The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 71: Quacks

The main reason for the quacks (unqualified Doctors) to proliferate and flourish, is the maldistribution of qualified Doctors in our country and their unwillingness to settle down in rural areas.

While 70% of our population live in rural areas, only 30% of Doctors work and 90% of quacks ‘practice’ in rural areas. Out of necessity, rural population patronize the quacks, mostly for first aid and sometimes for total care.

On the face of it, it may look cheaper than going to a qualified Doctor. But when the disease is allowed to get worse, due to ‘halfbaked’ treatment, then going to a higher centre will ultimately turn out to be more expensive.

Further, since the public is unaware of significance of qualification, any mistakes committed or complications arising out of the treatment given by the quacks, reflect on the quality of entire medical profession.

Unfortunately, the law enforcing authorities have a ‘soft corner’ towards quacks, since the qualified practitioners don’t ‘wet’ their hands periodically and they don’t want to kill a ‘golden duck’. It may not be surprising that many Doctors encourage quacks, since they advertise and bring them patients and of course get ‘commission’ from both, for their ‘service’!

Chapter 72: Family practice & house visits

One can recall in old movies, when some rich man falls sick, the family Doctor comes with a ‘medicine kit’ and gives him an injection and some tablets. With waning of Family Practitioner concept, we don’t see such scenes any more and the house visits by Doctors have virtually vanished.

There are many reasons for this unfortunate scenario, such as personal safety (especially to women Doctors), Doctor’s lack of confidence in making a clinical diagnosis (without lab support), legal issues arising out of some drug (injection) anaphylaxis, unwilling profession to be disturbed during odd hours and lastly Doctors’ calculation that it’s not remunerative commensurate with the time spent.

Young Doctors (and their parents) don’t want to stop with MBBS and they want to become ‘specialists’ by acquiring some postgraduate (or even superspecialty) qualification, for academic pursuit, as well as for better ‘quality’ of professional life.

A family Doctor is more than a Doctor, friend, guide and philosopher to the family, charges ‘affordable’ fees, accessible during odd hours, makes arrangements for his patient to see the ‘right’ consultant when required and follow through the further treatment.

He also counsels and arbitrates on nonmedical issues in the clients’ families. In olden days, Doctor became a GP by default, but now it’s the last resort, if there’s no option. The present society certainly misses ‘his’ 24/7 services, for which changed public mindset has to be blamed.

Chapter 73: Death in residence

One situation when it’s most appropriate for a Doctor to make a house visit may be to certify death occurred at home of a patient, who is under your treatment. But, before certifying, ensure that there’s no doubt of any foul play and it’s indeed a natural death.

The real dilemma is if you’d not seen or treated the patient before. Going by the family statements, perusing the medical records or circumstantial inputs, may not give you the whole truth. One option is to talk to the Doctor, who treated the patient last, if he’s available and get first hand information about probable cause of death.

Knowing the family earlier may be of some help, but also puts you in a situation where you can’t refuse issuing a certificate. Note that there is a separate Form meant for non-institutional (home) deaths, prescribed by the authorities.

As in the case of any death, if there is an element of doubt about the cause, it’s safe to inform police, whether family likes it or not, and allow the law to take its course. You can also convince the unwilling family members, that it’s for their own good, in the event some one contests about the nature of death, later on.

Chapter 74: Death in consultation room

The problem is very similar to a death in the residence. The situation is different if he’s brought alive in a critical state, some resuscitation was unsuccessfully attempted. On the other hand, he might have been brought dead. In either case, if the Doctor knows the patient, his previous medical history and is convinced that it’s a natural death, a certificate can be issued to that effect.

But even if there is an element of doubt of some foul play, the police has to be informed and postmortem advised, which will be done only at the discretion of the investigating officer, after some preliminary enquiry. The detailed history and the sequence of events have to be properly recorded and a copy of it is given to police, for the use of the Doctor performing autopsy.

The matter becomes more sensitive and complicated if the Doctor was not available in the office, when a critically ill patient was brought in. Assistant Doctor or senior nurse has to give first aid and contact the Doctor to decide further management or shift him to a nearby hospital. If the consultation room is located within a hospital, the patient can be conveniently wheeled to the emergency area for further evaluation and treatment, without much delay.

Chapter 75: Injection reaction

If injections are given in the Doctor’s office, it’s essential that all the emergency drugs to combat anaphylactic reaction, such as adrenaline, hydrocortisone, deriphyllin, avil, atropine, IV fluids and infusion set etc. are kept readily available. The patient should be asked to sit for at least 15-30min after the injection, before leaving.

It’s advisable not to administer IV medication to a patient, if the Doctor (or his assistant) is not in the office. It’s to be realized that neither giving a test dose nor history of taking the same medicine earlier by the patient, provides guarantee against anaphylaxis, but it may provide some legal protection.

In any case, it’s also wise not to use drugs commonly known to cause anaphylaxis (on parenteral use), such as penicillin, amoxicillin, carbamazepine, low molecular dextran, iodine containing contrasts etc. Of course, police has to be informed and postmortem to be performed, as per the prescribed medicolegal procedure, if the patient succumbs to the adverse episode.

We should also remember that sometimes it may just be a syncope of a vaso-vagal reaction to pain or anxiety, related to the injection, typically associated with hypotension and bradycardia. All that is required is to make the patient lie flat, allow good ventilation around and if necessary, IV atropine. They usually recover in a few seconds.

The Consultation Room