Private practice or "PP" as it is most fondly referred to among doctors is a highly controversial issue in Sri Lanka, both among patients and doctors. From a doctors point of view the basic purpose of engaging in PP is to earn some extra money. Don't be misled. That is the sole and only reason doctors go into private practice. Is it wrong or unethical? I don't think so. Contrary to popular belief, Doctors in Sri Lanka are among the most poorly paid professionals in the world as well as when compared to our counterparts in the region. The current all inclusive salary (allowance) of a house officer is approximately Rs, 18,000. Once you finish your internship you earn a salary of approximately Rs 25, 000. A consultant would earn around Rs 40,000. Of course these are the salaries paid by the state. But that is my point. It would be quite difficult to survive on these salaries alone. And when there is an obvious demand for their services in the private sector, I see no problem in doctors carrying out private practice during off duty hours as long as it does not interfere with their regular jobs.
What exactly happens in private practice? During my final year rotations I had the privilege (at least I thought so at the time) of working with one of the most senior and well respected general practitioners in Sri Lanka. My colleague and I spent about two weeks basically hanging out in his clinic and 'observing' and occasionally helping out with his practice. The first thing he told us on our very first day went something like this. "Almost all patients that come to you have one diagnosis; SLI, and they are all treated with ADT" The medical field overflows with abbreviations. In a hospital setting any given sentence spoken between doctors would involve at least 2 to 3 abbreviations. GTT, FBS, FBC, HB, CXR, USS, UFR, LFT, ECG, ERCP, D & C......the list is endless. Still I was pretty sure I had never heard of SLI or ADT. Well according to him SLI stood for "self limiting illness" and ADT "any damn thing"! At the time I thought he was just kidding. Now I know what he said is the gospel truth. The workload of a typical GP consists of a few viral fevers, upper respiratory tract infections, diarrhoea, gastritis type abdominal pain and muskuloskeletal pain(basically odd aches and pains that have no specific cause). These would make up at least 90% of the patient workload. It is interesting to note that many of these are actually self limiting. Basically what that means is no matter what you do, the illness is going to settle on its own. It doesn't matter how you treat a viral fever. In fact you cannot. You just let your own body do the healing, and just help in whatever little way you can. How about an upper respiratory tract infection like a cold or a cough, or sore throat. Same thing. You don't have to do anything. Various studies have shown that antibiotics, and cough syrups given in simple upper respiratory tract infections don't have any real benefit. Why do doctors prescribe them? Its easy and convenient, and most of the time boosts your doctor patient relationship.
Lets take an example which was actually a true incident told to me by a patient. This particular patient had an upper respiratory tract infection. Basically a cough and cold. Medical science knows that such an illness can take between 3-7 days for recovery whether you do anything about it or not. ie; it is a self limiting illness. The patient sees Dr A on day 3 of her illness. Dr A prescribes a cough syrup saying antibiotics are not necessary and she should be ok in a few days. On day 5 the patient still has her cough and cold, with just a slight improvement. Out of frustration at the lack of efficacy of Dr A's drugs she visits Dr B on day 5 of her illness. Dr B goes through her earlier prescription and notes she is already on a cough syrup and prescribes antibiotics, although there is no real need for it. The patient happily takes the "powerful drugs" and by day 7 her illness has disappeared and shes good as new. Patients conclusion; Dr B's excellent drugs cured her of her illness. The fact is whatever she did, statistically she would have been ok by day 7 anyways. Had the she seen the two doctors in reverse order then Dr A would have been the hero. Had she seen an ayurvedic physician or a homeopathy goon or even a quack, he/she would have been praised for her recovery. This happens day in and day out. Patients come to conclusions on SLI's assuming the drugs/balms/ointments/herbal supplements they have been prescribed have cured their illness. This particular patient was telling me, "Dr A didn't take any notice, he just prescribed a cough syrup. You don't need to see a Dr to get a cough syrup, I could have got one at any pharmacy. Dr B prescribed me some very good antibiotics. I was ok within 2 days." Who do you think the patient is gonna visit the next time she has an SLI? Dr B of course. Who do you think was the better doctor?
The ideal management of an average patient with a simple cough and cold with no co-morbidities is warm fluids and bed rest. A cough syrup may be taken at night to prevent nocturnal coughing but that is more than adequate. Unfortunately most patients don't know this, and doctors take advantage of it. Some of the most successful GP's are masters in the art of taking credit for curing SLI's. One particular GP used to prescribe drugs for the expected duration of the illness carefully explaining to the patient when his/her symptoms would subside and how long his drugs would take to "cure" the illness. Naturally when things happened right according to plan patients were impressed. The word spread around. This summarises the dilemma for the private practitioner. Remember, the goal of private practice is to make money. To make money you need patients. To get more patients you need to make your patients like you and spread the word around that you're a good doc. In certain instances what might be best for your patient might not be best for you. This brings about a conflict of interest. For example for a patient who requests antibiotics for a simple cough, refusing to prescribe them might lead to the patient rushing off to the next doctor. I have seen this happening on numerous occasions. I used to think Patient education was the key here. If you could explain that his or her SLI is going to settle on its own and antibiotics are not needed and may even be harmful, this would let you make the correct management decision while maintaining good relations with your patient right? WRONG! Studies have shown that most patients who do make a visit to their doctor with relatively minor illnesses expect a prescription and are disappointed not to have one. People obviously don't like to visit doctors. They aren't exactly the most fun people to hang around with, and why would you wanna wait hours and hours to see a typically rude and abrupt doc if u don't really have to. If you felt you illness was just gonna go away on its own you would most certainly not make that visit. People who eventually visit doctors feel that their illness needs some sort of medication and therefore feel the trip (and wait) to see the Dr is worthwhile.
What exactly happens in private practice? During my final year rotations I had the privilege (at least I thought so at the time) of working with one of the most senior and well respected general practitioners in Sri Lanka. My colleague and I spent about two weeks basically hanging out in his clinic and 'observing' and occasionally helping out with his practice. The first thing he told us on our very first day went something like this. "Almost all patients that come to you have one diagnosis; SLI, and they are all treated with ADT" The medical field overflows with abbreviations. In a hospital setting any given sentence spoken between doctors would involve at least 2 to 3 abbreviations. GTT, FBS, FBC, HB, CXR, USS, UFR, LFT, ECG, ERCP, D & C......the list is endless. Still I was pretty sure I had never heard of SLI or ADT. Well according to him SLI stood for "self limiting illness" and ADT "any damn thing"! At the time I thought he was just kidding. Now I know what he said is the gospel truth. The workload of a typical GP consists of a few viral fevers, upper respiratory tract infections, diarrhoea, gastritis type abdominal pain and muskuloskeletal pain(basically odd aches and pains that have no specific cause). These would make up at least 90% of the patient workload. It is interesting to note that many of these are actually self limiting. Basically what that means is no matter what you do, the illness is going to settle on its own. It doesn't matter how you treat a viral fever. In fact you cannot. You just let your own body do the healing, and just help in whatever little way you can. How about an upper respiratory tract infection like a cold or a cough, or sore throat. Same thing. You don't have to do anything. Various studies have shown that antibiotics, and cough syrups given in simple upper respiratory tract infections don't have any real benefit. Why do doctors prescribe them? Its easy and convenient, and most of the time boosts your doctor patient relationship.
Lets take an example which was actually a true incident told to me by a patient. This particular patient had an upper respiratory tract infection. Basically a cough and cold. Medical science knows that such an illness can take between 3-7 days for recovery whether you do anything about it or not. ie; it is a self limiting illness. The patient sees Dr A on day 3 of her illness. Dr A prescribes a cough syrup saying antibiotics are not necessary and she should be ok in a few days. On day 5 the patient still has her cough and cold, with just a slight improvement. Out of frustration at the lack of efficacy of Dr A's drugs she visits Dr B on day 5 of her illness. Dr B goes through her earlier prescription and notes she is already on a cough syrup and prescribes antibiotics, although there is no real need for it. The patient happily takes the "powerful drugs" and by day 7 her illness has disappeared and shes good as new. Patients conclusion; Dr B's excellent drugs cured her of her illness. The fact is whatever she did, statistically she would have been ok by day 7 anyways. Had the she seen the two doctors in reverse order then Dr A would have been the hero. Had she seen an ayurvedic physician or a homeopathy goon or even a quack, he/she would have been praised for her recovery. This happens day in and day out. Patients come to conclusions on SLI's assuming the drugs/balms/ointments/herbal supplements they have been prescribed have cured their illness. This particular patient was telling me, "Dr A didn't take any notice, he just prescribed a cough syrup. You don't need to see a Dr to get a cough syrup, I could have got one at any pharmacy. Dr B prescribed me some very good antibiotics. I was ok within 2 days." Who do you think the patient is gonna visit the next time she has an SLI? Dr B of course. Who do you think was the better doctor?
The ideal management of an average patient with a simple cough and cold with no co-morbidities is warm fluids and bed rest. A cough syrup may be taken at night to prevent nocturnal coughing but that is more than adequate. Unfortunately most patients don't know this, and doctors take advantage of it. Some of the most successful GP's are masters in the art of taking credit for curing SLI's. One particular GP used to prescribe drugs for the expected duration of the illness carefully explaining to the patient when his/her symptoms would subside and how long his drugs would take to "cure" the illness. Naturally when things happened right according to plan patients were impressed. The word spread around. This summarises the dilemma for the private practitioner. Remember, the goal of private practice is to make money. To make money you need patients. To get more patients you need to make your patients like you and spread the word around that you're a good doc. In certain instances what might be best for your patient might not be best for you. This brings about a conflict of interest. For example for a patient who requests antibiotics for a simple cough, refusing to prescribe them might lead to the patient rushing off to the next doctor. I have seen this happening on numerous occasions. I used to think Patient education was the key here. If you could explain that his or her SLI is going to settle on its own and antibiotics are not needed and may even be harmful, this would let you make the correct management decision while maintaining good relations with your patient right? WRONG! Studies have shown that most patients who do make a visit to their doctor with relatively minor illnesses expect a prescription and are disappointed not to have one. People obviously don't like to visit doctors. They aren't exactly the most fun people to hang around with, and why would you wanna wait hours and hours to see a typically rude and abrupt doc if u don't really have to. If you felt you illness was just gonna go away on its own you would most certainly not make that visit. People who eventually visit doctors feel that their illness needs some sort of medication and therefore feel the trip (and wait) to see the Dr is worthwhile.
Patient education does work sometimes. Some patients are grateful for not having to take any drugs, some are utterly disappointed and rush to the next doctor to get their antibiotics. Interestingly my parents happened to be from both extremes. My father is totally anti medication. He would consider taking a Panadol only if his life depended on it. He felt antibiotics were highly toxic drugs that would destroy your kidneys. He had read numerous articles about disastrous drug side effects, like the thalidomide disaster, and the monster of all side effects, Steven Johnson's syndrome. He failed to note however that the chances of experiencing some of of these side effects was like one in a million. You have a much higher chance of dying while crossing a typical road in Sri Lanka. However no amount of explanation would change his opinion. He would just stick to eating healthy foods and yoga for all his health care needs. So far its all good since hes been having only SLIs. Remember SLIs are treated with ADT. ADT includes antibiotics, cough syrups, homeopathy, aromapathy, reflexology, yoga, quack mixtures, whatever....
My mum is the extreme opposite. Soon as she develops a productive cough she requests a prescription for a good antibiotic. My attempted explanations go in vain as she strongly believes it is my inexperience that blinds me from the fact the she desperately needs an antibiotic! Thus, people have preconceived notions and attitudes. Just as certain superstitions and beliefs of people are impossible to get rid of so are their attitudes towards drugs and illness. Coming back to PP, I have noticed that doctors can't be bothered anymore. They just go with the flow. Anyone who wants antibiotics will get some. The same goes for vitamins. Specialists do the same. Its all about marketing your image and manipulating those SLIs. Two of my batch mates were working with a GP on a rotation basis. One of them was ranked among the top 25 in Sri Lanka in our year(from a total of about 750). I had personally worked with him and have loads of respect for him. He had excellent diagnostic and clinical skills with an in depth knowledge of diseases as well. If at all the only area he was lacking was his PR. He was pretty abrupt with patients and his tone can come across as rude sometimes. But that's just the way he is. Still I felt he would make a good Dr due to his medical skills. The other guy who was working with him was ranked in the bottom 200 or so. His clinical and diagnostic skills left much to be desired for and his management options were more than questionable. However in a GP setting these things hardly matter. After some time the relatively "smarter" one (lets call him Jim) was getting fewer shifts to cover, with more of these being given to the other guy lets call him Sam. Sam being a good friend politely inquired from the senior GP as to why Jim wasn't being called in. The GPs reply was something like this "Private practice is all about marketing. You don't need to know medicine to be a successful GP. But you do need to make patients happy. You need to make them feel like you care even if you don't. You need to pretend to take a great interest and take some extra time even though you actually need a minute or two. Jim is a good diagnostician, but he doesn't have that marketing element" Basically what he was saying is give the patient what he thinks he needs. Be it an antibiotic, vitamin, or simply a nice long chat and your practice will thrive.
I have a problem with this approach. Basically conning around to get your PP going seems unethical to say the least. However doing what you think is right and is best for the patient sometimes gets you negative points and is consequently detrimental to your practice. If trying to explain things to your patient only works sometimes, what then is the correct solution? Do you go with the flow and do your sales act? For me the answer is somewhere in between. A moderation of both extremes. Don't be a total con artist, and yet give some of the things the patient wants. For example I know one of the commonest complaints I get from patients regarding visits to their specialist is "They don't even look at you, they have already written the prescription before you have sat down" While this is an obvious exaggeration of the actual course of events the point is well taken. Most specialists spend a very short time with their patient. Most of the time that is more than the amount of time that is needed. When you visit an experienced specialist he has seen at least 500 cases just like you (unless you have a very rare illness). They know exactly what has to be done next. For example for a patient presenting with chest pain, the next most obvious step is an ECG. So if you're a middle aged man seeing your doc for chest pain, no matter what your chest pain was like, or anything else for that matter, you're gonna need an ECG 9 times out of 10. So as soon as you say the word chest pain any doc would know u need to check your BP, take an ECG, and order an FBS and serum cholesterol to assess your cardiovascular risk factors. This would be the next step in almost any middle aged patient with chest pain. Asking a few questions and writing these tests down on a piece of paper would take less than a minute. Thus such a consultation should take less than 2 mins. However such a consultation would not go too well with for your PP. You would be labeled as a rude doc who doesn't give a shit about his patients.
Unfortunately or fortunately specialists don't have the luxury of seeing that many SLIs and therefore cannot prescribe much ADT. Surgeons are a prime example. You cannot do ADT for a hernia or acute appendicitis. Your patient might end up dead. Hence most surgeons don't have to do the whole sales act. They just do their thing and if they are good enough they build their reputation on their surgical skills rather than their PR abilities. Nevertheless it is pretty disappointing the way most doctors go about their PP.
My mum is the extreme opposite. Soon as she develops a productive cough she requests a prescription for a good antibiotic. My attempted explanations go in vain as she strongly believes it is my inexperience that blinds me from the fact the she desperately needs an antibiotic! Thus, people have preconceived notions and attitudes. Just as certain superstitions and beliefs of people are impossible to get rid of so are their attitudes towards drugs and illness. Coming back to PP, I have noticed that doctors can't be bothered anymore. They just go with the flow. Anyone who wants antibiotics will get some. The same goes for vitamins. Specialists do the same. Its all about marketing your image and manipulating those SLIs. Two of my batch mates were working with a GP on a rotation basis. One of them was ranked among the top 25 in Sri Lanka in our year(from a total of about 750). I had personally worked with him and have loads of respect for him. He had excellent diagnostic and clinical skills with an in depth knowledge of diseases as well. If at all the only area he was lacking was his PR. He was pretty abrupt with patients and his tone can come across as rude sometimes. But that's just the way he is. Still I felt he would make a good Dr due to his medical skills. The other guy who was working with him was ranked in the bottom 200 or so. His clinical and diagnostic skills left much to be desired for and his management options were more than questionable. However in a GP setting these things hardly matter. After some time the relatively "smarter" one (lets call him Jim) was getting fewer shifts to cover, with more of these being given to the other guy lets call him Sam. Sam being a good friend politely inquired from the senior GP as to why Jim wasn't being called in. The GPs reply was something like this "Private practice is all about marketing. You don't need to know medicine to be a successful GP. But you do need to make patients happy. You need to make them feel like you care even if you don't. You need to pretend to take a great interest and take some extra time even though you actually need a minute or two. Jim is a good diagnostician, but he doesn't have that marketing element" Basically what he was saying is give the patient what he thinks he needs. Be it an antibiotic, vitamin, or simply a nice long chat and your practice will thrive.
I have a problem with this approach. Basically conning around to get your PP going seems unethical to say the least. However doing what you think is right and is best for the patient sometimes gets you negative points and is consequently detrimental to your practice. If trying to explain things to your patient only works sometimes, what then is the correct solution? Do you go with the flow and do your sales act? For me the answer is somewhere in between. A moderation of both extremes. Don't be a total con artist, and yet give some of the things the patient wants. For example I know one of the commonest complaints I get from patients regarding visits to their specialist is "They don't even look at you, they have already written the prescription before you have sat down" While this is an obvious exaggeration of the actual course of events the point is well taken. Most specialists spend a very short time with their patient. Most of the time that is more than the amount of time that is needed. When you visit an experienced specialist he has seen at least 500 cases just like you (unless you have a very rare illness). They know exactly what has to be done next. For example for a patient presenting with chest pain, the next most obvious step is an ECG. So if you're a middle aged man seeing your doc for chest pain, no matter what your chest pain was like, or anything else for that matter, you're gonna need an ECG 9 times out of 10. So as soon as you say the word chest pain any doc would know u need to check your BP, take an ECG, and order an FBS and serum cholesterol to assess your cardiovascular risk factors. This would be the next step in almost any middle aged patient with chest pain. Asking a few questions and writing these tests down on a piece of paper would take less than a minute. Thus such a consultation should take less than 2 mins. However such a consultation would not go too well with for your PP. You would be labeled as a rude doc who doesn't give a shit about his patients.
Unfortunately or fortunately specialists don't have the luxury of seeing that many SLIs and therefore cannot prescribe much ADT. Surgeons are a prime example. You cannot do ADT for a hernia or acute appendicitis. Your patient might end up dead. Hence most surgeons don't have to do the whole sales act. They just do their thing and if they are good enough they build their reputation on their surgical skills rather than their PR abilities. Nevertheless it is pretty disappointing the way most doctors go about their PP.
However its nice to note that patients are becoming more and more knowledgeable about their illnesses. In the West it has already happened. Most patients come to visit their docs with files of print outs from various online journal articles with the latest research findings about their illness. Some even use this as a tool to check how updated their doc is. While Sri Lanka has a long way to go to before coming there, I sincerely hope one day we can let our patients handle their own SLIs without having to spend their hard earned money on doctors consultations, unnecessary antibiotics, and vitamins etc etc. Who knows maybe even doctors may one day actually put their patients needs before their own. Well, it is nice to dream.....
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