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14 November 2011

Choosing your doctor

Dr. Arpana Neopane

In today’s busy world, people have little time for general medical education and often choose their doctors by going with the simple dictum: “whoever is talked about most is best”. A few months ago, a lady walked into my consultation room with her mother. She complained of suffering from headache and fatigue, but as I started to note down the history of her ache, her mother intervened: “Her headache has already been diagnosed by a neurosurgeon and she is currently on medication-we are consulting you for the remaining problems of her fatigue and shortness of breath.” I was surprised with the mother’s confidence in a neurosurgeon’s prescription for the case of a headache, and even more so that a neurosurgeon would take up the case. Such situations, where patients approach the wrong kind of doctor, occur frequently in our practice and the ignorance is often made worse by advice from misleading acquaintances and know-all pharmacists of drug shops. Though our patients have generally become more medically learned than before, we think some details on how the medical field functions may be useful.

There are two broad fields in the practice of medicine: surgical and medical. The surgical field deals with operative or procedural correction of illness. Thus if there is a lump somewhere in the body or a dislocated joint which needs correction, one needs to visit a general or an orthopaedic surgeon. Visiting a physician with these conditions will only have one be referred to the surgeon. Similarly, an attack of shortness of breath has to be evaluated by a specialist in the medical field. The medical practice can be very systematic if doctors respect one another, practice their own specialty and know their limitations. Similarly, patients too should know about doctors’ specialty and field of practice before they visit, and not be misled by hearsay.

Let’s clarify a couple of other things. After graduating with an MBBS, a doctor pursues post graduation in either a surgical or a medical subject, according to his choice. After this, he becomes a specialist and can practice as a general surgeon or as an internist—a specialist in internal medicine. After this, the doctor pursues super-specialisation in a particular system upon which their future practice is based and restricted. As this happens a doctor’s field narrows down to a system and becomes telescopic. Usually a super-specialist should be consulted after a specialist has localised the disease to a single system both in the surgical and the medical field. For example, if a patient’s disease is localised to the kidney, he will have to visit a nephrologist or an urologist.

Thus, the flow chart of medical consultation starts at MBBS and progresses to MD (medical) or MS (surgical), followed by super specialty in a single organ system such as the kidneys/lungs/ blood/chest, etc.

If patients enter the chart at the bottom where only a single system is dealt with, there may be a possibility that the disease not be diagnosed. A more general, wider approach is always a must while evaluating patients and this is available at the specialist level.

I hope the medical pedigree does not confuse you but helps you to choose your doctor properly. If the patient mentioned above visits a neurosurgeon first in getting help for her problem, you would guess what would happen next. The neurosurgeon’s field is a highly specialised one and so he may focus only on the headache and not consider other medical illnesses for the girl’s condition. A CT scan of her head was normal in her case and the headache got better with pain relievers, but other symptoms remained. After an analysis of the entire system, it was made known that the patient was going through severe menstrual blood loss and anaemia, for which she should have first visited a gynaecologist. She, however, focused more on her headache. The patient should have given thought to the sequence of her symptoms namely fatigue, shortness of breath and the headache, by which she may have approached the right doctor first. On the other hand, if she had been suffering from an increasingly severe headache followed by vomiting without fever, a neurosurgeon would have been the right choice for a first visit.

Thus what needs to be emphasised is that all doctors have their limitations as they are trained at different levels for different purposes. A patient should always learn about their doctor’s specialty before they visit. If in doubt, they should visit a GP or an Internist first who will tell them the type of disease they have and advise on the kind of doctor to visit. Though hi-tech investigations appear necessary for some diseases, they are not always required. A good history and examination done sincerely will diagnose almost 70 percent of all medical diseases and only the remaining 30 percent would require specialists and specialist investigations. As for doctors, they too need to stop the ‘Mixed Vegetable’ approach to medical practice and should stop seeing patients who do not fit into their domain and specialty.

Lastly, the government should enforce some health care rules and regulations, insurance policies, quality control policies, as well as patient guidance protocol to promote systematic medical practices.

Dr. Arpana Neopane MBBS, MD is an Associate Medical Professor at the Kathmandu Medical College

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