. If I am contributing to the family, my disease is reversible, my treatment is affordable, it is a different issue.

  2. RPR said

    The eternal question – can a present evil (letting a man die a painful death) be justified on the basis of future (and potentially unknowable) inconveniences and hardships?

    What is the guarantee that those extra 2 years (or even 2 days) of life would not have their own value? And who is to decide that the life of a 74-year-old man (very valuable in any traditional society, before the influx of other cultures corrupted them) is of less value than the (not at all certain) “loss to two generations?” By this argument, why not allow unrestricted MTPs (as our Government already does de facto) because of “potential financial and social difficulties?”

    If given the choice between playing God (as this so called “family physician” did) and accepting that there is a higher order to things (as you probably would), I pray I would choose the latter.

    This is the difference between the “ethics” of utilitarianism and a meaningful morality. You were right on this one.

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