Friday, October 23, 2009

Guidelines and Ethics in the Developing Countries!!

Doctor Doctor!!
Originally uploaded by Littman

For doctors in the developing world, have a look on this article:

Use of a simple, cheap intervention (MedPage Today) -- aldosterone antagonist therapy -- in patients with moderate to severe heart failure is the exception rather than the rule, despite ample evidence of its value, researchers said.
Despite being cheap there, they are investigating why guidelines are not applied.

If we asked the same question in the developing world, what we will say?

From the recent history, the recommendations of Beta blockers in heart failure. It is still under used in Egypt. I remember, even till now, some doctors hesitate while prescribing beta blockers in heart failure. I am speaking about my experience in a developing countries. Some does not know the strategy of adding beta blockers. They add large dose in inappropriate NYHA class. Then, patients deteriorate. Theere is lack the knowledge and experience among physicians. The same regards the use of statins in IHD but due to economics mainly. Also, the changes of guidelines in both CPR and Prophylaxis against infective guidelines were not well followed. Mostly due to worldwide controversy to both and lack of some awareness
of the details is a factor.

Why the guidelines are not applied well in developing countries?

1. Economics.
2. Patient awareness and compliance.
3. Doctor knowledge, motivation,.....and ETHICS.

PATIENT compliance is a combined responsibility between patient, family -especially if child or handicapped-, doctor convincing him,...
• Sometimes ECONOMICS control especially in expensive, unavailable medications, or procedures.
• The worst is DOCTOR factors: knowledge, awareness, and motivation....and ETHICS.
• Should doctor does not updating his knowledge and CME, he will not be up to date regarding practice and applying the guidelines. He may be behind the best treatment modalities. He is not honest regarding his oath of offering best care for his patients.

Usually, we throw everything over the financial factors and nothing else.

Especially in the developing world. The is not always the case. Why? How?

Here is an example:

Last month, I had seen three patients with heart block, one patient with Recurrent WCT, and an adolescent with large VSD.
According to the true clinical situation and investigations of these patient, they are in need for some operations, interventional procedures, strong expensive anti-failure medications,.....etc.
Among none of them, the guidelines were followed. The most dramatic is some doctors are telling that patient is not in a need of procedure –which is highly indicated according to guidelines class I- because doctors are busy or do not have the facilities at time. They were not honest during their discussion with patients and other treating doctors. So, they caught up the patients from obtaining the correct timed management according to guidelines. The adolescent patient MIGHT BE told about the importance of early correction before development of Eisenmenger syndrome. Now, they are still investigating the PVR and his feasibility of surgery or no. Economics, patient and family compliance played a rule.

Other female patient with impending VT and recurrent SVT. Patient has baseline LBBB, and sent for EPS. Junior doctors took the decision according to the general rule (sliding the case!), not the guidelines. They told the patient that (not indicated for any EPS now). The patient was aware about receiving DC and increase in the frequency of SVT. She asked second opinion in other University hospital. Of course, she was candidate for EPS and RFA. Three patients with CHB. Two died. One because no facility (CEONOMICS!). Other, because no honors. Third, still waiting. The factors are multiple. The death is one!

There are many other examples.....sorry for details. I will not say these doctors are dishonest with their patients as they may be ignorant doctors. If they are ignorant, they are dishonest with their oath of being up to date. No ETHICS.

To finalize, Economics sometimes control the application of guidelines. Patient have a rule. However, Honors, ethics, and awareness of doctors,..come first. These ETHICS are either inherited or gained, but NOT BOUGHT any were. I think we have to do something for the nurture of doctors. Just a thought.

doctor, patient, guidelines, economics, compliance, honors, ethics, developing world, developed countries, Egypt.

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