 the doctor-patient relationship has evolved from being a doctor-centric, paternalistic model of care to a more participatory method in which the patients and their families' choices and priorities are actively taken into account. Here, the role of a doctor extends beyond just treatment. Not only is the doctor expected to work in the best interests of the patients, he or she is also expected to help them and their families make informed choices, especially in the cases of medical emergencies. Take, for example, the case of Sunita. Her husband is in need of a kidney transplant after extreme hypertension led to both his kidneys getting damaged. Sunita's tests have revealed that she's a potential donor. While a sister-in-law is trying to convince her to donate, Sunita is apprehensive because of the risks involved. Dr. Vishwanath, nephrologist at Manipal hospitals in Bengaluru, is equally concerned about his patient, but also has the added responsibility to arrive at a resolution which will be in the best interest of the family. We have offered them transplant, which is the best option. So the minute we tell transplant, then the issue comes as a donor. So we have told them you search among yourselves because you have to have a related donor. It's a very sensitive issue. You can't force somebody to donate. So as I said, obviously it should be a voluntary donation. Donor is very important, of utmost importance, because donor is the healthy person who is going for a major surgery. He doesn't need the surgery, but he's going for it for somebody else. So for us, donors should be always safeguarded. A doctor's role as a counselor is further accentuated in situations of the critically ill. Many a time, as a patient's condition worsens, the family too feels the burden of supporting an expensive life support system, like in the case of Karan, a liver failure patient who has been on life support for five weeks and still is not showing any sign of recovery. Karan's parents come from a far-flung district of Karnataka and they're running out of money and resources to support his treatment. There's somebody in the ICU who comes in very sick, very critically ill and may require ICU with a lot of support for a long period of time and do have some resource crunch and financial problems. One of the ways by how our institute tries to tackle this problem is by trying to help them as best as we can. So we have a social works department which takes care of some of these patients. So we refer them to this department who make a thorough check of what is their socioeconomic status and based on that they try to help them out as well. There are two ways. The management helps in quite a bit by giving a lot of discounts in whatever is possible and also we try to contact philanthropists and other organizations which may try to help these patients and patients' families. Hello and a very warm welcome to this special episode of Manipal Hospitals presents Changing Face of Medicine. So how do you judge the success of a service industry? Only by how happy and satisfied the customers are, right? In the medical profession, the satisfaction of the customer is even more pertinent and important simply because the patient depends completely on the doctor to save his life or ease his pain. And this means that those in the medical fraternity and profession carry a huge responsibility. The doctor doesn't just have the patient to worry about. He has to take care of their family as well. He has to ensure they make informed decisions and help them deal with the stress of seeing a dear one in distress. A doctor has to make sure everyone involved with the situation is thinking right and making the right choices. On this special of Manipal Hospitals presents Changing Face of Medicine. Let us look at some of the most sensitive and challenging issues that the medical fraternity is faced with today when it comes to patient management. Let me start by introducing you to my esteemed panel from Manipal Hospital. Dr. Sunil Karanth, Chairman Critical Care Services, ICU physician, Manipal Hospital Bangalore. Dr. Vishwanath S, HOD and Consultant Department of Nephrology, Manipal Hospital Bangalore. Professor Dr. S V Joga Rao, Medical Legal Expert. Let me start with you Dr. Vishwanath. In the first case study that we had a look in the audio visual there was a patient who needed a kidney transplant. There was a challenging situation here. How can a situation of conflict in this case be avoided? As long as kidney donation is concerned there should be no forceful donation. Anybody willing to donate it should be a completely voluntary donation. There should not be any coercion. There should not be any undue influence. Whenever they are not comfortable in donating kidney or if they have their own apprehensions and it is not a completely voluntary donation what we do is we tell the family or whoever is forcing them that she may not be ideal person to donate and she may not be mentally fit to donate. In this way we avoid conflict in the family so that they do not have any problems in their future life. Dr. Rao, it obviously is a critical situation from the point of view of the legal aspect and also from the human point of view. What do you say the law says about this and what are the rights of the donor? Relevant legislation in this respect is transplantation of human organs at 1994 amended very recently in the year 2011. As per this legislation the rights of the donors have been very clearly laid out. The first and foremost is under no circumstances commercial dealing is allowed. Number two, the person who is willing to donate must voluntarily, volitionally agree for the same. Insofar as the donor and recipient is concerned the act very clearly brings out two important categories that is related donor and unrelated donor and law defines related donor as a particular manner. If the donor and recipient's relationship falls under this particular definition then there is a procedure, accordingly the relevant documentation will be reviewed and if the committee is satisfied with the authenticity of the information the approval will be granted. If it is unrelated donor, please remember the same file must be produced before either hospital based authorization committee or state authorization committee and after due review appropriate approval will be granted. Dr. Karanta have a series of questions for you. How important is the need of proper counselling of the patient and the family when they come to you? See counselling is an important part of managing a critical ill patient. Managing the patient and his requirements in terms of the multiple supports and the critical nature of his illness is one aspect of care but certainly managing the needs of the family and being empathetic and accommodating the emotions of the family is an equally essential part of our process of managing the patient because there is a lot of turmoil which is going through them so being empathetic and spending enough time to make them understand what the process of the disease is and also what are the implications of the future in terms of the recovery of the patient the end outcome and also what are the likely long term effects of this is also very essential part of the counselling process. What are the protocols when a critically ill patient is brought to your ICU? See when we talk about somebody who is critically ill ideally the treatment should start at on-site. In India of course that scenario is still not very well developed so we would say that the treatment starts at the pre-hospital level and once the patient reaches our emergency department there is a set pattern and protocol for most common diseases and there is something what we call as pattern recognition because many a time we are unable to identify or to get to the depths of the history and the background of the medical problems that the patient has got. So we would go more by the first line of what the pattern of the disease has been so if it's a trauma we know what is the protocol to go by if there is somebody who has come with a bad infection or a heart attack or a stroke so these are all things which can be picked up early on and we go treating these patients in a set particular pattern and as the patient gets wheeled in the ICU is notified and the ICU team gets involved in tandem with the emergency department and from then on we take on the care and ensure that the patient reaches the intensive care unit. Let us slip into a short break here but when we come back let us look at how more sensitivity and compassion can be brought into medical practices and how the sector can be overall made more organized and transparent. Stay with us. Welcome back you are watching Manipal Hospitals presents changing phase of medicine where topic of discussion is sensitive patient management and transparency in operations. We were talking about affordability and funding and now we are talking about spending of a different kind. Dr. Vishwanath my question to you is a lot is said these days about hospitals and doctors over recommending tests and surgeries in this scenario how does hospitals ensure patient interest versus commercial interest. Coming to the basic of this question patient interest always takes precedence so patients are of utmost importance. Whenever we order tests as accolations we may do it all together all tests depending on the criticality of situation or we may do it serially depending on what we find. Suppose we do basic test we find something abnormal we go to the next level. Definitely as long as there is no personal benefit or any incentive from the hospital to the doctor this practice can be curbed. That is my personal opinion. But Dr. Karan the intensive care unit is a different ball game all together and their tests are mandatory. How do you draw the line? We would be a little more liberal I would say in ordering tests when we are talking about somebody who is very, very ill because the priority there is to optimize things and there is another important thing we should remember when we are talking when somebody who is critically ill is start the therapy early and to get that we need the diagnosis early. Obviously Dr. Rao these are doctors talking from the point of view where the management practices are in order. But that doesn't seem to be the case in general. How do the legal system come forth in this case? To me the foundational and core ethical principle of medical practice is legitimacy in whatever the doctor does there must be a legitimacy in terms of justification and rationalization. The incidents what you have mentioned they lack the rationalization. I refer a patient to a particular scan because I get a cut of 10 percent or 25 percent etc. I think this is something unethical it cannot be allowed in any systemized principle. But what we notice in terms of popular practice I think is something cannot be denied I am sure you must be knowing this incident recently in Balbay I think in Maharashtra one particular doctor received some checks from a particular diagnostic lab stating that so many patients you have sent to them for us for tests this is the kind of incentive. In fact the doctor has not sent any of his patients to the lab you know what he has done the doctor the doctor filed a complaint against the diagnostic lab before Maharashtra Medical Council stating this cannot be allowed. I think that is something which we need to take. Dr. Karanth moving on how can the privacy of the patient be protected and are there any systems in place where you are at. See privacy and confidentiality is a fundamental right of the patient. The very faith of a doctor patient relationship lies on the fact that there is a lot of autonomy that the patient gives us because they trust us and there are two aspects to that called autonomy and fidelity which they trust us with. Most importantly we do not disclose most of the patient information to somebody who is unknown. I think the only persons who would be given access to patients records other than the healthcare providers in Manipal hospital would be the patient himself if they are competent and conscious enough to do that and the patients next of kin whom the patient would consider would be allowed to know the information. But in this context I would also like to say that this is not absolute the so-called confidentiality may not be absolute because there are certain instances like somebody for example could be positive for HIV for instance. In that scenario the greater risk to the partner or the third person or the public health will come into the picture. Now there is clear cut guidelines by NACCO and other governmental organizations which say that just quoting a specific example for HIV for example the first attempt will be to convince the patient and to persuade him to actually avoid what is called as high risk behavior and to inform his partner or the liable person or the person who is likely to get the disease. If that doesn't work we go to the next level where we notify the authorities which would be the local hospital authorities to help us with persuading and counseling him to do that and in the last step if that doesn't work it will be our ethical obligation to tell the third person who is likely to develop the disease. So in that scenario I think the confidentiality will be bridged to protect the high risk person who will be there with the patient. Doctor Rao as we wrap I would want to put a question to you on accountability that hospital management should have towards its patients and people coming to the hospital and also how a transparent system can be put into place. I think the contextual challenge for a hospital in terms of this particular issue is very clear. Health care delivery can only be carried through professional medical doctors. Therefore hospitals must put in place very stringent credentialing systems whereby any kind of fake degree any kind of forged documentation etc is absolutely to be allowed at the threshold level so that patient interest is not compromised. Secondly the most important I think this is something in terms of law hospital must take note whoever is the doctor who is responsible for treating the patient must have a valid proper medical registration either with the medical council of India or the concerned state medical council. Thirdly this is something in Manipal we very religiously follow continuing medical legal education we conduct. We inform consultants in the light of our own experiences these are the shortcomings these are the limitations these are the deficiencies this is what you need to take note of etc. I think in the process of educating we see a positive change in terms of inculcating a culture whereby the patient interest is given deserved priority. Similarly off late we noticed it is not only professional doctors even nursing staff also requires education because nursing care is a part of overall medical care. And by eluding to these steps I think institutions will be able to take very positive steps to prevent that kind of things. On that note it's a wrap on our special show Manipal hospitals presents changing face of medicine I thank you all for giving us your valuable time and all the best in maintaining the standards that you have set for yourself thanks for watching.