Vicious Circle

Why do most of the practitioners in towns maintain medical records? Everybody knows that this is the most important document both to the patient and the doctor. For the patient this is not only going to record all his health problems, but also small details that will help avoid future troubles like tremors to Salbutamol or extra-pyramidal reaction to Metaclopramide or drug idiosyncrasies. It saves the patient of remembering all these and narrating to each new doctor he meets along his life. To the doctor it documents all his actions. So it is helpful in many ways. It helps him to have a more complete picture of the patient. It helps him to defend himself in a court if something gos wrong – provided he has done all the right things. It helps him to think before acting knowing that he is documenting what he is doing instead of doing things reflexively. There is more chance for a doctor to keep himself up to date when he habitually documents then one who does not. Last but not the least, without records there is no statistics. This is one of the major reason for a country like India where infections are rampant, is unable to produce good quality scientific papers. In countries where medical records are mandatory like in USA, they are able to generate lot of data on the disease incidence, its progression, its response to medicines, number of patient who meet treatment goals (like HbA1C in diabetes, LDL levels in hypertriglyceridemia, blood pressure in hypertension),etc…So how come such an important document is not maintained as scrupulously or not at all in majority of the cases?
This happens, i think when the doctors are not paid adequately. When they are not paid enough, their motivation to give complete care comes down. Say a patient comes to a doctor with fever. The doctor’s job ideally does not end with treating the present fever. It should also extend in educating the patient on ways of preventing its spread to family members, ways to prevent it recurring in the future, etc… Not only that – the ideal doctor needs to screen him for presence of other problems like symptoms and signs of other common disease like diabetes, depression, coronary artery disease, high risk behaviors and what not(Like smoking, consuming alcohol, sedentary life…). You will be surprised at the number of condition that each person has, that needs to be addressed. There is so much that need to be educated.To do a complete physical examination after a detailed history, document it and work-out a plan for the current disease and the other underlying problems, it is going to cost a minimum of 45 minutes (In post-graduate exams a long case is given this much time to just assess the patient which most of the time is barely enough and there is no discussion with the patient of his disease and the treatment plan). If a doctor is going to be paid Rs 40 or 50 for a consultation ($1 compared to about $100 in USA), where is he going to get the motivation to do a complete examination and maintain a record? He barely has time to treat the present problem, leave alone future problems and spending on documenting it and retrieving it at future visits. Of course it is legally mandatory to maintain these records. Not every law is followed in India. How many of us wear seat belts in India? So some doctors who are a bit more motivated do one of the following things to maintain a quasi-health record – writing behind the prescription a short history,findings and treatment plan or asking the patient to buy a note and bring it for each visit and to any doctor he goes where the treatment notes are written in that or computerized records (Very few due to the fact it is going to cost a lot of money and time to maintain it). The written records are mostly useful only to the doctor who wrote it, since he only understands the scribble of notes and its significance. In cities, the doctor charges a higher fees and mostly works in a bigger set-up where the trouble of maintaining and retrieving records are done by the hospital. So he can afford to be meticulous. Given proper compensation for the time spent, i think any doctor will be willing to treat completely rather that the presenting symptom alone.
So the next question is why is the doctor not paid adequately? Mainly because many patients cannot afford it and there are many other doctors and quacks willing to treat the present problem at a lesser price. So they choose to go for the short term relief. This is the vicious cycle. The patient cannot afford – doctor does not spend time / maintain record – patient is not treated completely – repeated visits to the doctor with more and more preventable disease. A totally unhealthy situation to both the concerned parties – the doctor as well as the patient. So where is the solution. Health insurance. When effective and economical health insurance can come into place, the doctor will get reimbursed and he is forced to maintain a record. This will improve the medical care and all patients can get equal treatment irrespective of their affordability provided they have a valid insurance. This will in a way subsidize medical care to patients with multiple problems. This is what is happening in developed countries that we are lacking. The problems of insurance companies deciding who will get how much care will be totally another devil which we have to face as and when it comes. So let us fhope for a better health care in India this new year.

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