A few days ago the local Mother Dairy owner turned up at my place quite some time after clinic hours. With him was his grandchild, a cute girl of maybe 3 or 4 years of age. He explained that she had managed to stick a chickpea up her nose.

I invited them in so I could do a quick check to see if she was ok. The child was quite unperturbed about the consternation her achievement had caused, and looked back at me with curiosity as I looked her over.

I explained to the grandfather that this sort of thing was quite common with children her age, and was something an ENT (Ear, Nose and Throat) specialist handles regularly. I explained that I myself didn't have the expertise or equipment to do the job, but I knew a good doctor who could handle it properly. I made a phone call to a nearby hospital - Bhagwati Hospital - to ensure that someone competent would be available if the patient turned up.

I say "if the patient turned up" because, from experience, you can never be sure if people will follow up. Partly the reason for non-compliance is that it is hard to be sure of whether you should trust a doctor in India. On the other hand, for a good doctor in India it can get a bit frustrating. If you are the expert, and you know the ins and outs of things, and know what you are doing, and you are giving out the best possible advice based on your years of wisdom, then you need a thick skin to be able to handle the fact that people will often ignore your guidance and do something that causes more harm to them. Patient compliance is definitely a bigger problem in India than in the developed countries - people mistrust doctors more, for various reasons, some of which are valid.

Anyway, the next day as I was getting my milk, I was given a cheery hello by the grandfather, and he told me the rest of the tale.

Like I said, you never know if people will follow your advice. In this case, the milkman was waylaid by his brother on the way, who said something along the lines of "Oh, why are you going to that hospital? Come on, let's go to that [...name of swanky new hospital deleted...] instead!"

So off they went and waited for treatment. And waited. And waited. Nobody turned up, even though they had been called by the staff on duty. Eventually, the grandfather got annoyed at being left hanging indefinitely like that and went off to Bhagwati. There, the child was treated within a few minutes by a doctor on duty. The grandfather ruefully ended his story with the remark: "I really should have followed your advice."

I can hardly blame him for not following my advice. Because of a few unscrupulous doctors, laymen end up relying misconceptions and myths about how to get good healthcare. This incident is really a side effect of one of the prevalent myths. Namely, that the swankier a place, the better the treatment must be.

Let's go through a list of such myths:

Myth 1. Swanky hospitals give you the best treatment and are the most ethical.

Some places do have pretty good facilities and good treatment. But in surprisingly many cases, especially in Delhi, swankier (so-called "5-star") hospitals are found compromising on honesty and good treatment, even for basic cases. It may sound strange to a layman, but for a general GP-style diagnosis and treatment I prefer to send my closest family and friends to Bhagwati rather than to a 5-star hospital, because I know the competence, expertise and honesty there is impeccable. I do sometimes need to warn my family and friends in advance that they should not worry about the shabby outer looks of the place. This is because, as illustrated by the incident of the milkman, laymen can sometimes have little faith in a doctor's reasoning and decision-making.

Myth 2. No pain no gain

This myth is the belief that the more a treatment hurts, the more powerful it is. Hence injections are regarded as better than pills. As a result of this idiotic belief, quacks use injections as a matter of routine (usually with drugs that have a strong color as the ingredient). As a result of this misconception, many uneducated people judge quacks to be better than real doctors.

Myth 3. Free medicine is not effective medicine

This is a myth based on the perception that a doctor will only give away useless medicine for free, because good medicine must be expensive. I often get eyedrop sample bottles given to me by medical representatives. I give them away, as I am supposed to. But this is a problem with illiterate people. On a few occasions I noticed such freely given bottles were thrown away unopened nearby. The effort expended in trying to explain to such people that the free medicine is effective is considerable.

Myth 4. Summer is the worst time to get a cataract surgery done

This is an idea that affects eye surgeons most. People believe that it is best to have their cataract surgery done in the winter. This is quite wrong. The season makes no difference. It is the surgeon that makes the difference.

Myth 5. Older docs are better

People tend to trust a grey-haired doctor more. There are good reasons for this - a doctor who has been around for some time is obviously competent, and older doctors generally have more experience. But there are downsides to this. Past the age of around 60, a surgeon's motor skills are not as good as they used to be. Then of course, younger doctors tend to be more in touch with more modern treatments. In the end, it really depends on who the doctor is rather than the age and looks.

Myth 6. Foreign docs are better

Indians have a deep belief in the superiority of anything foreign - whether it be electronics, cars or doctors. A doctor with a degree from Russia is regarded by the layman is being better than an Indian doctor. However, the doctors with degrees from Russia have mostly gone through a donation college system. Within the Indian medical community, doctors from donation colleges, whether these colleges are in India or in Russia, are not regarded as being as competent as Indian doctors from the merit-based colleges.

Actually, in ophthalmology in particular, my experience is that the current good opthalmologists of India are pretty much the best in the world.

Myth 7. Famous doctors are better

Sometimes they are, sometimes they are not. There is a gruff doctor I know in the neighbourhood who is excellent and honest in his work. But his manner scares patients away, so his practice has never really taken off. And so he remains obscure, except amongst his peers, who have a great respect for his abilities. Conversely, there is another doctor I know who simply isn't much good at his work, but who has found ways of impressing people and manipulating the media to make up for it. As a result of this, he does a roaring business.

So no, fame is not a valid way to judge competence.

Myth 8. Glaucoma can be handled by a general ophthalmologist

This myth is a personal pet peeve since I am a glaucoma specialist. Glaucoma was managed by general opthalmologists many years ago. However, that is no longer the best way to manage it. One family friend regularly went for check ups and tests to a well-known general ophthalmologist, and followed the prescribed treatment diligently. His vision deteriorated due to not being refered to a glaucoma specialist from the start.

He is now being treated by me, but it irks me personally that so much of his vision could have been saved if he had only been managed by a glaucoma specialist much earlier.

I strongly feel that a general opthalmologists should not be handling glaucoma patients. The patient's health is always the priority, and the principle to apply is always "Do no harm". If a case is outside my own areas of expertise, then I will do a basic diagnosis and refer patients to the appropriate specialist for further treatment. Disturbingly many doctors do not do that, and that is an unethical betrayal of patient-doctor trust.

Myth 9. Eye care needs to be expensive

Not so. Cataract surgery is actually very cheap if you go for the ECCE with IOL route. It is even cheaper if the lens is not replaced, which is something unscrupulous places do. But phacosurgery is the recommended practice in most cases these days where the patient can afford it, and is necessarily more expensive (though not very expensive in India).

Myth 10. Foreign lenses for IOLs are better

Slightly. But it depends on the brand and it reaches a point of diminishing returns.

Myth 11. Medical tourism deprives the poor of health care

It doesn't. For a further analysis of this, see my entry of Nov 2005.

Myth 12. Good doctors are always wealthy

They won't starve, but it is currently not a lucrative profession in India due to lax standards of health and law. These lax standards allow unscrupulous doctors to take shortcuts to make more money, and honest doctors don't do as well in the short term. In general, wealth is often not correlated with how good a doctor is, nor is a good doctor necessarily wealthy.

Myth 13. More private hospitals in one location means more competition and cheaper medical care.

Not if there are more hospitals than doctors. What happens is that hospitals compete for doctors by competing at getting better medical equipment and offering higher wages. As a result, the hospital has to make the money back by charging patients more.

Myth 14. If the doctor is unable to cure a patient, the doctor must be bad.

If a person has a bad prognosis, then a private doctor will be reluctant to handle the case. This is because in India, patients and relatives, even after being told thoroughly in advance about the likelihood of a poor outcome, have a disproportionate tendency to place the blame on the doctor. This happens, even if the doctor is excellent and has followed all the best practices. Most experienced private doctors will only handle such difficult cases by refering the case to a hospital and effectively washing their hands of getting involved with them, which can mean an even worse outcome.

Some cases have such a poor prognosis, that no matter how good the doctor is, the outcome will be poor. It's common sense.