Doctor shopping

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This young monk is not a patient and this blog does not refer to him.

The patient rummaged around in her shoulder bag and pulled out a handful of small polythene sachets containing medication.

“Where did you get these?” I asked.

“This one’s from the hospital at Mae Sot. Those are from Phopphra Hospital. And that one is from a clinic in Burma. All these are from a private clinic,” she replied.

“Why did you go to all these places?” I admit, I am a curious about what makes my patients “tick”. Nosey, you might say.

She stared at me with a look of incredulity on her face. “Because I wasn’t getter better, of course!”

Now being a GP, I am convinced of the benefits of continuity of care. See the same doctor each time and your history is recorded in the same set of medical records, along with the results of investigations. This is the stuff of good medical care. But what happens if you don’t get better, or you lose confidence in your doctor, or they don’t give you what you feel is the correct treatment? In UK, you might switch practices, or go to an out-of-hours centre or to the Accident & Emergency Department to see a “proper hospital doctor”.

So I shouldn’t really be surprised by my patient’s “doctor shopping” behaviour. But what struck me was the variety of choice on offer, and her persistence in travelling up to fifty kilometres for another medical opinion. She was anxious because she’d been coughing up blood. For over four years. She had had three chest X-rays, five sets of sputum examined for tuberculosis, all of which were negative.

“How much did all this cost you?” I asked.

“All my spare cash. Sometimes I couldn’t afford to buy all the medicines I was prescribed. Private doctors are expensive, but you can see them quickly, you don’t need to wait for a long time in a queue. I’ve got my work to think of. I can’t just take days off anytime I want.

“Sometimes, I will get some advice from the person selling medicines in a shop. Or someone I know who has the same symptoms as me will tell me what he’s taking. I might buy medication from him. Earlier this year, I bought ten injections of streptomycin from him. He’s been taking it for three years. I couldn’t afford any more, so I stopped.

“Some people take traditional medicine, but that hasn’t worked for me. It is cheaper than going to the doctor.”

I found this health seeking behaviour fascinating, even though it was “queering the pitch”, making it very difficult to analyse what was going on clinically. She was balancing out the costs and benefits of different medical settings. “So you finally came to our clinic because you heard about our good reputation?”

“No. Your clinic is free. I don’t have to pay for medication, either. The trouble is, it is always so busy, I have to wait a long time before I get seen.”

We provide free care, at the point of access, just like the NHS, for people who don’t have the right or the cash to access the Thai health services. Five years ago, the vast majority of patients coming to the border clinics had malaria, or fever caused by another infection, such as dengue, typhus, typhoid, leptospirosis or respiratory viruses. Now we are seeing increasing numbers of patients with long term conditions, such as diabetes and hypertension. I suppose this is inevitable.

Public health doctors call this phenomenon “epidemiological transition”. There is less infectious disease, which gets treated quickly, and more disease associated with economic development, related to obesity, smoking, abuse of alcohol and less active lifestyles, which are chronic problems. My advice is, “Shop around for the medical care that suits you, by all means, but if you have a long term illness, stick with one doctor/clinic.”

But I would say that, wouldn’t I? I’m a GP.

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