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In simple terms, a catastrophic health expenditure is a healthcare-related bill that exceeds your capacity to pay. It often involves the encashment of savings and assets, including, at times, homes and businesses. It can impoverish and devastate families for many years.

Medicine is magical…(Paul Simon): Modern medicine is a great example of Arthur Clarke’s statement: “Any sufficiently advanced technology is indistinguishable from magic.” This magic show comes at a price. Formerly fatal illnesses can be salvaged by the ability to sustain and prolong life functions with machines, often well past the likelihood of meaningful quality of life after discharge.

Here’s the bill: In India, treatment in a fully-equipped Intensive Care Unit (ICU) with all life-support measures can cost a lakh or two rupees per day. Most ICU stays will last for a week to 10 days, some even more. So, do the math. In developed economies, the figures are equally high with proportional adjustments for living standards.

OOPs (out-of-pocket) expenditure: India has the world’s highest out-of-pocket (OOP) expenditure on health care – a stupendous 60% as opposed to the global average of about 15%. Here’s a graphic comparison.

Catastrophic health expenditure hits us Indians harder than any other society. It is estimated that catastrophic health expenditure impoverishes 3.3% of Indians every year.

• It’s one of the leading causes of families being driven below the poverty line.

The need of the moment: More than any other, this devastating economic event makes a strong case for Universal Health Coverage (UHC) programmes. In advanced societies, particularly the United Kingdom and Western Europe, the existence of cradle-to-grave social welfare programmes buffers individuals from the cost.

The price of exit: It’s also worth pointing out that catastrophic health expenditure will usually occur in the last year or two of a person’s lifetime, contributing in no small way to the dissatisfaction with the spending. All this, only to see them die…?

Reference: Prevalence of catastrophic health expenditure and its associated factors, due to out-of-pocket health care expenses among households with and without chronic illness in Bangalore, India: a longitudinal study

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No, it’s not just in the movies; it’s real. The person facing you has been deemed to have a poor chance of surviving for any meaningful period of time. A typical example would be one where an advanced stage of cancer has been diagnosed. It’s likely that the person has only a few weeks or months left in their lives based on data and statistics of good quality.

Going beyond: I am going to venture beyond the limits of this question. There are many major elements of terminal illness that are important. In my practice, this situation is possibly the hardest encounter I have had with patients and their families.

Be truthful, be gentle: The most important thing to do in this situation is to be truthful without being blunt; a lot of gentleness and empathy are needed.

• Never deny hope, never give hard numbers and data; I prefer to speak in general terms.
• Hiding information from a patient out of a mistaken intention of being kind actually does them a disservice. There are personal agendas and activities that may need to be fulfilled. The person should be given a chance to go after them.

Pain: An important question that always arises is the prospect of pain in the final days. There are strategies available that can keep them comfortable while maintaining clarity of mind. This has to be handled with confidence.

Home, not alone: I also advocate that the last few days be spent at home, in familiar surroundings, rather than in a hospital, cut off from family and close friends.

DNR: A “do not resuscitate” decision, once taken by the patient, has to be announced to the care givers. The issues at hand have to be clearly discussed ahead of time.

“Lies, damn lies, and statistics”: There is one important reason why I stay away from giving hard numbers. There is always a patient or two who goes well beyond the expected time frames and survives for much longer periods than predicted. The human body-mind is a mystery we cannot fathom.

Must read this: In conclusion, I would recommend reading a superb article on terminal illness written by the well-known evolutionary biologist, the late Stephen Jay Gould — objective and hopeful. The median isn’t the message

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This is a very important question that you are asking.

The stock answer from any young person who is asked “Why Medicine?” is that they would like to relieve pain and suffering in people. Anything else sounds awkward, even if sincere. If the truth be told, the major attraction is the good standard of living that medical practise gives to its practitioners.

At the age of 18 or so, when you make this career choice, it’s virtually impossible for you to feel the emotions that Medicine can wring from you. As you get into the practice, the demands can get quite overwhelming. One of two things happens:

• Most often, you numb yourself and keep going, hating yourself for the inability to appropriately respond to the emotional needs of patients—often their only real need.
• Or, you can’t handle it any more and drop out of Medicine, or go into a sub specialty where you don’t have to deal directly with people.
• To be fair, there are any number of doctors who genuinely care for their patients and go the distance for them. The trick is to feel the emotion but not get swallowed up by it. True empathy is a verb—action, not a noun—emotion.

The way we select young people for a career in Medicine makes no attempt to assess this emotional competence. The sole criterion is the ability to score highly on an absurdly difficult entrance exam. Little surprise then that the public sees doctors as cold-hearted, money grabbers.

Here’s my advice to any young person considering Medicine as a career.

• If you think that a lifetime of listening to and watching people in pain and suffering is likely to be too much, then do something else with your life.
• If you have the ability to feel other’s pain, and, without letting it get you down, do everything to help them, then that’s all you need for a medical career. Keep with it and you will be a terrific doctor.

Absolutely not. Offering a patient the option of a second opinion is one of the major tenets of ethical medical practice. A patient always retains the right to seek confirmation or rebuttal of the diagnosis or treatment offered by the primary doctor when there is lack of confidence, for whatever reason.

Any doctor who is secure in their own reasoning and judgment should not feel threatened or insulted by the request. It’s equally important that the second doctor treat the request with due respect and not belittle the first decision or portray the primary doctor as ignorant or inferior.

If the second opinion concurs with the first, ethics demands that the patient is firmly encouraged to return to the first doctor for further management. The patient; however, retains the right to stay with whoever they feel is in their best interest.

• A study of almost 6800 patients reported in 2015 showed patient-initiated second opinions led to recommended changes in diagnosis for about 15% and in treatment for about 37% of participants. The larger number of treatment differences is not surprising; a substantial amount of disagreement exists in treatment choices for common conditions. Close to 95% of patients reported they were satisfied with the experience.

Confidence in the skills and integrity of your doctor is the foundation stone for success in treating patients. Lack of trust, triggers the “nocebo” effect. The patient expects harm and, much like in the placebo effect, enhances chances of an unfavourable outcome when there is a lack of perfect trust in the doctor.

This is a very complex question. Here’s how I would address it.

From a purely statistical standpoint, the risk of any procedure (intervention) needs two essential inputs:

1. A comprehensive list of all the things that can go wrong. At least to some extent, such lists are available. The only, truly unacceptable risk is that of dying (mortality). All else is relative and a matter of perspective and expectations.
2. A hard look at data for every procedure and the creation of a 4-way table: Exposure vs. non-exposure; outcome present vs. absent. This will allow us to establish odds/ risk ratios. An objective number can then be used to gauge the likelihood of any outcome from surgery. These statistics are available (though hotly debated) for many common surgical procedures. Examples include: wound infection, deep vein thrombosis, urinary infection, pneumonia, and so on.
   1. The moment you start hitting patients with these numbers, most often their eyes will glaze over and you will lose them. Most patients don’t want “just the facts.” You do have to discuss them, but in general, practical, down-to-earth terms and language.

• Enter, comorbidities: Fine and dandy, but these numbers are muddied by co-existing diseases that can alter (usually adversely) established risk; common examples are heart disease, high blood pressure, diabetes, obesity, age, previous illness, and so on. To make it worse, a combination of comorbidities is not merely additive in terms of risk; they multiply risk.

So, you get the picture? Even experienced surgeons can rarely explain the risks of surgical procedures completely. Knowing that surgeons, as a breed, are poor communicators, you can “do the math”.

Here’s my take.

Leaving risk aside and looking at outcomes—what the patient really needs—I would look at the issue from two standpoints.

1. Will the operation completely or significantly improve the problem at hand?
2. To what extent will you be able to go back to all that you did (activities of daily living-ADL) before the surgery? Be wary of unrealistic promises (Doc, can I play the violin after my surgery? Sure! Terrific, I couldn’t earlier.)

Remember: Risk is only a proportion, a probability at best, not a guarantee. Adverse outcomes, as far as the patient in concerned, either happen or don’t: 0 or 100%.

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