A physician practising in a remote and resource constrained setting is frequently faced with clinical situations which fall in the grey zone at the fringe of her/his competence and comfort level. In such situations, most doctors choose to refer patients to next level of care citing the poor infrastructure, and absence of the needed workforce and lifesaving drugs at their primary health centre (PHC). Their argument is around patient safety, medico-legal consequences, and risk of community outburst if something goes wrong. Few also cite “evidence-based medicine” as a justification, missing the fact that “evidence-based medicine” is often “context void”. While doing so they often overlook the reality that the next facility is far away and the patient may deteriorate on the way, or that the patient may not have the resources to access care, or that family circumstances may make the referral difficult. Such a decision may turn out to be hazardous and may even sound the death knell for the patient.
Few physicians however follow a different path, by trying to manage the patient themselves to the extent possible. They either take an informed decision to treat the patient themselves, accepting the consequences; or they work to stabilise the patient first and then consider referral. These acts are what may be called as “clinical courage”, where one goes beyond the usual and enters into a previously unchartered area, to manage the patient in the best possible way.
There are many factors which influence the physician’s approach, such as the type of training received, previous work experience, professional role models, childhood experiences, and workplace environment. The last and extremely vital of these comprises of several domains such as administrative and clinical workload, support from their reporting officers, support for clinical guidance, and capacity of supporting staff. As an example, in India, a physician working at a PHC is entrusted with managing over 40 national health programs, the operations of the PHC and 5-6 sub centres, attending and conducting various trainings and meetings, and documentation and reporting, in addition to seeing patients at the PHC. The work culture is extremely bureaucratic and hierarchical, often focusing on a fault-finding approach rather than a problem solving one. In such scenarios it is very difficult for a doctor to adopt clinical courage in-spite of genuine interest.
In this piece we share our experiences from a PHC which serves remote tribal villages in southern Rajasthan, India. The facility is almost 50 km away from the nearest secondary care hospital where investigations such as ultrasound, X-rays, and facilities such as blood transfusion and caesarean section are available.
One evening, a 30-year-old woman Durga* reported at the PHC with complaints of excessive vaginal bleeding and falling blood pressure. Her husband worked at a city 400 km away and she alone took care of their four children. A month earlier she had taken medicines from a private pharmacy for inducing abortion and since then was having vaginal bleeding. We diagnosed her as incomplete abortion with severe anaemia (haemoglobin – 6.1). In this situation, the guidelines clearly recommend referral to a secondary care facility, due to the risk of worsening of anaemia or of developing shock. However, Durga and her family were reluctant to go on account of the expected cost of care, distance, and responsibilities towards her children and the farm. For us, there was clearly a moral dilemma in referring her to the next level. What if we just referred her and she went home, or to another general practitioner, or even to a quack and left things to her fate? What if we decided to manage her at the PHC and she deteriorates further and how shall we handle the outburst of the family and the community? We consulted our senior colleagues and decided to stabilize her first and then consider the need for a referral. The PHC had the required medications (intravenous fluids and uterotonics) and these were promptly started. Slowly her bleeding reduced and almost stopped and by the next day, she was stable enough to return home. While trying to stabilize her we could almost completely manage her condition.
A few months earlier, an 18 months old child Ramila* was brought to us with severe acute malnutrition (SAM) and severe pneumonia. Her father too was a migrant, working in a place over 300 kms away. On account of increased risk for mortality, SAM and severe pneumonia in children are both criteria for hospital admission under a pediatrician. However Ramila’s mother was reluctant to go, on account of her father being away. While the PHC had oxygen, injectable antibiotics and nebulisation, it lacked a paediatrician and ventilatory support. Since sending her home would have certainly predicted an adverse outcome, we decided to manage her in the best possible way at the PHC, under the guidance of a paediatrician on call. Within a few hours her distress was much relieved and in a couple of days, Ramila had improved significantly. Her mother continued to seek care for several weeks till Ramila recovered from severe malnutrition.
These stories give a glimpse of the situation in remote communities in southern Rajasthan as well as several other regions in the country. Almost 70% of the households have at least one male member migrating to far-off areas for work. There is a huge burden of malnutrition and morbidities on the one hand, and reluctance and fear in visiting city hospitals on the other. In such situations, acts of clinical courage can change the outcomes from near-miss or even death, to survival. This also significantly reduces disruption or financial burden for the family. For a healthcare team, there can be no bigger boost than saving a life, and the opportunity bolsters their own confidence and team spirit. Last but not the least, it restores the community’s faith in the primary health care system who stops seeing it just as a gate keeping mechanism but sees it as one which refers only those who really need an admission and itself treats all that is possible.
*Note: Names changed for anonymity.
Authors: Shyamsundar Raithatha (MBBS, MD) and Sanjana Brahmawar Mohan (MBBS, MD)
Shyamsundar is a community physician from Gujarat, India with interest in primary health care. He is currently on a gap year to understand health issues and primary health care delivery in rural India.
Sanjana is a paediatrician and a public health professional by training. She is a co-founder of a not-for-profit organisation – Basic Healthcare Services which aims to provide quality primary health care in some of the most remote locations of southern Rajasthan, India.
Competing interests: None
Handling Editor: Neha Faruqui