Blissful Life

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

Author: akshay

  • PGDMLE Paper 3 – Medical Professional, Patient & The Law – The Legal Relationship

  • PGDMLE Paper 2: Law and Health – an Interphase

  • PGDMLE Paper 1

    It's been a long time since I posted any question papers on this blog 😀

    I've been doing a distance course in medical law & ethics from National Law School Bangalore. I love the course. So much so that I didn't take exam the first time so I could extent the duration.
    This time I had to take at least two papers. (I'm taking four, and skipping dissertation for next time).
    This is paper 1 which is common to all diploma courses (among child rights, cyber law, and so on).
    I've ticked the questions I answered.

  • Good Riddance, WhatsApp!

    I took the jump. Deleted my WhatsApp account.

    Yes, I know. There are too many important groups. There are people who can’t use email or other means of communication. Coordination of so many things will become difficult. What harm is there in keeping the account, and not using it? What if there is an emergency?

    But, I am sorry. I deleted the account.

    The idea isn’t new. Pirate Praveen doesn’t have a Whatsapp account. Prashanth NS doesn’t use Whatsapp. Cal Newport advocates digital minimalism. All in all, plenty of people have done well without WhatsApp and actively inhibit WhatsApp usage. But I won’t ask you to uninstall WhatsApp just yet. Maybe at the end of this post.

    WhatsApp is a good chat app. It has a simple interface. It works consistently in poor connectivity areas. It has various features that make chat easy. It may not be the best. I personally prefer Riot (a client of Matrix protocol) and Telegram for chat. But, WhatsApp still does its job.

    Maybe it is chat that I do not like. Synchronous messages create a sense of urgency. The delivered/read ticks on WhatsApp forces me to respond quickly to messages. Maybe I’m not ready for that. Maybe I want to respond to messages when I want to.

    Yet I use other chat apps. I use Telegram extensively. I use slack. What’s the difference?

    Perhaps I should start from the beginning. First, we invented the telephone. We could talk to each other at a distance. That is a definite value addition. You no longer had to travel long distances to talk to people.

    Then there was internet. With that came email. The good thing about email was that you could send it across very quickly to large number of people (like mailing lists) and people could skim through many many emails very quickly.

    There also was blogging. Blogs are like books. People may read you. People may not read you. A million people may see it. Nobody may see it. Blogs fulfilled the role of people wanting to reach out to the world and influence the world.

    Then, there was the mobile phone. And with that came SMS. SMS was sort of like email, and sort of like phone call. It was designed to be short. It was designed to be direct. That allowed for quick, non-distracting, short message updates.

    That is the point at which chat apps come to the picture. The biggest feature of a chat app is the group chat. Individual chats are just like SMS, but with pictures and videos they could be called SMS on steroids. But group chats is an entirely different paradigm. Group chats let people talk to multiple people at the same time. Sort of like a broadcast, but multi-way broadcast. That allows quick coordination of large groups.

    I almost missed social networks. Social networks are like the sum of all the previous innovations. They combine the intimacy of group chats with an experience similar to walking through a virtual world and influencing a large number of people.

    All of these are not without consequences. Firstly, our attention is now deeply fragmented. We have a thousand things we can engage with at any point in time. In the attention economy everyone has to shout louder to be heard. Soon everyone is shouting even more loudly. It becomes like a party floor where nobody can hear nobody else.

    Secondly, it is so easy to bombard each other with messages that sooner or later people get strong opinions about things. And that makes for a heavily polarized world because people always tend to have differing opinions.

    Thirdly, and most importantly, people are unable to work on hard problems with their mind into it because that requires focus and peaceful mind. I have a very big hunch that this is the biggest reason why economies world over are failing – because people simply aren’t productive any more.

    All that said, now I can state the reasons why WhatsApp and Facebook (and more recently twitter) are especially to blame.

    The way Facebook is designed, you connect to your friends and family. And then you hear from them. Sure you can connect with various organizations, etc. But yet, nobody keeps their connections devoid of family and friends. This “social” prat of the social network makes it a very mediocre place. There is a very good chance that the best people you can listen to on any particular topic is not in your social circles. The best writers, thinkers, or analysts on the planet probably didn’t go to the same high school as you did. Therefore, if you wanted to put your attention on the best things on any topic, Facebook is a very bad place.

    Similarly, WhatsApp is designed for people who know each other well (well enough to have each others’ phone number) to communicate. Even with group chats, you are probably not going to share groups with very smart people. WhatsApp, therefore, has the same pitfall as Facebook. It encourages mediocrity and conformation.

    Apps like Telegram and Reddit do not have this problem. (Although the attention economy is still a problem there). And therefore WhatsApp gets an extra negative mark there.

    And then, there are all the other reasons. WhatsApp is not free software. WhatsApp is owned by Facebook. (And since the last update it clearly shows on the splash screen that it is owned by Facebook). And Facebook is evil in various ways.

    Of course this post would be incomplete without me telling how I actually managed to pull this off.

    First, I had notifications turned off for WhatsApp through Android settings. It had been that way for months. Essentially, I would see WhatsApp message only when I opened the app.

    But, about a month back, right around the time CAA was passed, I started doing another thing. I used a firewall app called NetGuard (which doesn’t require root) to block internet to WhatsApp. And I hid the WhatsApp icon in the Niagra launcher I use. And I turned off background data (just an added measure because NetGuard anyhow stops background data). And I changed my WhatsApp status to let people know that I won’t be online. And I changed my profile picture with a message that I won’t be online. And then I kept silent for days.

    The first time I did that, it was in solidarity with the people suffering from internet shutdowns in India. When I logged in after about a week, I noticed that I hadn’t missed a lot of important messages at all.

    So, I tried it again. This time I did it for two weeks. And this time too, I hadn’t missed anything important. My patients could either directly call me or my clinic manager for appointments. My colleagues could message/call/email me any important thing from the WhatsApp groups. And I was insulated from all the “Merry Christmas and Happy New year” gifs.

    The only reason I wouldn’t go ahead and delete WhatsApp was that I wanted access to the past messages. Or so I thought as you will see in the next paragraph.

    Today I thought I would install WhatsApp Business and set up an “auto-respond while away” message for giving people who contact me a fairer warning that I won’t be reading their messages. But turns out that feature works only if you turn WhatsApp on and let it receive messages. While trying to switch to WhatsApp Business, I also lost the chat history (because for some reason it restores only from Google Drive backup while switching between WhatsApp and WA Business). And then I realized that I probably don’t need access to my chat history.

    To sum up, I had enough time away from WhatsApp and I was convinced that WhatsApp was an unnecessary evil and that life without it would be as convenient, if not more. And so I just went into the settings and deleted the account.

    Now, nobody can inadvertently wait for a response from me because they won’t be able to message me. And I can do my own deep work.

  • Fixing the World is Whose Responsibility?

    This week I attended a session on quality improvement in healthcare practice. The definition of quality is subjective. What may appear to be “high-quality” to me, may not stand up to external scrutiny. There could always be room for improvement. But this is not a big problem. Some level of objectivity can be attained in measuring quality by using tools like standards. We can easily figure out areas that are below par and areas that are good enough. Identifying problems and areas to work on is not a problem at all.

    The real challenge is in identifying responsibility. Whose responsibility is it to fix the problems? Sometimes fixing a problem is much easier than figuring out who the right person to fix the problem is. Most often it is not. Most often fixing problems require persistent effort and continuous follow-up. It takes time, energy, even money. And depending up on the scale of problems, these things can easily blow up. There are also some problems which have quick-fix solutions that are less sustainable than the proper but energy-intensive solutions.

    After some months of joining Vivekananda Memorial Hospital, there was one evening when I was in the reading room. Dr Kumar who is now the CEO of SVYM walked in and asked me how things were. The conversation somehow came to my anger at the medical education system and how there was a lot of corruption in medical colleges. I was furious about my own alma mater and told him how I would never want to step foot in that college again. Dr Kumar, incidentally, had done his post-graduation in the same college and could relate to what I was talking about. But then, he told me the story of how he worked with, through, and for the system and made it better. He told me how he would challenge and oppose, yet be dear to the administrators. He told me how he could improve things at least by a bit while he was working there.

    The transformation in my mind was instant (similar to how MAB once made me rethink the way I look at a disinterested audience). I, who was seething with anger at the system, suddenly saw possibilities. I could see the difference between productive contributions and blind criticisms. More importantly, I learned the concept of agency. I was no longer feeling helpless or like a hapless victim of the system. I was feeling like a person who could bring about change but was not yet utilizing my full powers.

    The stories of Ananth Kumar, SVYM, Taru Jindal, Lalitha & Regi, and every other inspirational stories I’ve heard in the recent past demonstrate that simple principle. That if you put energy and effort, things will change. That even one individual matters.

    I think the question of whose responsibility is it to fix things can arise of two things. One, the feeling that I cannot fix something because I’m powerless. That is a logic consistently proved wrong by many of these people I mentioned in the previous paragraph. But there is a second, more difficult reason people might choose not to fix problems. That is when I choose to not fix a problem because I don’t have the time/energy to because I devote it elsewhere (in a place that I think is more important to focus on and solve problems in).

    This second reason, is in my opinion, the bigger problem. This is the reason why even talented people can fail to deliver. Changing the system through innovation or persistence requires dedicated effort. It requires someone to show up regularly and stand up for the cause. It is the same as making a successful startup or raising healthy young children. It requires a lot of smart work. It requires productivity.

    It all should start from the realization that every great person who has walked on this planet has had only 24 hours in their day – the same number of hours everyone else has in their day. What really matters is how much we can draw out of those hours. And for various reasons, not everyone is equally privileged to draw the same value from their days.

    But what is really worth thinking about, is whether we are drawing the maximum value we can. Because if you can find a way to cut the cruft and get more work done, you might find just enough time to fix the world too.

  • How to Travel In Bangalore – Get A BMTC Bus Pass

    I've now spent more than an year using the public transport in Bangalore and made the best investment only this month. That is the BMTC bus pass.

    Previously my commute was fully reliant on metro, but recently I joined MetaString foundation where I have to take the road to reach. There is a direct airport bus from where I stay to the office. The BMTC app gives a fair sense of where the buses are and how quickly I have to run to catch them. But giving 80 rupees in change every time I take a ticket was a pain. And unlike the metro, BMTC hasn't introduced smart cards yet. That's where the passes come in.
    There are three classes of bus pass. The cheapest ones are 1050 including tax and lets you ply only in ordinary buses (non-AC). The next slab is 2363 which allows you to travel in volvo buses as well, but doesn't let you get on Vayu Vajra (airport bus). For the last category there is a 3570 rupees pass that lets you "yelli bekadru odaadubodu" (run around anywhere). But even that gold pass won't let you go in Bangalore Rounds bus (I have never seen a Bangalore Rounds bus). On the other hand, gold pass gives you a travel insurance which covers accidents.
    I got my gold pass from Majestic (Kempegowda Bus station). But just getting the pass is not enough. You also have to get a BMTC id card. The ID card can be obtained on the other side of the bus pass issuing window of Majestic. You have to give a stamp size photo, your address, and phone number here which they enter sloppily in a register. The ID card has to match the pass and that's how they ensure that two people don't use the same pass.
    The biggest advantage the bus pass provides me (even though it makes no economic sense for me who don't go to the airport every day) is the mobility. WIth the bus pass you can get on any bus and travel for any distance. This lets you make on-the-fly (pun intended) decisions about changing route/direction/bus. If there are better buses starting from the next stop, you can get on in any bus in the current stop, get down at the next stop, and switch to the better bus.
    Additionally, the conductor can no longer make you feel guilty about not having change.
    And above all, you save the environment. Less the Uber, less the traffic, less the pollution, faster the buses.
    PS: I also got a new wirless keyboard. I'm now composing this blog post from a Vayu Vajra bus through my phone.
    PPS: Also checkout "moovit" app which is a citizen app for travel information.

  • Lessons One Should Learn From Shehla Sherin’s Death

    If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

    1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
    2. There was delay in taking her to the hospital
    3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
    4. Child died on the way.

    I won’t unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

    Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

    There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

    There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn’t as serious as it sounds, but be really really careful before making that decision.

    I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that “someone must have hit him”. My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other – fang marks!

    We immediately told the bystander that this is not “someone must have hit him”, it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me “please do whatever you can here itself, don’t refer us to higher center”. We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren’t available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

    There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn’t even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

    We’ve had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I’ve had a patient with diarrhea go into dehydration and shock. I’ve had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We’ve had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We’ve had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I’ve examined a kid with high fever who had febrile seizure on the way out. We’ve had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We’ve had a child in waiting area who wasn’t breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I’ve had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

    Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven’t even seen yet. Communicate a lot. Err on the side of cautiousness.

    Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn’t, you’ll regret that your entire life. And that is a pain.

    Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

    There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you’ve chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

    Risks shouldn’t hold you back from attempting something that’s required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital’s Medical ICU. I was trying to insert a catheter into someone’s jugular but I was going too superficial. My senior then told me “Always remember, what you’re doing is for the benefit of the patient. You’re only going to harm them by not doing it confidently. The patient will die if they don’t get this line. So you may as well put it in boldly.”

    There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

    Too many doctors think that by not committing something they’re keeping themselves safe. But their fake sense of safety comes at the cost of the patient’s suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That’s what your license is for.

    Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don’t give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason – use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. “Higher antibiotics” are not reserved for higher centers. Use vasopressors (and for heart’s sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you’ve learnt to deliver care. That’s why you’re a doctor.

    And if you feel you’re under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

    Epilogue

    I had a rule when I was working in ED – “Nobody dies when I’m on duty”. The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.

  • Permanent Record (Book Review)

    You could call it an autobiography of Edward Snowden or you could call it a manifesto for democratic citizenship. You would be right either way. This book is a how-to guide for becoming a hacker (in the realest sense of the word), a good parent, and a good lover.
     
    A fair bit of caution advised though. The book will leave you paranoid. Once you realize the perverse amount of surveillance that you are subjected to without your knowledge, it becomes surveillance with your knowledge, and I don’t know which is better.
    I had once written a blog post titled “When Doing Good is Bad For You” from my own experience. In that I talk about how social revolutionists will perpetually face the dilemma of not doing anything versus fighting the system and putting themselves at risk in the hope of being able to improve the system. I have seen many others face the same dilemma. Edward Snowden also faces the same dilemma and we know what path he chose.
     
    But till I read this book, I could not make that connection. That Ed Snowden is a human just like you and me. That he went through situations just like you and me. That the choices he had to make are the choices that confront us all similarly. That we are all perfectly capable human beings who can do great things.
    It also gave me another realization. That the democracies we live in are very far away from ideal democracies. And that forgetting this can have real life consequences. And that despite all that it is necessary to continue the fight.

  • Understanding Adrenaline Dosage

    Have you ever administered adrenaline for anaphylactic shock? I’ve never had the unfortunate need to. I’m sure anyone who ever does will forever remember the correct dosage. But for me, it is always a confusion. Every time I vaccinate someone at my clinic, I look up the dose of adrenaline just to be sure.

    The first problem is the dilutions. Dosages of adrenaline are (or were) mentioned in dilution. 1:1000 & 1:10000. There begins the confusion.

    Firstly, let us understand where the 1000 comes from in 1:1000. Have you seen a small vial of adrenaline? That is 1mL. It has effectively 1mg of epinephrine/adrenaline. But why is it called 1:1000? Because 1mL of water = 1g of water = 1000mg. So, the 1:1000 actually refers to 1mg of adrenaline : 1000 mg of water. Unnecessarily complex!

    All you had to say was 1mg in 1mL. And that is why this labeling is now being followed in some countries.

    So, there you have a small vial – a 1mL vial – with 1mg of adrenaline in it.

    Now, let us look at the other form epinephrine comes in. Epinephrine also comes in a big syringe of 10mL. But even this 10mL contains only 1 mg of adrenaline. The total amount of adrenaline in this 10mL form is the same as a small vial.

    What is different then? Well, when the volume increases without increase in amount, the concentration drops. The 10mL form is more dilute than the small vial. Can you guess the dilution? It is 1:10000 or more easily expressed as 1mg in 10mL.

    So, the first thing to internalize is that the small 1mL vial we see has 1mg of adrenaline (it may say 1.8mg of an adrenaline salt, but the effective amount of adrenaline is 1mg). And this is a concentrated form of adrenaline.

    What that also means is that the 1mg/1mL adrenaline is never used directly IV! The reason is that this can cause an arrhythmia or other damages to the heart muscles.

    If you’re bored reading text, watch this youtube video telling these same things.

    Now, the dilute form and the concentrated form are for slightly different uses. The concentrated form is given IM in anaphylactic shock. The dilute form is given IV in cardiac arrest.

    When giving IM adrenaline for anaphylactic shock, the dosage in adults is almost always 0.5mg (0.5mL of the concentrated vial). If you can remember this fact it is easy to calculate the pediatric dose as well. The adult dose can be thought of as if it applies to a 50kg person. So 0.5mg for 50kg = 0.01mg/kg and that is the pediatric dose. (This 50kg adult approximation applies for many other drugs in calculation of pediatric dose. Let me know in comments below about other drugs that can be calculated this way).

    When giving in cardiac arrest, in which case the dilute form (1mg in 10mL) is used, the adult dose is the entire 1mg (or 10mL) given intravenous and repeated based on the protocol you follow.

    That is all there is to know. Just a 0.5mg and a 1mg.

  • 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.