WHEN you go to a doctor with a health problem, he or she asks some questions, examines you, orders tests, and on the basis of the test results starts therapy and prescribes medicines.

How does he (since most of our professions are still male) decide which tests to have and which treatment to recommend? What is going on in his mind while he is doing all this, and is he always correct? The evidence indicates that a medical practitioner in the United States, even with that country’s vaunted training and costly hi-tech support systems, is wrong at least 15 per cent of the time. God alone knows how often we are wrong in Nepal.

There are a large number of examples, perhaps too many. A lady with stomach symptoms and weight loss found after many years and a large number of physician encounters to have celiac disease (an allergy to a substance called gluten in wheat flour), the fit man who had a heart attack missed because it did not show up on the standard tests, a self-confessed crazy woman with a hormone-secreting tumour which made her blood pressure shoot up every time she got excited, and a host of others - aortic aneurysms, diabetic coma, ectopic pregnancy and aspirin poisoning. Why were the mistakes made?

Most often they were because the doctor was not listening and repeatedly interrupting the patient’s narrative (on an average every 12 seconds) in his hurry to see the next customer and make more money. The doctor thus jumps to the most obvious diagnosis that comes immediately to mind, that is available, without pausing to consider any other. One thing leads to another and the patient is dissatisfied, unrelieved of his/her symptoms or, at worst, dies. The old style mentoring, whereby juniors were apprentices of skilled and experienced medical craftsmen, is gone.

Our social structure is also a factor because it is so different from the rest of the world as the doctor hardly gets to listen to the patient’s history without interruption. The poor patient, especially a woman, is usually not allowed to get in a word edgeways because her husband, mother-in-law, sisters-in-law and numerous children each want to take over centre-stage and relate the symptoms on the patient’s behalf and then start arguing about the details.

The traditional diagnostic giants start assessing the patient the moment he walks through the door, much before he starts speaking. Now the new generation of doctors considers that so-called science overrides all else and unthinkingly follows a set of guidelines and algorithms and flow charts which are evidence-based (the current buzzword), forgetting that all these were constructed from data obtained from averaging large populations of patients and not always relevant to the poor, frightened individual sitting opposite.

Also a doctor might be influenced by factors which should really be extraneous to his relationship with a patient. He may be depressed, pressured by diagnostic laboratories and pharmaceutical companies or even dispensing chemists to order unnecessary tests and treatment or even have a negative attitude to a patient who is fat, talkative, aggressive or even sadly, unlikely to be able to afford his fees, though compassion is a doctor’s most important virtue (the secret of the care of a patient is caring for the patient).

Should we really be so upset if we miss complex diagnoses because if you hear hoof beats, think horses not zebras. Common things commonly occur, and in Nepal, this seems to be even more true than in any other part of the world.

There are completely different thinking problems that doctors in Nepal are faced with every day, other than making fancy diagnoses. Should we order expensive MRIs and CTs to be super accurate or should we advise treatment on the basis of strong probabilities knowing that we might be wrong in some cases?

Should we offer the same treatment to the rich and poor? Most of the doctors modify the patient management depending on whether he is rich, lives in a city and is able to access costly healthcare, or whether he comes from a small village in east or west of Nepal when he probably recommends a one-time procedure like an operation rather than prolonged treatment with expensive medicines.