Ever since the publication of David Werner's Where there is no doctor, one has yearned for a book addressing the situation: 'Where there is a doctor'. The growing evidence of avarice among clinical practitioners makes this need particularly acute, and the books under review are welcome. The fact that these are written by practising doctors is noteworthy. The first book looks at the current, dismal health-care scenario and lists some measures to cope with it. The second is a guide for patients to make intelligent use of medical care.

 

In Trick or treat, the author takes the reader through a discussion of most issues related to the state of health care today - focusing on the rural scene - leading to the most important question of how to cope with the system. How to get… is meant for the urban patient, particularly the well-to-do urban patient with access to computers and the internet. Reading these books together presents a picture of the larger canvas of the current health care scenario, with some useful advice on how to deal with it as a patient.

 

 

 The book cover states that it is meant to make readers aware of the flaws in the system; for women to understand gender-related risks in hospitals and how to avoid sexual harassment; for activists to learn to discuss the pros and cons of multifaceted heath care issues; for health professionals to see the current health crisis from a client's viewpoint and avoid litigation, and lastly for administrators to understand the complex nature of health-care-related problems. The book describes the current crisis in health care, and the resulting evidence of large-scale malpractice. Unnecessary surgery and laboratory investigations, glamour-based (as against necessary) medicine, the 'cut' practice, and quackery… Dr. Sethuraman pulls no punches in his exposition of the tricks that practitioners and medical institutions play on gullible patients. The book is written in an easy-to-understand, jargon-free style, and the accompanying cartoons make an impression. I found the repeated use of parables to illustrate the author's points unnecessary and sometimes jarring, but this is only my personal preference.

 

Though none of the information is new to those in the healthcare industry, it will be important and useful to lay readers and consumers of health services, outlining worrisome trends in private and public health services which need to be addressed.

 

Still, the book misses out on the near complete absence regulation or governance from the medical councils, and the proliferation of substandard private medical colleges charging exorbitant capitation fees (charges that are passed on to the patient later). There is a passing reference to the Medical Council of India (MCI) but little discussion of the fact that medical councils' inaction is hurting the health care system.

 

 

 The book states that it is 'a guide for the intelligent patient'. Also written in a simple style, it even gives "guidelines to understand the jargon" used in medical language. Almost every situation urban patients could encounter in a doctor's office or other medical service is explained. Putting this information into practice would make a 'champion' patient. No sarcasm should be read into this statement; patients who put to practice everything that Drs. Malpani advise would become truly empowered participants in their therapy.

 

However, some of the advice is difficult to put into practice. "As a patient, your responsibilities are wide and varied and you need to play several 'roles' at various times" These roles are: medical information researcher, medical team manager, treatment decision maker, medical record keeper, financial manager, and communicator. This is a tall order when most practitioners do not respect these 'roles' for the patient. But this may become possible if - with persistence and sobriety - patients force action in this direction, and particularly if many clinicians support the idea.

 

Another example: "Today, ironically, it (foetal monitoring) is often used to justify a Caesarean section operation to forcibly take out the baby as determined by the foetal monitor! A much simpler alternative would be to opt for 'kick counts', a procedure in which the mother simply keeps track of how often her baby moves in a given time period." This information can be an important tool for the pregnant woman but what will she do if her obstetrician insists on using the foetal monitor?

 

There are suggestions to include clinical practitioners from all systems of medicine: "Diverse modalities such as Reiki, yoga, ayurveda, acupressure, hypnosis, homeopathy, naturopathy… can work .. as a part of a unified team rather than in competition," they tell us. Splendid idea in theory. In practice, it sounds idealistic at best. Both books rightly stress the place of a good general practitioner in health care. Unfortunately, this tribe is fast dwindling. Of those still there, many, it seems, have taken to getting 'cuts' on referring patients to specialists. Transparency in health care is constantly eroded. Under such circumstances, it is refreshing to see practising doctors speak up and support the patient's cause. Anyone interested in the welfare of end users in health care must read these books, and make use of them.

 

 

Anil Pilgaokar, 34-B, Noshir Bharucha Road, Mumbai 400 007. Email:mailto:anilpil@bom5.vsnl.net.in