Today we observed a day in the Outpatient Department of the Orthopaedic Clinic at the hospital I’ve been observing at. To give you an idea of the day, let’s start with this. 10 or 12 doctors saw over 250 patients in a little over an hour and a half.
Yes, that was 10 doctors and 250 patients. Yeah, that means they saw 25 patients each. In one and a half hours. Which means each doctor saw 16 patients an hour. Each patient got 3.75 minutes. Which seems higher than what we observed.
To paint the scene for you, we were sitting in the doctors office, in two chairs facing a eminent ortho surgeon. He was sitting in one chair, and the chair next to him was for the patient. Patient’s treatment cards were dropped off, and he called them in the order of the cards arrival. (Speaking of the cards, they cap patients at 250 per OutPatient Day- the first 250 get cards and subsequent treatment). So, the doctor would call out a name- said patient would come in, and they’d sit down, by which time the doctor had asked them what the problem was. As the patient spoke, the doctor would be looking at their X-rays, CT scans, or MRI’s. Then, as they went along, the doctor would do a quick physical exam, without asking the patient to disrobe, scribbling in the card the whole time, tell the patient the treatment or tests required and send them off. Then, the next patient and so on. As time went along, the room got more crowded as patients started waiting within, other doctors would pop in for consults and more patients would be standing around while the patient being seen was being questioned about their ailments.
How different from the ideal patient encounters we’re taught in medical school. Forming a bond with your patient, open ended questions, exposing an area for a physical exam, vital signs, not to mention washing one’s hands all went out the window. The doctors worked like automatons, seeing patients one after another, sorting, treating, prescribing and diagnosing.
As it went along, we saw things we’d never heard of in the US. Skeletal Fluorosis, and Osteoarthritic Tuberculosis. Patients who had TB in their L3-L4 vertebrae, and patients who’s teeth and fallen out and bones were brittle due to excessive Fluoride. It was astounding, and though the doctor was swept off his feet, in minutes snatched between patients, or while the patient was sitting there we’d learn about these diseases and unique presentations of others.
I saw the benefits of the paternalistic model of physician-patient relationships once again. Patients who’d religiously follow the doctors lifestyle prescriptions. Anything they said, from exercise, to stop eating this, stop doing that, was met with a Ji, Doctor Sa’ab (Yes, doctor). The doctors would say, quite clearly, “This problem you’re having is due to your weight. Lose weight.” and the family would follow their orders to the letter.
Part of me considers that perhaps we should move back to a paternalist model of medicine, where the doctor knows best- you’ll solve the problem of non compliance. But, at the same time, doctors aren’t equipped to make a value judgement based on their patients lives. The only one who can do that is the patient. If I were enough of an idealist, I’d imagine that a perfect blend of the two exists to have neither’s drawbacks and both’s positives. I share no such hope- I just realize that some systems work in certain places and others work well in different places. It’s all about the culture and society you set it up in.
Thoughts?
Sarab Sodhi 
The question of whether paternalistic medicine has to do with the culture of the society, at least in part. Here in America, the mystique of the physician has waned to some extent as Americans have learned to question authority more and more. Now, perhaps if doctors were paternalistic from the start over her there’d be a different paradigm from the start, but I think that it’d be hard to have a completely different standard from what patients are used to in their everyday lives. Of course, there is a danger in missing a diagnosis when you barely listen to the patient while looking at an X-ray. Osler said, “Listen to your patient, he is telling you the diagnosis,” Then again, with the high volume you have in your area, a good, patient-centered approach may not be practical. As you go through, you’ll have to adjust your approach based on your personality, patient population, and specific patient. However, I would urge you never to blindly follow paternalistic medicine and only fall back to it if you’re in a situation like you presented in your post. Good luck!
By virtue of the US medical school training I’m receiving, I’m quite uncomfortable with the idea of paternalistic medicine as a whole. So, that’s part of why I’m so surprised that it works so “well” here. That being said, I’m being forced to see that it works effectively sometimes, especially given the culture here- like you said.