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a few times come to mind over the ten years as a registered nurse . There are times I have politely disagreed with a doctor and entered into a discussion about and we have been able to both explain our side and reach an agreement. It is a fine line I suppose / as a student nurse I was trained to question and understand and to use my brain and conscience to advocate for my patient. So I certainly wouldn’t blindly follow any orders. But at the same time there may be a reason the doctor asks something that I don’t know about - which is where communication is so important and I have found most doctors happy to listen to my objections or concerns and explain their reasoning. Some times it’s a matter of weighing risks and it’s not an exact science. There’s been times I have disagreed and perhaps been in the wrong. There’s times I have done something reluctantly I felt was wrong , and times I followed an order and it still haunts me to this day as I feel I shouldn’t have. I haven’t thought about my nursing experience in a long time. One time I felt I wanted to write a book. But because of confidentiality and because I don’t want to scare people from getting help from nurses and doctors I was put off that idea. Doctors and nurses are human and yes there’s errors in judgement and there’s also times the law doesn’t allow for doing the right thing. But even though sometimes things happen that aren’t right , I believe there are people out there advocating for the patients and learning from the mistakes.there is much more good that happens than bad. But the bad tends to stick in my mind I suppose.Things are coming to mind as I write this that I felt I had forgotten. The one time I clearly remember refusing a doctor order It was a night shift and I was the senior nurse (I had been nursing approx two years and some of that was in aged care so I was not very experienced in acute care. ) we had an elderly gentleman with many problems. He had end stage bone cancer as well as dementia. He no longer spoke English and his family said even in his native language he didn’t make much sense. The patient had come in from an aged care facility. They had been forced to transfer him to the emergency room in the middle of the night as they had no palliative care orders or not for resus , and as his breathing deteriorated they had to call the ambulance as dictated by legislation at the time in that state.(This happened often in aged care. When I worked there the ambulance would arrive and shout at me for wasting time and resources with a clearly dying person. I agree with them the person would be better off with palliative care in their own bed and family around. But the law doesn’t allow a nurse to make that call. It’s a bad system. )This hospital did not permit nurses to have end of life or palliative discussions with patients or family. I watched a young Intern talk to the daughter of this man and say to her “well he’s pretty sick. You don’t want us to do anything for him right ?”The daughter had come from interstate hadn’t seen her father for weeks and wasn’t aware his deterioration or prognosis. She felt put on the spot and tried to ask for more information. The Intern told her “sometimes it’s better to let people go.” The daughter replied she and her father were catholic and valued life. The doctor said “You don’t want to send him to Intensive care and waste all those resources. I am catholic too but in my job I’ve seen much suffering it makes me in favour of euthanasia”. And the daughter after hearing the word euthanasia immediately insisted her father be treated fully.Being a new nurse I understand this intern not being able to properly have this talk he was likely nervous and it was overnight he may have been on call for days etc so I’m not making a judgement on him. But to the daughter this sounded cold. And soon as he used the word “euthanasia” - which was not what this case was about - it was about good palliative care - the daughter became anxious. She immediately replied they were catholic and she needed to talk to her priest. On Monday. This was Friday. No matter what treatment the man received he was unlikely to live until Monday. But the doctor walked away - leaving a very upset family member and no palliative orders. As the paperwork stood this man was for full active measures including resus and met calls. However he did have pain relief charted and as he was moaning and displaying other non verbal signs of discomfort I administered pain relief to him. His daughter was happy with this as she didn’t want him in pain. And I explained it may depress his respirations - but we weren’t giving it for that reason just to control his pain. And that with his other Illness his body may start to shut down. I was crossing a line saying even that as the policy at the hospital was doctors were to have all those conversations. But there was no doctor around and he botched the first attempt so I felt it appropriate to assure her that we were caring for her fathers pain and try to prepare her for the consequences.sure enough half hour or so later the patients resp rate and bp plummeted. We had a procedure at this facility on when to call the met team - including these two criteria the man now displayed as well as “any time a nurse feels worried for a patient”. While yes I felt this man was not long for the world , Calling the met team was really not In my patients best interest. I did it though -with hopes the doctors who arrived would see the situation and talk to the daughter and write some palliative orders. i explained I would call the team due to the deteriorating in breathing but because of the pain meds which he needed they would not likely be able to do anything and they would talk to her when they arrived about the options. the team arrived and assessed the patient and the file, the patient now had a high temp too and previously had been on oral antibiotics. The doctors gathered round talking to each other and asked me to give iv antibiotics as this was the daughters wish, while they debated about sending him to icu. Even though it wouldn’t do much for the man I didn’t feel it would hurt as he had iv access -and so I drew up the antibiotics. I wasn’t entirely comfortable with it but I felt maybe it was important for the daughter to see we were doing things to help her dad and I didn’t think it would hurt. As I was about to flush the iv with saline the patient - barely breathing and hadn’t spoken English for years - grabbed my wrist and said very clearly to me “lady ! Why you Do this ? Didn’t they tell you I am old man dying ! I don’t want this !” I know he had a fever and many other conditions and pain killers but that man looked into my eyes and I felt I knew his heart. It was my instinct already that he needed pain relief and comfort and dignity to say goodbye to his family.I put down the anti biotic and went to speak to the drs about what he said and that I hadn’t given the antibiotics. After a conversation with the daughter they maintained he was for full active resus and ordered not only the antibiotic but narcan. I was a new nurse in acute care. I was shy and lacked confidence. There were tears in my eyes as I shakily said no. I would not put the man through it. It would wipe all the analgesia from his system and he would be in agony and still dying from end stage cancer. And I strongly believed he didn’t want any more intervention. The doctor told me it wasn’t my call and my job was to obey. He told me “no one wants to waste time on this but it’s the law the family want it.” I felt sad for this man that he no longer had a say and I felt angry at this daughter. I contacted the nurse manager on call in the hospital and told her what was happening. She told me “if you don’t want to give it that’s fine let the dr give it.” I told her that may absolve me but it doesn’t help the patient and I hysterically asked her to come and intervene. She did. She had many years as a nurse manager dealing with situations but I could see she too was a bit hesitant to step on the doctors toes. I followed her into the patients room where two doctors were holding the man down trying to get blood gases from a femoral artery ! It astounded me they would traumatise a palliative patient like this. But again they had a job and per the paperwork and protocol this was what they had to do or risk being accused of killing patients. they had narcan on their trolley but not syringes or needles ( too bad if it was a real emergency !) and asked me for a needle and syringe. I said no. They asked for the key to the cupboard where the supplies were. I said I don’t have it. Which was a lie it was in my pocket. I felt so justified at the time but also a part of me was screaming what are you doing refusing to give a doctor supplies !!i was then kicked out of the room while (in front of the patient) the doctors and nurse manager argued ). I saw the daughter sitting crying and went to talk to her. I wasn’t sure what to say. It was my place to advocate for my patient and so I decided to Be frank with her. I explained that because there was a full active treatment order it meant any time we gave pain relief her dad may had effects like depressing his breathing. And due to the orders it meant a team like this had to come and focus on his breathing and bp and keeping him alive - as opposed to his comfort and dignity. i asked her if she knew her dads prognosis. She said she knew he would die very soon and was trying to make the right decisions for her dad and by her religious beliefs that life is sacred. She felt withdrawing these active measures was giving up on life. I talked to her a little about my own belief In God and why I wanted to be a nurse. It occurred to me she didn’t have the view point I had of seeing many palliative patients die in agony. She only knew she loved her father and the doctor Had made a comment about euthanasia and she then felt she had to stick up for her father and make sure he was treated. I told her that her fathers Illness would likely take his life soon - the choice she had was to make him comfortable and dignified and sit with him - or fight the illness and send him to intensive care with no pain relief and tests. I told her what he had said to me as I tried to flush the iv. He hadn’t spoken English in years and I wasn’t sure she would believe it. But she told me he used to call all the nurses at the nursing home “lady”. She had been made to feel that if she loved her dad she would fight for his life. But I helped her to see that his comfort and dignity and wishes mattered too. She had been made to feel that things like giving pain relief were because we were “trying to kill him quicker to save resources”. I explained what narcan would do and the pain he would be in and it would happen each time he had pain relief and breathing slowed. I explained to her that for me I felt there was a very big difference between euthanasia and actively ending someone’s life - and palliative care in a terminal case where life saving treatments are withdrawn and comfort given. She was very religious and felt she had to fight for life at all costs as her priest told her. I was a Christian at the time and I tried to explain my beliefs that sometimes medical intervention went too far. The treatments couldn’t help her father he would die very soon and she couldn’t change that. Only change the way the last days were. She felt she was killing him to give him pain killers. And I explained perhaps it may hasten his passing but it will make sure he is comfortable. Withholding pain killers and sending him to icu wouldn’t help him only hurt him and prolong the agony. She was silent for some time and I was scared I had spoken out of turn and over stepped. But she then asked me “why didn’t the doctor tell me this? He didn’t tell me that active treatment meant my dad couldn’t have pain killers? He didn’t explain it he just said he believed in euthanasia and was a catholic so it was ok for me to Not get my dad treatment. “In the interns defence he probably never had that talk with a patient family. And he maybe assumed she knew already. It’s easy to forget that many people don’t have the experience and knowledge of palliative care. Especially back then this was some years ago. The rest of the doctors who responded to the met call had been told “the daughter is a religious nut and wants full measures. Do it or we will be taken to court “. I found out later there had been a previous incident where the met team made a judgement not to take a palliative man to icu and the family took legal action. The family said the doctors pressured them to sign the forms etc. the case shook them and they were told follow the paperwork from now on. None of them tried to talk to the family as they had been told the family were “religious nuts “ and they Didnt want to be accused of pressuring them. They presumed the intern had a full talk and the family understood and wanted full treatment.After I had talked with the daughter she approached the met team and signed the pall care papers. Much to their relief. They didn’t want to be doing it to this man either. After a bit of drama I felt it was a good outcome for the patient and daughter and for all to staff too. Yet one of the met team approached me moments after and said he would report me for having the conversation with the daughter as end of life care etc should be discussed with a doctor. I was torn between feeling bad and feeling justified. He went on to say he would report me for refusing to give narcan or unlock the supply cupboard. The nurse manager came up behind me and told him “my nurse wouldn’t have to have that conversation if any one of you had bothered to do it hours ago. It would have spared this man and his family this pain. I’ll be Making a report too! I shouldn’t have to be called to the ward to sort this out when there are five doctors here. You are lucky she didn’t give you the keys because if you had given narcan to that patient I would make sure you lose your licence. The family would have a legal case against you as you didn’t inform the daughter the consequences of what you were doing. I understand there’s legal limitations to what you can do - but stop and look at the patient and talk to the family and then my nurses wouldn’t have to defy your orders.”I never heard a word about it afterwards. I asked the manager weeks later she said no one filed a complaint either way but that there was now mandatory training about how to talk to families in those situations as well as liaising with nursing homes about the importance of sorting this out before it gets to an acute situation. In some ways I understand the dr being angry as I defied his order and perhaps I could have done it differently but end of the day the patient was palliative and comfortable and the family was happy all the paperwork in order and yet he was angry as if he was saying it would be better if we gave narcan and took him to icu.Sadly this isn’t uncommon. Years later as I worked a shift in a nursing home I had an almost identical situation. A patient with terminal illness and dementia who fell and hit his head. Because of the dementia and the medications he took there wasn’t a reliable way to determine if his neurological state was deteriorating. Despite having end stage cancer which he was not having treatment for , there were no documented end of life wishes from him or his family. Being the middle of the night and an acute situation (as in if he was bleeding in his brain we couldn’t wait til morning if it was to be treated) there were little options. I called the next of kin — a son who lived nearby - and explained what happened - that he may or may not have a head injury - and we can keep him here and comfortable or send him for x rays etc which would be uncomfortable and due to his condition very likely nothing they could do that we weren’t doing here - keeping him comfortable etc. it’s a hard conversation to have especially over the phone in the middle of the night. and The son decided he didn’t nescessarily want his dad transferred to hospital but did want a doctor to see him. So we called the on call doctor who arrived a couple of hours later. Like us he wasn’t able to determine any neurological injury due to the patients condition - and he called the son to explain this - that if there was some injury there would not be anything the hospital could do. The son didn’t disagree but said he didn’t want the responsibility of signing the not for active treatment not for resus. If the man hadn’t hit his head he would have died shortly from his illness and having no “not for resus” puts the nursing home in a hard position. Legally you are supposed to attempt resus and call and ambulance -but atthe same time it’s a terminally ill patient where the doctors have written the prognosis is the patient will die soon and there is no treatment. anyways because of the paperwork the dr called an ambulance to cover himself , I may have done the same too if it were my call. I like to think I could stand for my patient and just pretend the fall never happened or pretend we found him too late and hope the family doesn’t sue us. But it’s so hard not just because the law isn’t on your side - because there’s a nagging voice in your own mind telling you that this is a person and a life and you have to do all you can for them. It’s one of the things that drove me out of nursing. It’s hard to know what the right thing is. Anyways the ambulance came and abused us for wasting time and for “torturing “ the patient. I don’t blame them I felt the same. I told them if you think it’s the wrong thing then you can refuse to take him. But they didn’t want to wear the legal consequences either. So they took him. He was in the emergency room for three hours and died there alone rather than in his bed in the home he lived for seven years with staff he knew and pain relief. That haunts me to this day what I could have done differently and why I didn’t stick up for that patient like I did the other man in the hospital. it’s not just the law that made me go along it’s something else hard to explain. We all just go along the doctor the ambulance the ed staff no one stands up and says this is wrong and I don’t know why I really don’t. I would have thought years later I would be more equipped to talk to the son or defy the dr but the years in the system somehow had the reverse effect and I let that man Down. The system did too. A terminal patient in a nursing home should have end of life orders documented and the family should know what to expect and what palliative care plans are in place. I can’t tell you the number of times I’ve called family or an ambulance in the middle of the night for a terminal patient who has no pain relief charted no instructions what to do no pall care order no not for resus. These things shouldn’t be decided in the middle of the night at the last minute.another time I refused a doctor was again in a nursing home we had a patient who was unresponsive. I called the on call (it was night shift ) and without looking at the patient he told me not to bother - she had alcoholic dementia per her chart - and it was expected. I explained this lady (in her early 50s) was very alert and active only half hour before and something was wrong and I wanted to transfer her to a hospital. He said “no don’t waste their resources , call her gp in the morning“. And he left. I called an ambulance after that and they came. They looked at the chart and saw the diagnosis and scoffed too “it’s a nursing home patient with alcohol related dementia she’s supposed to be out of it”. I explained the sudden dramatic change in her consciousness and the fact that aside from the dementia she had no other problems and insisted they take her. They did so - but warned me that I would be sorry for this , and that they would be back in twenty minutes when the dr discharges her. I felt stupid I have to say and started to question if it was nescescary to call an ambulance and defy the dr. Ten mins later I hear the helicopter over head and the patient is being transferred to the city hospital with acute renal failure. She was treated and then returned to the home happy and healthy and enjoying her quality of life. I shudder to think if I hadn’t called the ambulance. What was even more horrifying is the reason why the patient was in renal failure. She was vocal at night and one of the night staff had been giving her (non prescribed ) sedatives which lead to her being drowsy and not eating or drinking enough. This staff confessed it to me after I sent the patient to hospital and said she was so glad I did otherwise she would have a death on her conscience. I reported this and the nurse denied it - and nothing happened though the counted the sedatives a bit more closely after that.Another time I was an agency nurse in a dementia wing. I had worked a few shifts and knew the patients and one patient appeared to be in pain. He was non verbal and unable to walk he was full care. But he was grimacing and moaning -unusual for him - and he was vomiting. Something in his eyes was not right. He was a palliative patient and had no family , Sl I didn’t want to send him to hospital just some pain relief for him. This nursing home didn’t have a dr on call it was a locum in the community who was very irate at having to come to a dementia ward in the middle of the night. He went in and looked at the patient and came out saying “he’s not in pain.” I politely said I disagree and asked how he came to this conclusion. The dr said “he didn’t complain of pain when I asked him.” He hadn’t spoken for years so he wasn’t able to complain. I explained I knew this patient and he was not well and I felt he needed pain relief. The doctor said he didn’t think it’s needed and “shove a couple panadol suppositories In him if you really want to.” And walked off. Ashamed to say I just stood there. Another nurse was walking past and heard this and followed the dr out telling him “i hope when you’re dying some dr comes and shoves a suppository up your ….” He marched back to the desk and wrote a morphine order ,a small one, and stormed off. The nurses and I gave the pain relief but he was still in discomfort. His own gp came first thing in the morning and prescribed regular pain relief and he died shortly after. He had a major coronary event and would have been in a lot of pain. He got pain relief at the end but he spent that night in pain and it was so needless. Having said that his own doctor should have written prn orders as he knew the patient was terminal and likely to be in pain at some point. I asked the doctor about this and if there was legislation that prevented him writing prn orders for this purpose and he said there wasn’t any legislation but he preferred to be called when his patient was unwell or unstable to come see them and prescribe. That’s fair enough but the same gp won’t allow nursing homes to call overnight and a locum who doesn’t know the patient has to come and isn’t likely to want to write a prescription like that.The other time that springs to mind again in an aged care facility where there was a scabies outbreak. Not a big deal it happens and is easy to treat. For some reason the manager and the doctor of the facility wouldn’t address the problem. I would write notes documenting rashes and itching and the manager and doctor would come on the next day and say there was no rash and no itching. Staff began to get scabies and went to their own dr for medical certificates and went to the management and were told “you can get scabies anywhere you didn’t get it here .” It was so frustrating because the residents were ill and the last thing they needed was more discomfort. To this day I don’t understand why they denied the problem. We approached a skin specialist who assessed the staff and two of the patients who went to see him with their family and he diagnosed scabies and they were treated. He offered to come to the home to look at the others but the home refused and stated they had their own dr. Week after week this doctor would write absolute lies about no rash no iTching. We made a complaint to a higher authority who came in and spoke to the manager and doctor and left again without any action. The doctor wrote in several patient notes “this patient does not have scabies. Night staff are hysterically paranoid about scabies and imagining symptoms. I have examined the patient as has the nurse manager there is no scabies.” I was angry at the insult as well as the patients suffering and that night took photographs of the rash on each patient who had a rash , those who could talk I quoted their description of the problem in their notes. The doctor also wrote some of them had “heat rash “ because night staff were putting too many blankets on and that’s why the rash was only there at night. So we documented the room temperature the number of blankets what the patient was wearing etc, and a colleague on day shift did the same , taking photos of these rashes in the day shift to show it wasn’t night shift imagining it. We made another report to a different organisation. The nurse manager and doctor called me to the office next day to tell me “no one has scabies. But to get you nurses to stop freaking out we will treat everyone in the facility. But you have to take out the progress notes and photos you put in the patient notes. “ i knew several patient families had made complaints and asked for the patient notes - and I wanted to leave my notes there to support their complaint that nurses reported the problem and the management and dr did nothing. Besides it’s a legal document and my notes were the truth ! I refused as did other nurses who had done the same. The doctor finally ordered all patients treated (almost one year later ! Some of them passes away with horrible itching that was easy to treat !) but he wrote on every single order (patient doesn’t have scabies - just treating to please hysterical nurses ). The patients were treated (twice ) which involved staff from nurses to aids to cleaners and laundry staff volunteering extra time without pay to get it done. Everyone did so willingly because we had been fighting so long to get this treated. And there were suddenly no more rashes or itching. I know it seems a small thing a bit of itching -but we had a responsibility to provide care to those people and we failed. Again I look back and wonder what I could have done differently. After I refused to take my notes down or alter them I was told if I didn’t I would lose my job. I quit. I probably could have tried to fight it but I didn’t want to work there anymore. I felt bad leaving though as if all the people who speak up against things like this leave - who is left to speak for the patients ? Five staff left the same time I did all staff who were fighting for the patients to be treated. Later the home was investigated over the incident and the dr and manager convinced everyone there was no scabies just hysterics nurses who have now all left.I haven’t thought about nursing in a long time - suddenly things come back to me. When I was a very new nurse in a nursing home we had a patient with terminal cancer and very early Alzheimer’s. She was alert and oriented and knew where she was and who she was and very cognitively aware most of the time. She had back pain from metastatic cancer. Her family told her she had a back injury and put her into “respite “. They didn’t want her to know she was sick or dying as they felt she couldn’t understand due to her Alzheimer’s and it would confuse and upset her. As such the dr wrote in her notes that staff were not to discuss her diagnosis or prognosis with her per family request and dr order. This wasn’t a problem until the patient started asking me what was wrong with her. Why did she have so much pain. She felt her family were keeping things from her and she said to me “they don’t want to upset me but please tell me the truth”. I told her to talk to her family and then immediately contacted the manager about my concerns in keeping things from this patient who seemed very alert and oriented and was asking me very clearly things about her pain and prognosis. The manager said to go along with the doctor and family. So myself and another nurse approached the doctor about it - he said it’s what the family want and the patient is cognitively impaired so she can’t judge for herself if she can cope with the diagnosis. She had a history of depression and the family didn’t want her upset. I felt this was wrong but felt a bit stuck at the time. The next night the patient asked her family for a priest to say last rights. The family said no there’s no need you’re just here for respite. That really bothered me as this lady was very religious and last rights were important to her. She wasn’t silly she knew she was dying and that everyone was keeping it from her. She felt she could trust the nurses and asked us over and over if she was dying. Again I raised my concerns with the doctor and manager about calling the priest and that she had a right to the last rights. The doctor said fine to call the priest but no last rights. This made me more and more upset that the patient couldn’t have this ritual that was important to her or time to say goodbye to her family etc she was distressed and knew something was wrong and yet we were told in no uncertain terms we were not allowed to talk about her diagnosis or prognosis or last rights. Myself and another staff contacted an advocacy group for aged care patients with dementia and they were fantastic. They came in and spoke to the family - acknowledging their good intentions but trying to explain the patient was able to hear the truth and she was alert and oriented and knew what was happening. The doctor was furious that someone had come in telling him what to do and that nurses had gone over his head. He made no attempt to hide his anger about it. He was told to tell the patient the truth if she asked him. That day (a Friday) he wrote in the notes about the advocacy group meeting and that he would talk to the patient Monday and if she asked him and was alert he would discuss her diagnosis. He then left without seeing the patient. The family were upset too they felt they had been told off and disrespected so it wasn’t a nice situation at all. The lady died over the weekend - the dr knew she would likely not be around Monday or be too sick to talk about anything. She died confused and agitated. I called a priest and the family allowed him to come but not to acknowledge or talk about the fact she was dying. we left the room and I don’t know what happened in there but I like to think the priest was a better person than me and was able to be honest and give her some peace. After she passed away the family were distraught. Through the process I had been angry at them. But as they cried and asked me if they had done the wrong thing I could see they were doing what they felt best. They said the doctor thought it best and they didn’t want to upset their mum , but she asked them if she was dying and they felt bad they hadn’t been honest or allowed the priest to come or say goodbye. And I asked myself if I had ever tried to talk to them about it ? I argued with my manager and the doctor and reported it to advocacy groups as I felt the patient had no one to speak for her rights - but I hadn’t approached the family and asked them why they made that decision or if they felt things changed and they wanted to tell her the truth. I was so frustrated with them for the way this lady had died - but as I saw them crying I told them I knew they made the choice because they loved their mother and were doing what they felt best - and it didn’t matter now it just matters they were there in the end with her and she knew they loved her.Now I think on it I suppose there are more times I wish I had defied the doctor then times I actually did. Many times it’s not the doctor who is the problem it’s the system as a whole so I’m not trying to say doctors are terrible or anything. And these bad examples are only a few. There have been many amazing doctors I have worked with but the bad times haunt me I suppose and stick in my mind.

Oh boy do I use email. ALL DAY Son!! Even whilst you sleep.Please trust me that I use email A LOT!! I love it. I far prefer it to speaking on the phone. And, lots of people have my email address. In fact, I have 4 active email addresses ... a personal Gmail account, a Gmail address for work related stuff, my old university email address that occasionally still receives something interesting and the email address assigned to me by work.But, I won't give ANY of these email address TO YOU. Blame the lawyers. If you had my email address you'd run to your lawyer and sue me. Don't lie ... you would! To understand, please take a look at the type of emails I deal with every day. I'm willing to bet it's the kind of stuff that is familiar to everybody.These are the emails that arrived in my 4 accounts overnight and distracted me from making coffee whilst I awaited the arrival of my first patient this morning ...my accountant - my tax return is overdue. I need to email her some further receipts before she can submit my return. I have 5 days to do this or the tax department will send me a large bill that I cannot afford to pay.my bank - I locked myself out of my internet banking account overnight (because I couldn't remember the answer to some random security question about my wife's sister's wedding anniversary), and, without access to my banking I can't send my accountant the above details.my son's soccer team - this weekend is my son's last game for the season so the entire team needs to bring a shirt for after the game so they can hand in their uniforms. As the team's coach it is now my responsiblity to ensure not only my own child brings a spare shirt, but, every other child on the team as well.my own soccer team - if we win our soccer game on the coming weekend we'll come first and get a cheap, plastic trophy. Apparantly, this is worthy of some stirring motivational banter. Furthermore, it requires debate about where and how we would celebrate a victory in the grand final. We are also required to decide whether we are going to attend the presentation night, to collect our cheap plastic trophies, at the end of the year. I do not play in the English Premier League ... although these emails may convince you I do.my wife - she needs to stay back at work tonight and I need to collect the kids from childcare and arrange dinner for the family.my group of friends - someone is turning 40 and is arranging a party. They want everyone to respond with their availability for the next 3 months so that they can determine the most suitable date.my GP training provider - they've updated their website with information they thought would be useful to me and wanted to let me know. History would suggest they send me an email every time someone in their office touches a keyboard.my GP registration body - they're campaigning against a government freeze on medicare payments and want me to sign up.online training sites that I have subscribed to - they have new resources on their site and need to make me aware.a cooking school - I once bought my dad a lesson at a highly respected restaurant. He loved it and so I've remained on the mailing list to see if there's any other lessons that he'd enjoy.a real estate agent - I once looked at a property near my house and actually wrote my real email address on the sign-in form. Now I receive emails every time a nearby property goes on sale.a medical recruiter - I made the mistake of considering extra shifts when I was working in the hospital system and now I get regular emails about random and unusual jobs around the country.the receptionists at work - who have forwarded requests to call back patients who have phoned for results or medical advice.the practice manager - who wants to remind me about requirements of an upcoming compliance audit.And these were just the emails that I have some interest in, and, were in my primary Inboxes. This doesn't count all the promotional emails, advertising, requests for feedback and notifications from Quora. You know, the stuff that gets dealt with using the 'Select All' and 'Delete' buttons.The following is therefore why I don't want emails for medical assistance added to my 'To Do" list. These are listed in order of importance - maybe not in the order you'd expect ...1) It invites poor medical care.If you had my email address, you would email me with medical questions. This is a very bad way of seeking medical advice.Trying to assess a patient via email (or over the phone or via video conference or text message) is a poor substitute for having a patient in front of us. It robs us of many tools that we use for our craft - tools like non-verbal cues, the ability to examine and the efficiency of a face-to-face conversation. Proper medical advice via email would involve numerous replies to gather the required information to ensure our advice was reasonable. It's a highly inefficient way of providing medical care.Poor medicine is very popular because it's quick, cheap and convenient. It can also be very profitable for a doctor. There is a lot of money to be made in the provision of cheap, quick, low quality medical care to lots of patients. However, despite it's popularity, it nevertheless remains poor medical care. In this particular instance, the customer is NOT always right.I personally do not want to participate in poor medical care - regardless of how popular and profitable it is. That's not why I got into the job. If you want quality medical advice from me then you'll need to provide me with the tools I need to do my job. That involves seeing you in the flesh.2) I don't want you to sue me for doing you a favour.If you take a look at the long list of emails I faced this morning, none of these people can SUE ME for my response to their email. The worst that can happen is I'll face a large tax bill if I ignore my accountant and I'll have to pay a fine to the childcare centre if I'm late to collect my kids. However, if I provide a medical opinion via email then I am legally liable for that medical advice. Just as liable as when I provide medical advice after talking with, and examining you, in my consulting rooms.A lot of people try to contact doctors via phone or email (or Quora) wanting brief medical advice that they don't feel needs a trip into a doctor's office. In their mind, at that time, it's a friendly and simple request - they're just asking a quick question. The problem is, this friendly and casual attitude will immediately change if something goes wrong. If our quick favour results in a poor outcome you'll hold us responsible.The fact is, doctors are responsible for the poor outcome of medical advice even if results from you supplying us with incorrect information. If we advise you to treat your unwell child with fluids and pain relief, unaware that you haven't mentioned your child's purpuric rash, then you'll blame us for the fact their meningitis was missed. Your lawyer will argue we shouldn't have provided advice without seeing your child in person. Your excuse for supplying incorrect information will be something like "I'm not a doctor. I didn't know I was supposed to tell you about that rash". And, you'll sue us. Successfully.3) It risks medical confidentiality.Confidentiality of your medical information is extremely important. If memory serves me correctly, breaches of confidentiality are the number one reason for medicolegal action against doctors. We get sued when someone in the office mindlessly blabs something about you to someone you haven't given us permission to tell. Even admitting you'd come in yesterday for an appointment can get us sued.Now, I have NO IDEA who has access to the email account that you've supplied me. I don't know if it's a work email address and the IT guy will be reading my correspondence to you because the phrase "rectal foreign body" will flag your workplace internet filter. I don't know whether you share your email account with your wife - who would be unimpressed to read that you've tested positive for chlamydia and need to advise your mistress to get tested. In fact, I don't know whether your email originated because you forgot to sign out of your email account at a public cafe and a random stranger is now asking me to email them your medical history.In all the above scenarios, once you run to your lawyer and complain that medical information contained in my email fell into the wrong hands, I'm going to be in a court answering questions about how I can prove it was you that composed the email, whether you expressly gave me permission to email the exact details that I did and how I could be sure nobody except you would read that information. I hope you can understand I have no interest in participating in these medicolegal games. The only time I like seeing lawyers is when I'm scuba diving and they have concrete around their ankles.4) I'd like to be able to sleep on occasion.You, and your lawyer, know that my smart phone alerts me to new emails 24 hours a day. So, how will I defend myself when I sleep through an email notification at 3am on a Sunday morning? Especially when you decide to email me about some crushing chest pain that has caused you to wake from sleep. Your lawyer will point to telephone records to show the email arrived on my phone. So now it's up to me to prove I didn't see your email, and choose to ignore it, until I started work on Monday morning.I don't want to have to access my phone or email 24 hours a day, every single day of the year, just in case someone has emailed me instead of calling an ambulance. I don't give you my mobile phone number for the same reason.5) I don't have time.All of the issues brought up by the non-medical emails that arrived in my Inboxes overnight have to be dealt with inbetween an entire day of patients who have booked an appointment to see me in my rooms. No doubt, some of those patients will require longer than the time they have booked for an appointment and, therefore, I'm confident my lunch break will be quickly eroded and I'll be late to get the kids - ordering take away rather than cooking a dinner.At some point today I have to find time to organise my banking and finances to avoid a tax bill, arrange for my son's entire soccer team to bring a spare shirt on Saturday, organise dinner for my family tonight and to email a friend my timetable for the next 3 months so they can organise a birthday party.I simply don't have free time to deal with MORE emails adding to my 'To Do' list. I don't want more jobs to do from people wanting me to be legally liable for providing an opinion that I do not have the tools, or time, to ensure is actually good medical advice.6) It's unpaid work.Please note that this is the last, and least important, point. I don't care about doing free work. Doctors do it all the time. But the fact is I get paid nothing for answering an email. An emailed or phoned request for me to do something is an expectation that I provide that work for free.Emails and phone calls pay nothing. Doctors only get paid for the time that a patient is in front of us. We're not on an hourly wage. Our income is derived from the face-to-face care we deliver.So, in summary, an email to a doctor is a request that they expose themselves to potential legal action, without the use of the tools they require to do their job, with time they don't have, and, for free. Ummm ... thanks but no thanks.In conclusion, emails are great for dealing with problems that aren't that important or can wait. However, if a medical issue is worthy of seeking an opinion from a doctor then it's not worthy of an email.YOU may not think an issue is worthy of a doctor's appointment, but, you're not a doctor and you're not legally liable for that decision. You also won't assume liability for that decision if something goes wrong.Even if we look at something as simple as a repeat script: who has decided that medication is still working as it should? Who has checked the underlying disease isn't causing hidden problems? Who is deciding that a change in treatment isn't required? If doctors are handing out something as simple as a repeat prescription without seeing the patient then they're risking being held legally liable for any complication that arises from that ease and convenience.I don't get my car serviced via email. Similarly, if you want good medical care then please book an appointment.

taken from Taking a Second LookSome opinions on the second opinionTwenty-eight physicians, ethicists and sociologists responded to a questionnaire on the role of the second opinion in medicine today. Their comments provide the basis for further discussion on this practice, the issues involved, and the ethical complexities in a changing health-care scenario.When a physician agrees to attend to a patient, there is an unwritten contract between the two. The patient entrusts himself to the physician and the physician agrees to do his best, at all times, for the patient. This contract disallows the patient from seeing another medical expert for opinion or advice without a referral note from his physician. It also enjoins the physician to respect the autonomy of the patient so that if the patient so desires, he will refer the patient to another physician for a second opinion.Traditionally, the concept of a second opinion is based on certain assumptions. First, that the physician has studied the patient's medical history and clinical findings; if he is the patient's family doctor, he has also over time acquired a fund of medical and socio-economic information on the patient and his family. Second, that the physician is knowledgeable about the various specialists in the town or city and their respective strengths and capabilities, and is thus qualified to advise on whom to consult for a second opinion, and provide that consultant relevant and often crucial medical infomation on the patient. Were the patient to consult another physician on his own, these benefits would be lost.However, second opinions are often not sought on these principles. Some patients move from doctor to doctor without the primary physician's knowledge. They obtain a variety of opinions, often conflicting. Without any one doctor in overall charge of their therapy, they may follow whatever advice they choose to accept. If a complication ensues, no particular doctor can be held responsible.Patients who do ask their primary physicians for a note of referral to another doctor are no better off. Such requests are often taken as a personal insult and evidence of lack of faith or trust in the doctor. Some doctors react by withholding key information, such as detailed notes on surgical operations. The result is often a general breakdown in the harmonious relationship necessary for good patient care.The problem is compounded by the absence of clear-cut guidelines on the use of the second opinion. In India, our medical councils have failed to contribute to the discussion, or to regulate the use of the second opinion in any way.It is in this context that colleagues were asked their opinions on the need for, and use of, the second opinion. By recording the views of respected academicians and medical professionals, one hopes to lay the ground for further discussion on the question. The following essay is an attempt to extract, from the responses received, considered thoughts on some aspects of this issue. Excerpts from the responses have been included to illustrate various perspectives.Is the doctor-patient relationship a contract or fiduciary relation?While several medical colleagues agree that the doctor-patient relation ship today is some sort of unwritten contract, there were many qualifying notes. Ruth Macklin raises a fundamental question: what kind of contract is it, anyway, if it is both unwritten and unstated? "A contract in which the provisions are not clearly spelled out is not really a contract at all. In a legal sense, it would be considered invalid. From an ethical point of view, how can all partiesphysicians or patients be fully aware of their obligations or, for that matter, their rights? Contracts in the strict sense of the term are (usually) written documents that spell out the provisions clearly, say what all parties are obligated to do, and also specify penalties or remedies for breach of contract. That sounds very different from the physician-patient relationship, which is perhaps better described as a fiduciary relationship".Clearly, this question needs further discussion for any systematic understanding of the issue.And in fact Thomas George holds that it makes little sense to talk of contracts and obligations in our health care system. He would support enforcing the doctor-patient contract, and expecting referral notes from every patient, if we had a structured health care system, "as, for example, in the National Health Service (NHS) in the UK. Borrowing only one part of the system leads to a lot of problems for the patient. At present there is no system at all in India and the patients are completely at sea as to whom they should consult".Homi Dastur argues that patients would not accept the enforcement of such regulations. "Very few patients would be willing to observe, accept or even understand (the concept of an unwritten contract), as is evident from the frequency with which those who can afford (to pay the different consultants) will seek multiple opinions. Many patients will reveal that they are under the care of another doctor only after the consultation is over. Sometimes one becomes aware (of the earlier consultant) only after reviewing reports which mention the name of the referring doctor".Likewise, Bela Blasszauer suggests that such a contract would work only in theory, for doctor-patient relationships rarely develop in the prescribed manner. "Physician-patient encounters may take many forms. I may bump into the physician. I may have no other choice. I may be shopping for a suitable one. And so on." 'Many doctors oppose enforcing contracts because they perceive the doctor-patient relationship as unequal, and liable to be misused by unethical doctors. "I would like to spare the patient the trauma (of having to face a doctor unwilling to refer his patient for a second opinion)," writes George. Blasszauer suggests that such contracts can generally not be made binding on the patient, since the conditions under which he sought advice or treatment were heavily weighted against him.Others perceive the relationship differently. Eugene Robin and Robert McCauley suggest that the physician-patient relationship is a partnership and not a contract. "Either (patient or doctor) is free to 'terminate the relationship without cause', with the doctor having the additional burden of informing the patient when this occurs, and remaining available for such time as is reasonable for the patient to find another doctor who will assume responsibility for delivering medical care". This is generally true in the urban US, they state.Sociologist Rohit Barot suggests that the Indian situation resembles private sector health services in Britain. He has been a patient in the UK National Health Service, as also with private practitioners there, and comments that the doctor-patient contract and the rules of referral seem to apply only in the NHS.The American Medical AssociationAccording to the American Medical Association's code of medical ethics, physicians should recommend a second opinion whenever they believe it would be helpful in the patient's care. When doing so, they should explain the reasons for their recommendation and inform their patients that they are free to choose a physician on their own or with their assistance. Patients are also free to seek second opinions on their own with or without their physician's knowledge.With the patient's consent, the referring physician should provide any information that the second-opinion physician may need. The second-opinion physician should maintain the confidentiality of the evaluation and report to the first physician, if the patient has given consent. Second-opinion physicians should provide their patients with a clear understanding of the opinion, whether or not it agrees with the recommendations of the first physician.Where a patient initiates a second opinion, it is inappropriate for the primary physician to terminate the patient-physician relationship solely because of the patient's decision to obtain a second opinion.In general, second-opinion physicians are free to assume responsibility for the care of the patient. . . . By accepting second-opinion patients for treatment, physicians affirm the right of patients to free choice in the selection of their physicians.There are situations in which physicians may choose not to treat patients for whom they provide second opinions. Physicians may decide not to treat the patient in order to avoid any perceived conflict of interest or loss of objectivity in rendering the requested second opinion.Physicians must decide independently of their colleagues whether to treat second-opinion patients. Physicians may not establish an agreement or understanding among themselves that they will refuse to treat each other's patients when asked to provide a second.opinion. Such agreements compromise the ability of patients to receive care from the physicians of their choice and are therefore not only unethical but also unlawful.Council on Ethical and Judicial Affairs: Code of medical ethics. _ Chicago: American Meditial Association 1997. 191 pages.A one-way obligation?Does the patient have responsibilities as well as rights in this relationship? "The doctor's duties, ethics, standards are well-known in theory and lapses from accepted norms are recognised in practice", writes Farokh Udwadia. "It is equally important (to emphasise) the patient's duties, responsibilities and obligations... It is time for this aspect to be discussed and the discussion circulated, for it must never be forgotten that the doctor-patient relationship is not a one-way street".Again, this view is a matter of debate. Jagdish Chinappa and Lawrence White argue that the two groups are very different. "The patient is the consumer who has needs based on certain beliefs and attitudes. The doctor is a service provider. Patients, under the stress of their illnesses, should be expected to behave irrationally and inconsistently". Therefore, Chinappa goes so far as to say, "honest and ethical action is therefore dependent only on the doctor and has to be decided upon the merits of every case. Certainly, the emphasis on autonomy guarantees a patient the right to ignore a doctor's advice, and to seek whatever opinions are wished. (I believe that this, even though considered a nuisance and counter-productive regarding patient care, is nonetheless a good thing.)"Likewise, White notes, "Just as it is not an equal relationship in terms of power distribution, vulnerability, etc, so it is unequal with respect to promises on either side... it is generally accepted that patients have the right to do whatever they wish, including shopping for alternative opinions, etc". This does not mean that many physicians like or accept (the practice). "However, to demand otherwise will reinforce the physician's position of power and elitist attitude, which I believe would be a regressive step".Why doctors should want a second opinionThere are a number of reasons why a second opinion may be sought. Traditionally, general physicians and patients seek specialist opinion and advice with benefit, especially when the disease is uncommon or the patient's condition serious. The patient with a hole in the heart, a brain tumour or failing kidneys will do better in the hands of specialists.In certain situations a second opinion is almost a 'must'. "Take for example a 'shadow' in the lung of undetermined aetiology", writes Farokh Udwadia. "Is it tubercle, pneumonia, cancer or a rare disease, for example, Wegener's granulomatosis? What is the patient to do about it? In fact, it would be advisable to take more than one opinion..".Christopher de Souza adds that young consultants would welcome second opinions from respected seniors — provided they were sure the patient would return to them for definitive therapy — in order to validate the line of treatment they propose. The senior consultant's concurrence would protect the younger colleague against unjust accusations and boost the patient's confidence in him.B N Colabawalla feels that a second opinion may benefit the primary physician in yet another way. "Patients are now increasingly conscious of their rights and it would be improper for any physician to deny the patient his autonomy and right to seek a second opinion. It would be in the interest of the primary physician to make the necessary reference for a second opinion."Unfortunately, requests for a second opinion from other consultants are uncommon. "The practice of referral from primary to secondary to tertiary, or from general physician to specialist remains an ideal not realised," according to M S Valiathan, who has rarely had a primary consultant seeking a second opinion from a senior consultant, or referring a patient to him. In cardio-thoracic surgery, at any rate... a senior consultant usually enters the picture only when the primary consultant fears medico-legal trouble in a given situation.That is not to say that patients aren't asking for them. One reason why seond opinons are relatively uncommon is the absence of any publicly available medical audit. "Patients approach several consultants simply because, at present, they have no way to get authentic information on the quality of services provided by a given consultant or institution", says Valiathan.Outpatients come to Anil Desai because they are dissatisfied with the information their primary physician gave them, or with the treatment's progress. "I always request a referral from the family physician, but (find that) many families do not not have a family physician".However, the hospitalised patient is unable to obtain a second opinion without permission from the admitting physician — and even discussing such permission can be a source of stress for the patient and his relatives.Is the second opinion a right?All doctors surveyed felt so, though they did not agree on whether there were any limiting condiions. Some, like BIasszauer held that patient autonomy required that it be unlimited: "The patient has a freedom of choice, and even the responsibility... to go to as many doctors as he wishes. It is his life or that of his loved one that is at stake!" This right becomes particularly important with the deteriorating physicianpatient relations."Since trust in the medical profession has been greatly eroded, it is small wonder that patients (and I, myself, too) try to find the person who is up to date in his profession and displays humane features as well. In an open market system, this is no real problem. Even where there is a national health care system it may be cheaper for the system as well, if I can find the solution".Others would limit that right, mostly to when the physician ignores the patient's wishes. Udwadia feels that the patient's right to consult another doctor (independently) is absolute when the treating physician refuses to allow another opinion in spite of the patient's request; is clearly disinclined or procrastinates unduly in granting permission to seek a second or third opinion, more so when the patient's condition is not improving or is, in fact, deteriorating; when he reacts with anger or displeasure to a request for another opinion, and the patient feels that he now no longer receives the care he expects and needs."Also, when the problem ... is of serious, unsolved diagnostic import (the patient) has an absolute right to seek as many opinions as he wishes. However, the physician should caution the patient that... too many opinions would only confuse and harm the patient".But there are limits to this right, according to Udwadia. "It would be unjustified, in bad taste and bad manners if he seeks fresh medical advice of his own accord when already under treatment for an ailment for a considerable length of time by his primary physician. He should not seek a consultation with a new practitioner without permission and a referring letter from the primary physician. If the patient is dissatisfied, for whatever reason, with the primary physician, he should have the gumption to tell him so and inform him that henceforth he proposes to get treated elsewhere. This... absolves the primary physician from further care of the patient. It is not uncommon for many patients to surreptitiously see many doctors (as if to test the primary physician's management), and then quietly go back to the primary physician without the latter even being aware of this duplicity."The General Medical Council, UKThe General Medical Council (GMC) recommends that patients should continue to see specialists only on referral from a general practitioner. The GMC has strongly defended the referral system as a proven feature of medicine in the UK. Specialists should not usually accept a patient without referral from a general practitioner. The referral system is seen as the best way of ensuring that patients see the right specialist.General Medical Council News, Spring 1997, pages 1-2.Why don't patients tell doctors that they're 'double checking'?Why do patients behave 'duplicitously'? P. K. Sethi and Colabawalla see the reason in the behaviour of most doctors. "In practice this (request by a patient for a second opinion) seldom happens because the public has an apprehension that I may be annoyed. It is we, as a profession, who should work towards dispelling this impression. We have not done so," writes Sethi. He holds that patients are justified in breaking their contracts if physicians are rude at the mention of a second opinion. And it is "morally, ethically and possibly even legally unjustifiable" for medical professionals to withhold information and case history details, either from the patient or the second opinion physician.How should it be done?Under the UK's National Health Service, only the primary physician can refer a patient for a second opinion, writes Blasszauer. The physician must make the request in writing and provide all relevant medical details. In return, he obtains in writing the diagnosis made by the consultant and his advice on treatment.But this is rarely done in India, writes Thomas George, pointing out that patients rarely go up the primary, seondary and tertiary levels of care. Samiran Nundy notes thatmost patients in India do not have a doctor they can call their primary physician.V. R. Joshi points out that even the most punctilious of consultants would find it hard to enforce such a protocol. "Patients often travel long distances from other cities or states to reach you. It is only when they reach your office that they are made aware that a referral note is required.""Having come after seeking an appointment, I cannot refuse to see them just because they have no referral note," writes P. K. Sethi. "If, however, I discover that the patient is admitted to a local hospital and has come to me without informing the treating doctor, I ask him to go back and bring a referral note I feel this is in the interest of the patient and also conforms to the code of medical ethics... The advice is often no implemented."But it is not always possible to get a letter from the first doctor, feels Arunachalam, giving the patient's side of the story. He may be unavailable, or the patient hesitates to inform him, afraid the request would spoil relations. In fact the second opinion is often most needed when the patient is in the hospital — and least able to take an opinion without the admitting doctor's co-operation. Desai has always helped patients under his care obtain a second opinion without his physical presence, giving them full access to his case notes and the help of his house physician. On the other hand, if they seek a joint consultation — something Desai may also sometimes find necessary — he reserves the option on which consultant should be called in. There are also times when he recommends a joint consultation with the patient and relatives.This is not always the practice. "We do not permit second opinions from outsiders under any condition", writes Prakash N. Tandon, arguing that the second opinion can only be used ethically within a structured format. Patients wanting such opinions must first get themselves discharged from the hospital. "Every patient discharged from our ward, either by us or at his request, is given a discharge summary with full information on the various investigations carried out, a copy of the operation note, our final diagnosis and condition on discharge. The patient is at liberty to use this information for whatever purpose he wishes." Tandon's hospital does not provide the patient copies of X-ray films and other imaging tests, but sends them directly to the consultant if asked.Tandon argues that the patient's interests are met through multiple internal opinions. "Every patient admitted to our wards has the benefit of the collective opinion of the whole team which includes several senior consultants. By tradition, every patient is jointly discussed on more than one occasion."Permitting a second opinion from outside would create administrative problems on the one hand and a difficult clinical situation." For example, he asks, what if the second opinion was at variance from the first opinion? Who would implement it?"As a corollary, we refuse to provide a second opinion on patients admitted to other hospitals unless it is formally sought by the person treating the patient and with the permission of his administration. For purely administrative reasons, this is limited to public hospitals. The opinion is given to the treating surgeon and not to the patient or the family. At times, a joint meeting held with the family is addressed by the treating surgeon and ourselves."White disagrees with such a practice. "If a doctor does this, it strikes me that there is a component of spite and petulance arising out of the doctor's own needs. Patients, particularly if seriously ill, often feel the need to validate their doctors' opinion; after all, it is their life in the balance. Further, there are often enormous pressures from friends and relatives to get 'another opinion'." In other words, the second opinion can be taken for many 'ethical' reasons.Robin and McCauley add, "If the primary physician learns that the patient is following advice not consistent with his principles of treatment, the doctor should advise the patient of the difficulty/danger as best the doctor sees it... It is the patient's choice how to proceed. The doctor can be held responsible only for his own errors, not those of others.""If the patient is already admitted to hospital under another consultant, I would under no condition see the patient unless specifically asked to do so by the treating consultant," writes Udwadia. "This would apply even if the patient concerned has been previously under my care for several years. ""In the initial stages, before starting on a course of treatment, a patient may seek multiple advice," says Mr Harsh Sethi. "But once treatment has started, then a new doctor should not accept a patient without a note of referral from the first doctor (provided he knows that the patient has been under treatment). At the last, he should speak to the first doctor, and seek concurrence."The unreferred approachWhat does one do when a patient seeks a second opinion without obtaining a note of referral from his primary physician? Macklin does not see this as a dilemma. "If a patient approaches you, seeking a medical opinion (whether it is a first or a second opin-ion), the patient is in need of diagnostic or therapeutic attention. You can decline to form a relationship ... or accept the patient in your care and thereby establish a new doctor-patient relationship."Most respondents feel that it is the duty of the second physician to see the patient even without a note of referral from the primary physician, though such a note is desirable.S. H. Advani adopts a firm stand. "I am absolutely clear in my mind regarding the patient and doctor relationship. In this relationship, the patient has the major say. It is the patient who is going to receive the treatment and he has to make sure that he receives the best treatment. I give my frank opinion to the patient (whether or not he comes with a letter from the primary physician) because I strongly believe that the patient has the right to take a second opinion..! don't want the letter from the primary physician to participate in the second opinion."Ashok Bhanage emphasises that the doctor must work at all times with the patient's interests at heart. "If I realise that I am the second consultant, I write my notes in more detail and elaborate the reasons for my decision. The patient is at liberty to show this note to the first or a third consultant."Aniruddha Malpani emphasises that the autonomy of the patient demands that a second opinion, should be provided. A letter from his primary physician is not necessary. "My relationship is with the patient and I am answerable to him, not to his primary doctor."Taking over the patientWould you take over treatment of a patient already under the care of another consultant? This is one fear physicians have when referring their patients to their colleagues.Some might argue that this is the patient's prerogative. Arunachalam notes, "If I have changed doctors, I will certainly expect the second doctor to take full responsibility in treating me. If I consult more than one doctor (for getting opinions), I will retain the right to decide by whom I should ultimately be treated."Others are unequivocal: "If I find out that the patient is under the care of another consultant, I advise him to go back to that consultant," writes Gajendra Sinh. "I do not take over treatment of these patients."On the principle that a patient has a right to autonomy over his decisions, most respondents see no difficulty in taking over the patient's management at his express request — provided such a step is in his interests.However, Homi Dastur adds, "The suggestion to take over medical care would, at no time, come from me. It would have to be broached by the patient's general practitioner, if present, and the patient himself. Acceptance would follow only when persuasion to return to the primary physician fails."Advani differs. "The patient has the absolute right to be treated by the physician of his choice. If the patient decides to be treated by me, I would not normally hesitate to accept. I may inform the primary physician, though I don't consider this obligatory".Blasszauer argues that the doctor must was incompetent, mistaken, negligent, or in some other way not acting in the best interest of the patient. Patients need physicians who seek to act in their best interest. Physicians owe more to the patient before them than they owe to other members of their profession. Even if 'physician etiquette' dictates that one doctor should not treat another doctor's patient, medical ethics demands that patients receive the best medical care. Notes of referral and reluctance to treat patients under the care of another doctor are elements of physician etiquette, not medical ethics as understood today."Barot feels that the second consultant is duty-bound to approach the primary physician for all relevant medical information on the patient.Colabawalla outlines his approach: "If I am aware that the patient has been under the care of another colleague, I will offer my opinion and leave the choice to the patient. I would not 'take over' the case by ascribing to myself the arrogance that I know better! I would then try and persuade the patient to allow me to discuss the case with the primary physician.""The difficulty arises when the patient unequivocally informs you that he does not wish to be treated by the primary physician, and requests you to take over the management. I would try to resolve that dilemma — not that any dilemma can ever be resolved — by accepting that the patient's autonomy and right to choose must be respected"."If the patient is being looked after correctly I would persuade the patient to return to his consultant". writes Udwadia. "If the patient's problem has been wrongly diagnosed and if it is critical or life-threatening (e.g. a dissecting aneurysm of the aorta or an impending myocardial infarction), I would admit him to hospital under my care, inform the primary consultant and request him to see the patient in hospital as and when he wishes, so that we can jointly look after him".The dangers of mixed therapySome patients will see several physicians to obtain a clutch of prescriptions, selectively following that advice which suits them. How can we help such patients avoid the complications that may follow?Udwadia has seen patients who have gone through half a dozen or more physicians. "This is not uncommonly revealed to me at the end of the consultation! I ask that the treatment advised be carried out under the supervision of any one doctor of the patient's choice, as I would be unable to follow-up on his problem as often as I would like to. I then write a letter to that doctor , outlining what I feel about the patient's problem and how, in my opinion, it should best be tackled. (Finally,) I tell the patient that if he wishes to see me again he will now have to get a letter from this doctor".White agrees that selectively following advice offered by several physicians is courting trouble. "These are difficult situations, and in my opinion there is no one right answer. If I have a patient who is 'mixing and matching', I gently tell him he is receiving fragmented care, and that this is dangerous. Usually I tell the patient that I wouldn't continue management without a clear mandate. I feel strongly that patients have the right to several opinions, but that one doctor must quarterback the actual care. If he should suffer a complication, which of his medical attendants would be held responsible?"And the state of the bypassed..Many feel that the primary physician is justified in terminating his relationship with the patient. Valiathan sums up this sentiment: "The primary physician is not obliged to treat a patient who consults another physician or follows another line of treatment without his knowledge. When a doctor undertakes to take care of a patient he accepts a sacred contract with obligations on both sides. I do not agree that the doctor must take care of a patient 'under any circumstance'. Even Charaka, who imposed many strict conditions on the physician, recognised situations when a physician can terminate his sacred contract."At times, the bypassed physician feels rejected and acts accordingly. Sometimes a seriously ill patient is told, "You have decided to consult X without informing me. I do not wish to have anything further to do with your medical care. Please go back to X".All our experts frowned upon such behaviour. White writes: "Under these circumstances, the doctor's behaviour would be considered patient-abandonment. I would consider it a breach of ethical standards on grounds of beneficence, non-maleficence, fidelity to patient, and respect for patient's autonomy. What would be the physician's reasons for wanting to do this? The relationship starts out unequally, with the doctor having more power. This is counterbalanced, in my opinion, by the greater responsibility of the doctor, who needs to put his needs and wants aside and honour what is both a contract and a covenant. This is a critical issue - the physician's failure to put the patient's needs ahead of his own".Colabawalla writes that the physician should "gracefully end the 'contract... in his own interest" if he feels that he has lost the patient's confidence"for whatever reason".Barot strongly feels that the primary physician must pass information about the patient to the consultant or whoever else the patient may have chosen to deal with on health matters. The underlying ethic is that the primary physician should provide all necessary information as it concerns the patient's health (potentially a question of life and death).Blasszauer agrees. "The primary physician should not shed his responsibility to the patient without clarifying his patient's motives", he writes."The physician should ... understand: he may have failed the patient; the patient may be out looking for hope, or proof that his doctor's diagnosis is right or that the recommended therapy is the only solution. If he cannot find the answer for his patient's motives, than he should sit down with the patient and have a frank discussion. If he sees that the patient had no ground whatsoever to abandon him, he may advise the patient to look for another physician, since without trust no such relationship could be beneficial. But until that moment, I believe, he does have some responsibility. The patient should not fall between two stools. The primary physician should be available till he — on acceptable grounds — terminates the relationship 'officially' . An insult to my vanity is not an acceptable ground."Gajendra Sinh concurs with the need for reform within the profession. "Unless we put our own house in order it is difficult to see how we can restore the doctor-patient relationship".Will a second opinion clinic work in India?In Australia, a group of consultants from different disciplines offer counsel on the clear understanding that they will not take over the patient's medical management. Would such a clinic work in India?"It is fairly common in the U.S., in this connection, for a patient to be referred to a second physician for a decision about, say, the desirability of hysterectomy", write Robin and McCauley." The ground rules here are that the consultant will not be involved in the surgery; is not affiliated with (preferably doesn't even know) the treating doctor; and is paid the same, whatever his opinion. As you may imagine, this system has its own flaws and a long essay could be written about the good and bad aspects of this practice".Several respondents fell that such a clinic has little chance of success. Chinappa holds that it could not work in "an unorganised health care facility like that in India. You need a high level of education in the patient and a high level of ethical and moral integrity in the medical profession for this system to work".Colabawalla adds that the idea is good, but "I doubt if it will ever be welcomed by most professional colleagues. There will always be the doubt that patients would be misappropriated". Also, most medical professionals in India think they are too good to be challenged thus.Udwadia agrees. "You require a general improvement in ethical standards for this to come about. When this does happen, specialist clinics for second opinions would be redundant."Bhanage expresses some hesitation: "It is virtually impossible to get a genuine second opinion in private practice where even the most senior doctors are very insecure and distrustful of their colleagues. A second opinion clinic will have to be manned by a senior doctor with a reputation for integrity."White sees a similar problem in the US. "Medicine here has rapidly become a market commodity (unfornately, in my opinion). A physicial income often depends on 'capturing market share' from other physicians. Thus physicians and hospitals engage in extensive marketing and advertising to 'steal' patients from others.""Can a member of the clinic reject the patient's request for treatment after he has attended the clinic?"Hemraj Chandalia feels that if a patient insists he be followed up by the new consultant, "I will not deny the patient such an option