Rich medicine for the rich and poor medicine for the poor

Rich medicine for the rich and poor medicine for the poor

Vijay Gopichandran

There is a question I fear asking myself on some days in our clinic. That is “Would I accept this treatment if I were to have this illness?” Many times, the answer is “no” and that scares me. As a doctor in training, we are taught “don’t do to others what you wouldn’t want to be done unto you” It seems logical to follow this dictum in the practice of medicine. However, this does not work out very well. Today, I saw four patients for whom we provided treatments that I wouldn’t take if had the illness. I have been doing this for more than 10 years now, but still, the confusion, uncertainty, and conflict rings loud, as it did the first time. I have changed the names of all the 4 patients for purpose of confidentiality, but the events are true.

Mrs. Gangamma, a cheerful lady who always greets me with a very loud, “How are you doctor?”, came very sick today. She was breathless at rest and in obvious pain and distress. She has hypertension and has been on medications and under good control. But she was suffering from vague and diffuse body pains, one of the sites of the worst pain was the lower chest. She grasped the sides of her lower chest just above her waist and winced in pain. On examination, we identified a new cardiac murmur, a harsh systolic murmur, which has never been found before. We started thinking, whether this could be an acute heart attack with rupture of the papillary muscle and mitral regurgitation, or if it could be infective endocarditis with valvular heart disease and heart failure. We did an urgent ECG and it showed lateral wall ischemic change, but no evidence of a heart attack. The standard of care for her would be to refer her to a tertiary care center to get an echocardiogram to visualize the chambers of the heart and the valves. But we had to send her home on treatment with nitrates, atorvastatin, aspirin, medical treatment for a heart vessel disease, without any further evaluation. Would I have agreed to this line of treatment, if I had the same problem? Most likely, no, but I had accepted to give this treatment to Gangamma. Gangamma is elderly, she is dependent on her son, daughter-in-law, and grandchildren for her living. With this arrangement, she hates being a burden on her son and his family. If she went to the tertiary care hospital, her sons’ family would be burdened with caring for her and all the financial implications. She also had a very fatalistic viewpoint about her health and this disease and so it was not a difficult decision for her to refuse any aggressive treatment for herself. Sometimes we have had similar patients where we have called the son/daughter, explained the situation and had them take the patient to the tertiary care center. But that was not Gangamma’s wish in this case. She was very clear she wanted only a “simple treatment” that can be provided in our clinic.

Mrs. Sasikala is a 60-year-old lady with diabetes. She has been on optimal doses of oral anti-diabetic medications for more than a year now. All her quarterly blood sugar tests had shown very poor control in the range of 300-400 mg/dl. So in the previous visit, I had recommended her to take insulin. I had written out a prescription, taught her how to use the insulin and had even discussed with her, plans of taking the help of a relative who is a young nurse living near her house, for the initial few days of treatment. Today when I saw her, her blood sugars were over the roof, and she grinned sheepishly and said, “No, I have not started taking insulin. I did not take insulin because my son asked me not to. He said I will become dependent on it and so he said that I should not start insulin”. As we were planning on starting insulin, we had even stopped some of the tablets that we were giving her. So not only had she not started insulin but was also diligently following the rest of the prescription with a watered-down dose of anti-diabetic tablets. I was highly frustrated to see this and tried reasoning with her about taking insulin. I told her that I am worried about her sugar levels and unless we controlled the sugars, she might start developing complications. She already had a burning sensation over her feet due to diabetic nerve damage and intense itching over her genital area due to a fungal infection which is again a consequence of uncontrolled diabetes. I explained that these symptoms were indicating that she requires insulin and if she doesn’t take insulin these problems may worsen. But she was very reluctant and said that she will only take tablets and will never take insulin. Here again, if I had complicated and uncontrolled diabetes, I probably wouldn’t continue the same anti-diabetic tablets. But I was allowing her to do exactly that.

Mr. Raja had hypertension and Sick Sinus Syndrome. He was on amlodipine for his blood pressure. I had clinically diagnosed Sick Sinus Syndrome a few years ago because of repeated episodes of syncope with bradycardia. His Holter monitor revealed several episodes of bradycardia and he was advised to undergo cardiac pacemaker implantation. The nearest tertiary care hospital, Chengalpet GH, did not have the electrophysiology facility and he was asked to go to Chennai GH. Mr. Raja was reluctant to go that far. He refused to go for the pacemaker implantation. He could not arrange for the expenses to have the pacemaker implanted in a private facility. So, he settled for the simpler option, taking tablet Alupent – a drug which would drive the heart at a faster pace to overcome the problem of the sick sinus syndrome. He came to the clinic today with a severe toothache. His dentist has requested me, his primary physician, to provide a fitness certificate to give him local anesthesia for the dental extraction. Mr. Raja, who has a very weak sinus node, had stopped taking his Alupent, which was the drug, which was helping him drive his heart because he felt that the drug made his abdomen burn. On examination today, his heart rate was less than 50 beats per minute. He was in a precarious condition. There was no way I could give him a fitness certificate. I tried my level best to explain to him the importance of taking Alupent regularly. If I had the sick sinus syndrome, I don’t think I would have accepted taking only Alupent instead of the pacemaker and I wouldn’t have stopped Alupent, even after knowing that my life depended on it. But that was happening to my patient.

Mr. Iqbal, a 40-year-old man, came accompanying his wife and daughter to the clinic. They had come for treatment of the daughter for cough and cold and for the wife for leg pain. While seeing them, I realized that Mr. Iqbal is also an old patient. I vaguely remembered his face. So I just asked out of courtesy, how he was doing. This made the man warm up to me and he blurted out that he is off all his diabetic medications since the past 4 months. I asked him what happened. He replied that he had a fight with some members of his village and was evicted from the village. So he had moved to a distant location and had to build up his life, his work, daughter’s schooling, etc. in the new place. In all this stress, he had stopped taking his medicines. After talking about all this for a few minutes, he said he will bring his case-sheet and he wants to resume treatment as he was not feeling very well. He had started developing leg pains and muscle cramps. He was passing urine more than 10 times each night and was feeling very thirsty and tired. I asked him to get his blood sugar checked and it turned out to be unmeasurable by the glucometer (more than 600 mg/dl). I immediately recommended initiating insulin treatment. He refused and said, “I am going through a very difficult personal situation. I am in a new place and struggling to get a job. Financially my situation is very tight. I will not be able to focus on work if I take insulin. Please give me tablets.” His fear of insulin was so severe that it almost paralyzed him. I had to give him tablets in maximal doses. I don’t think, I would have done that to myself if my sugars were so high. But here I was doing that to this patient.

These are all unique situations which a practitioner in a rural poor setting typically encounters. I see many such complex clinical problems. I do not have the resources to give solutions to these problems at my clinic. The social situation of my patients does not allow them to access these services easily. So I am often pushed to a situation where I have to practice “less than optimal” medicine. I have many times been criticized for practicing “low quality” medicine. One of my doctor friends had seen a patient with hypertension, under my care during a visit to his hospital, where the patient had gone for his diabetes treatment. This patient was on Atenolol for his hypertension. However, he was also an occasional wheezer. Patients with wheezing are usually not given atenolol, as atenolol can exacerbate the wheezing. But when I had attempted to change the prescription, the patient had resisted. As the patient was tolerating the atenolol well, he was only an occasional wheezer and was reluctant to stop it and change to another drug, I had allowed him to continue. My doctor friend had seen the prescription of atenolol and commented to my patient that it was “the wrong drug” and my prescription was wrong. When seen out of context, what I had done in good intent, seems like medical negligence.

In his description of evidence-based medicine, David Sackett himself talks about incorporating patient preferences into the practice of evidence-based medicine. We may also need evidence that is relevant and responsive to the context in which it is implemented. So, should we have rich medicine for the rich and poor medicine for the poor? I think it is not fair to have such discrimination. However, there is a need to incorporate context and social settings in the practice of medicine, for the practice to be meaningful and relevant to the people. In the chase of a target glucose control of HbA1c of 7%, I should not lose perspective of the social, cultural values and beliefs of people, which prevent them from accepting insulin. I need to socially and culturally be relevant and responsive while incorporating the best evidence into the practice of medicine. Therefore, it is not “rich medicine for the rich and poor medicine for the poor” but it is appropriate medicine based on social, cultural values and preferences for each person.