Great Equalization: Is MBBS From India Equal To M.D. In U.S.A?

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AAPI Journal • March 2009 FEATURE Crisis! by Dr. M. P. Ravindra Nathan M. P. Ravindra Nathan, M.D. Brooksville, Florida “Come to the office right away”, Becky, my nurse, interrupted my ICU rounds. “Sally fell in the examining room. I think she has a fractured hip,” her words exploded in my ears. Knowing the patient well, I panicked sensing this could portend her end. When Sally presented to me for the first time, she looked like living death; very frail and much older than her age of 60 years. She was a poor Medicaid patient from another town where no cardiologist would accept her. I was the new kid in town and coming from a teaching hospital, I was fascinated with the challenge she offered, too naive to think in terms of dollars and cents. Boy, did she turn out to be some challenge! Sally had chronic rheumatic heart disease and already had three mitral valve surgeries. She currently had a dysfunctional prosthesis with severe mitral regurgitation and a baggy left ventricle which looked more like end stage cardiomyopathy. Type II diabetes, peripheral and carotid vascular disease were additional burdens to cope with. As expected, she developed severe heart failure complicated by pleural effusion and ascites. During the next several months, Sally needed multiple hospitalizations. I thought each one would be her last, but her indomitable will and undying optimism pulled her out. My nurse even delivered diuretics and antibiotics to her home, as she had no money or reliable 24 www.aapiusa.org transportation. I never saw or talked to any of her relatives, including the daughter who worked for a local dentist, with whom she lived sporadically. Her folks had seemingly abandoned her, Sally having become a big liability. There was near pandemonium in the office, by the time I reached there. Sally was on the floor, quite short of breath and pale. The nurse was administering oxygen. The ambulance promptly arrived to take her to the ICU. I wanted to inform the relatives but she gave me, between short and difficult breaths, her usual answer: “Oh, don't bother to call my children, they don’t care. You are my family, Dr. Nathan, I trust your judgment”. During the last few years, amidst many critical care admissions, there were no enquiries from the family. Becky and I were her sole guardians, literally. I liked and respected her almost like my mother and she, of course, was very grateful for the attention we showered on her. She used to become visibly upset whenever we mentioned her relatives. <strong>To</strong> make matters worse, Sally developed carcinoma cervix with pelvic metastasis, and I had to use my wit and charms on one of our radiation oncologists to accept her as his patient. <strong>In</strong>itially, she couldn't even lie down long enough for radium implantation and I had to readmit her to relieve her pulmonary congestion before she could complete a course of radiation therapy. Now Sally is in the intensive care unit (ICU), with a fracture of the left hip and was steadily going downhill with full-blown heart failure, almost into cardiogenic shock. An emergency thoracentesis yielded a liter of pleural fluid. Her diabetes was out of control. She was in Atrial Fibrillation with rapid ventricular rate and a BP of 90/60 mm of Hg. The orthopedic surgeon was reluctant even to touch her and the anesthesiologist didn't like the idea of her dying in the operating room; the risk was much too high, for surgery. And without surgery, Sally would never walk in the near future. Just then, the ICU nurse announced there is a bunch of relatives waiting to see me. “Finally, I get to see Sally's folks, it's about time,” I thought. My enthusiasm was very short lived. I saw a half a dozen hostile, irate faces in the conference room. The eldest daughter, the self-appointed spokesperson of the family, had only one question for me: “Doc, what is the name of your insurance company?” I was stunned and speechless for a moment. Trying not to show my rage, I politely replied, “But first, don't you want to know how your mother is doing?” “Well, she fell in your office, didn't she?” Without mincing words, a clear message was delivered. A barrage of Continued on page 25
AAPI Journal • March 2009 FEATURE Crisis! Continued from page 24 questions followed, faster than I could answer, each designed to intimidate me into an admission of guilt. She didn't care how her mother was doing. It hardly mattered if my nurse and I contributed anything for dear momma’s welfare in the past six years. The dialogue deadpanned. I could sense a legal battle royal brewing. I took my lumps and retreated. Clearly they didn't travel all the way from New Jersey to Florida to see their mother getting better or give me a personal ‘thank you’ for all what I have done for her. On the contrary, I realized much to my dismay, that they have already retained a lawyer. I informed my liability lawyer too; I didn't think that any malpractice has been committed. With her frail condition, Sally could have sustained a fall anywhere, in my office or any public place. During the next few days, poor Sally teetered between life and death. Even the nurses could sense that this family didn't care and probably would be very delighted if Sally didn’t make it. With a heightened sense of responsibility I worked on her, in spite of the odds stacked against me. With appropriate hemodynamic monitoring and all other state-of-theart critical care therapy, we managed to pull Sally out of the crisis, the surgeon and the anesthesiologist handling their parts very well. At long last, Sally was discharged on crutches. During this long-drawn saga, the relatives asked the nurses repeatedly: “How long can mother last like this?” Sally’s recovery was a true miracle and we gave high-fives to each other. The relatives appeared disappointed, or so I thought. And now, the epiphany. A few weeks late my lawyer informed me that the family unsuccessfully contacted 3 trial lawyers who refused to accept the case. They couldn’t find a single thing wrong. Sally will hear nothing about legal action against me. She even gave a Pharmaceutical Advertisement: Makes For Better Healthcare For All? Continued from page 22 inception of DTCA has been unable to raise any of the health indices in the countries, but has increased the amount of GDP expenditure on health care. Although, this does not disprove the use of DTCA because the results of the medications prescribed might be relevant 10 or 20 years in the future, but it does bring into light the fact that a country like Turkey spends as much on childhood vaccinations as it does on treatment of erectile dysfunction. Conclusive Remarks DTCA of pharmaceutical products has the potential to become a major changing force in driving healthcare decisions. Physicians are informed consumer of medications, not patients. Advertising to a third party that becomes the recipient of your product is reasonable, because they might be able to stimulate demand for your product, as evidenced by increasing number of medications prescribed in countries with DTCA. This approach also brings out statement to the nurses that her fall in my office was entirely her own fault. One of the daughters had hinted that Sally may have been pushed from the examining table but this didn't hold much water. Finally, the attempt at a malpractice suit met an inevitable demise. I felt vindicated. Finding that they couldn't collect from my insurance company, the family dumped Sally back in her small house and went on their way. We arranged a home health care agency to take care of her. As a last act of gratitude to me, the family also transferred Sally's records to another cardiologist, much against Sally's wishes! I get a hearty laugh when I think that Sally is relaxing in a recliner surfing TV channels and enjoying whatever life is left for her. She must have a chuckle too, having beaten the odds and taught a lesson to her greedy, neglectful children. And as for myself, I learned that relatives of patients come in various types and attitudes and I have to handle all situations with equanimity. problems that are far worse than that of the actual disease process and poor allocation of resources for disease management. Pharmaceutical corporations would be advised to create informative websites to allow physicians to direct their patients to those banks of knowledge rather than provide a thirty second highlight about noncohesive symptoms hoping to have patients inquire enough about the medication to have the doctor prescribe it to them. www.aapiusa.org 25
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Great Equalization: Is MBBS From India Equal To M.D. In U.S.A?

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