Blissful Life

When you apply skepticism and care in equal amounts, you get bliss.

Month: September 2019

  • The Curious Case of Consultation Fees in General Practice

    Today as I was returning home in metro two lawyers occupied the seats next to mine. I was reading A Reader on Reading by Alberto Manguel. But I distinctly heard one of them tell the other “I have two cases tomorrow evening”. That set me thinking.

    Advocates have “cases” and so do doctors. Advocates have “clients” and so do doctors. (Some doctors call their clients patients because some clients are indeed patients. But some doctors call even their patients clients, appreciating the fact that ultimately the people who come to them are dignified individuals seeking a service and with autonomy in choosing service providers.)

    Advocates are also notorious for charging sometimes lakhs for an “appearance”. But here doctors have itt slightly different. Doctors also get called money-minded and unscrupulous, but they get called so for charging much less than what advocates usually charge. Why is this so?

    I came up with various possible reasons. One, the huge lawyer fees that we hear about usually are in big courts for defending big crimes. Perhaps the stakes are really high in those situations. To add to that, a court case is usually once in a lifetime situation for most people and one they probably have never encountered before. Therefore the clients are in a much more vulnerable situation and would be willing to pay a lot.

    This “high stakes” reason appears correct because there is similarity in healthcare. When you go to a hospital with a heart attack, you don’t care how much the hospital charges are going to be, you just want your (chest) pain free life back. But when you have a cold (which is probably the 14th time you are having it in your lifetime), you know it is going to be better in a few days and there is no real reason to spend lots of money.

    That probably explains why the market rates in general practice is very small. People usually present with simple illnesses and a sense that their illness is a simple one. Therefore there is not much value they are seeking from the doctor – most clients are in for quick relief from symptoms, if possible.

    Therein lies the complexity of general practice too. I’ll explain that in a bit, but first let us look at one more difference between lawyers and doctors. Lawyers take money from clients and work for clients by being sharp witted and coming up with strong legal arguments. But their “appearance” is in front of a judge. The favorable outcome is defined by the client but realizing that outcome requires very little of the client’s participation. Usually, the judgement made by the judge also unequivocally settles the judgement on the lawyer’s performance.

    Now let us talk about general practice. In general practice, your client does not just pay you, but also has to work with you for their own success. There is no third person involved. The client has to believe in the doctor, has to believe in the advice given by the doctor (that the advice is for their own good), has to follow the advice strictly, and also has to make a judgement about how good the entire process have been. This is where the previous point comes in.

    The reason why clients come to a general practitioner is often for quick relief from their symptom. Most of the time in medicine there is no quick relief which is also good. For example, painkillers are quick relief from pain due to strain. But the good thing to do maybe in many cases to take rest and allow body to recover. Common cold may slightly improve with nasal decongestants, but overuse maybe harmful. Sometimes sticking to medicines which cause nausea, vomiting, diarrhea or many other tolerable side effects are required in the face of greater dangers like multi-drug resistant tuberculosis.

    Sometimes the right thing to do in the view of a doctor maybe different from what the client thought would be the right thing to do. This would not be a problem for a lawyer as the client does not have a role in deciding the success of the lawyer’s approach to the “case”. But when doctors are in this situation they have to use all the skills they have in convincing the client about why there needs to be a change of expectations. And the success of the treatment itself relies on this “winning over” of the client.

    And after all that exercise, the client has to pay. ICUs, OTs, and emergency departments have it easy. There is a lot of money to be paid, but most of the work is done by nurses or doctors and the sick person usually just has to lie down on a bed (conscious or not). General practice? Totally different ball game.

    With that context, how much is a reasonable consultation fee in general practice? 50? 500? 1000?

    Before locking our answer, let us look this from another side. The general practitioner is a small entrepreneur. The GP has a home and has a life. The GP needs to make money to survive. But the GP is also a doctor. No conscientious doctor can do injustice to their profession or their clients. They cannot simply symptomatically treat diseases without thinking about root causes. Diseases have to be managed correctly. Counseling is an important aspect of treatment. And all of that requires time – time to be spent in consultation. And time is money.

    The question on consultation fee thus has to be somehow linked to the consultation duration. What is the minimum time a doctor should spend with their client to fulfill their obligation/duty? There can of course not be a single answer to this as every consultation is different. But practically, from my experience, in a single person clinic the doctor (who is the single person) has to spend at least 20 if not 30 minutes in a consultation for there to be some quality.

    How much of that can be delegated? Whom to delegate to? Of course in a single doctor clinic the only person to delegate to is the client themselves. Can clients prefill questionnaires about their health condition? Can clients read informational pamphlets instead of having to listen it directly from the doctor? Does trust suffer in attempting such time saving measures? These are all questions with no definite answers.

    Does building a healthcare team help? It can definitely help. At Restore Health we have a multi-disciplinary team where a lot of tasks are shared. But still there is considerable amount of time spent by each person of the team in providing care to a client. And we charge 500 in general practice consultations. Are there people who think that is too much? Definitely, yes. Including sometimes our own doctors. But there are times when we have saved the client a lot of money and good health and spent considerably more time in the process. We do not have “dynamic pricing”.

    Perhaps there needs to be more thought put into showcasing all the value that is created by a GP and monetizing some of that at least. All this while treading on the right side of ethics and not breaking the delicate thread of trust that connects a client to a doctor. Who says general practice is not challenging?

    My train of thought was derailed when the train I was sitting in reached my destination. As I stood up to deboard, the lawyer next to me took my seat. Perhaps she was thinking about how much to charge her next client. Perhaps not.

  • Healthcare in Consumer Protection Act 2019, VP Shantha and why you should read the source

    There are good journalists and bad journalists. It is the reader’s duty to discern between what is right and what is wrong. The problem in the 21st century is that that duty is completely thrown into water under the guise of “forwarded as received”.

    There are a lot of articles in newspapers talking about dropping the world “healthcare” from the list of services under the consumer protection act of 2019. Many of them have fancy headlines suggesting that healthcare will not be a service that falls under the ambit of the new consumer protection act. At least some of them have written objectively stating where the word is dropped from without going into judgement on what this means.

    But many doctors are reading headlines and thinking that the consumer protection act will not apply to healthcare henceforth. What they need to read to know they are wrong is just one judgement by the Supreme Court in the “Indian Medical Association vs VP Shantha, 1995” case.

    That judgement was specifically about settling the question of whether healthcare is a service that falls under the definition of service as defined in the consumer protection act (the act of 1986). For ease of reference I will quote the definition from the old act:

    “service”
    means service of any description which is made availĀ­able to potential users
    and includes, but not limited to, the provision of 
    facilities
    in connection with banking, financing insurance, transport,
    processing, supply of electrical or other energy, board or lodging or both,
    housing construction, entertainment, amusement or the purveying of news or
    other information, but does not include the rendering of any service free of
    charge or under a contract of personal service;

    Notice that healthcare is not specifically mentioned. Supreme Court read this definition and confirmed that healthcare is included in the broad definition of “service of any description” and spelled out conditions where it would be excluded.

    Now, here is the definition from the new act:

    “service” means service of any description which is made available to potential users and includes, but not limited to, the provision of facilities in connection with banking, financing, insurance, transport, processing, supply of electrical or other energy, telecom, boarding or lodging or both, housing construction, entertainment,amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;” (emphasis for words that have been added)

    Where is the “healthcare” word dropped from then? Well, it is from the draft bill that was introduced.

    Now you can read the full judgement on how the new definition also includes healthcare in it.

  • Meftal-Spas vs Meftal-Forte for Menstrual Pain

    I was recently asked by someone whether Meftal-Forte is a better drug than Meftal-Spas for menstrual pain.

    I hadn’t heard about Meftal-Forte till then. So I looked up. 1mg told me both the drugs are manufactured by Blue Cross.

    The page about Meftal-Spas gives us what I knew already – it is a combination of Mefenamic Acid 250mg and Dicyclomine 10mg.

    The page about Meftal-Forte told me that it is a combination of Mefenamic Acid 500mg and Paracetamol 325 mg.

    Based on this, the quick answer is “No. Meftal-Spas seems to be better suited for menstrual pain in people who find relief by using it. But self-medication may not be the best way to manage menstrual pain.”

    The longer answer is that dicyclomine is an anti-spasmodic that is widely used with anecdotal evidence supporting its use in primary dysmenorrhea. Mefenamic acid is an anti-inflammatory drug that is indicated for use in primary dysmenorrhea. Paracetamol is not really indicated for primary dysmenorrhea. Therefore if forced to choose between these combinations, the one with dicyclomine makes more sense to be used in primary dysmenorrhea. But self-medication is mostly not the right thing to do because a lot of dysmenorrhea maybe secondary to things like endometriosis and maybe better treated by other drugs under the guidance of a family doctor or a gynecologist, and sometimes just mefenamic acid (in the right dosage) might be enough to control primary dysmenorrhea.

  • Practical Career Guide for First Benchers

    This is partly a response to “All That Glitters” by an IITian and partly a message to my brother who is an IITian.

    Although I used to sit mostly on the back bench during school, I fit the first bencher stereotype more – good scores, liked by teachers, great expectations. I currently have a career tragectory that I am happy in. It hasn’t stood the test of time and that is a caveat, but otherwise I’m perfectly qualified to write this guide.

    The problem

     

    What to do in life?

    The dilemma is faced by every first bencher just after their schooling and throughout their college years. For me it extended till about an year after that.

    Image by moritz320 from Pixabay

    It is a dilemma because there is choice overload and there is opportunity cost. There are virtually an infinite choices on what to do in life, especially so for the first bencher. The “back bencher” has it easy because a lot of choices are eliminated by steep barriers and therefore their options become simpler. But the first bencher knows nothing called impossible. They feel that they can do anything if they put their mind to it. And so they have all the options they can think of.

    But the opportunity cost is real. No matter how productive you are, you can’t sleep 8 hours in 4 hours. There is an opportunity cost to every damn thing. And that’s where the crux of the problem lies.

    What to choose to do in the limited time alive? What things to prioritize? Happiness? Sure. But what brings about happiness? Does money bring happiness? Does autonomy, creativity, and intellectual satisfaction bring happiness? Does good relationships bring happiness? Can one not have all these? What if I do what everyone else is doing for a while and figure out in some time? What if I get stuck in that rat race? What is the meaning of life?

    Existential crisis apparently is sort of depression.

    Potential solution

    I’m very wary of prescribing one size fits all solutions. There is one approach I have followed in my life which I’ve found to work very well for me. I call it “being ambidextrous”.

    The fundamental tenet of this approach is to shun exclusionary thinking. Exclusionary thinking is when you think “if I take up a 9-4 job, I can’t become an entrepreneur”, “if I get married, I can’t do adventures”, or “if I become a doctor, I can’t become an engineer”. There is always a way to pursue two or more interests together.

    The challenge is in finding that way. Sometimes it is hard and will involve moving geographies, spending money, losing sleep, etc. But once you find a way to follow your heart in all directions your heart wants to go, you will have a happy heart.

    Should I not make money?

    There are a few basic things you need in life

    • Food
    • Clothing
    • Shelter
    • WiFi

    You really need to take care of this. And that involves making some money. But the money required for meeting these basic needs is trivial to make for first benchers.

    Then there are some other needs which also require money

    • Friends & Family
    • Health
    • Entertainment
    • Transport

    These are some areas where frugality really helps. With good accounting of income and expenses, careful planning, and hard work the money required to take care of these can be kept low. When you don’t need a lot of money, you don’t have to make a lot of money.

    What about ambition?

    There are two ways to look at this. One is that ambition is bad/unnecessary. That success is hyperromanticized. In this outlook, you try to make time for simple things in life. You call ambition as society’s unreasonable expectations from you.

    The other is that ambition is helpful. That it gives a direction in life. That it gives meaning to life.

    But do you notice the circular reference in that latter approach? How do you choose your ambition?

    Here also being ambidextrous has helped me. It is important not to go too much behind meaning. It is also useful to have a few ambitions. Maybe a better word is goals. Not all goals need to be achieved. Goalposts can be shifted. In fact, if you grow up, you’re bound to realize some of your goalposts were wrong.

    Footnote

    I’ve had two mentors tell me that confusion is a sign of thinking mind. So if you’re confused, that’s a good thing. Another thing is that the confusion never ends. Mid-life crisis occurs at all ages and at all junctures in life. The approach to deal with this that I suggest above is greatly influenced by Zen Habits.