Poor Diagnostic Care At St. Louis Hospital

[TallGuyJohninBKK]

In the years I've lived in Thailand, I've always wanted to be an advocate for St. Louis Hospital... a reasonably priced, private hospital, religious affiliation, not part of a corporate chain, etc etc.. Plus various reports from members here of good care there.

Unfortunately, in the past few months, I've have two very clear (at least to me) episodes of poor/bad diagnostics by doctors at St. Louis -- one involving myself and the other involving my wife -- that pretty much have put me off of going there for care or being willing to rely on the expertise of their doctors.

In the first episode, my wife had suddenly come down with ongoing and pretty bad pain in her lower back/kidney area...without having had any history of problems there and without any physical injury or exertion that might have caused such pain. She also was having corresponding changes/problems with her urination.

So one day, we went to St. Louis and wanted to see a specialist, but none was available/on duty that day. So rather than coming back again the following day, we agreed to see a general doctor in their general walk-in outpatient clinic. My wife went in to see the female doctor, and after explaining the pain and symptoms, the doctor there did a urinalysis that produced a negative result and then ultimately suggested that my wife take muscle relaxant medications for her pain.

Not satisfied with that result, we ended up later that day being able to see a different specialist at St. Louis, and then later a specialist at Ramathibodi, and they all treated/diagnosed my wife as having some kind of kidney stone or obstruction, and prescribed medication accordingly ...though the subsequent IVP testing done several weeks later didn't show any obstruction, and the pain eventually disappeared.

In the second episode, I woke up one day feeling very bad and beginning to have sores on my hands. I knew a dermatologist at St. Louis that I had seen before, so went to see that doctor. I showed him my hands and told him I also was feeling really bad/fatigued and had a sore throat. He didn't pay much attention to those symptoms and gave me a diagnosis based solely on a visual exam of dyshidrosis, which is a kind of severe eczema.

I'd never heard that term before, so when I got home, I read up on it, and found nothing that would account for the other symptoms I had including a sore throat and severe fatigue. So I ended up going to see an ENT doctor I trust at BNH Hospital, recounted everything again, and he sent me to a different BNH doctor for several different kinds of blood tests, that confirmed I in fact had a kind of enterovirus that produces the same kind of skin symptoms, as well as sore throat and fatigue among its common symptoms.

Clearly, there is an element of art (along with science) to diagnostics in medicine. And even the best doctors sometimes will diagnose wrong. But in the case of St. Louis, the doctor prescribing back muscle relaxants for my wife when broader indications suggested a kidney issue, or my St. Louis doctor pretty much ignoring the sore throat and fatigue symptoms I explained to him and then the subsequent blood work at BHN showing an entirely different diagnosis, give me considerable cause for doubt about the quality of diagnostics at St. Louis.

Edited February 20, 2013 by TallGuyJohninBKK

[Sheryl]

I have said it many times and will say it again: there is no such thing as a hospital where all the doctors are good (though there may be some where none are), and you must carefully choose your doctor, you cannot rely on the fact that someone works in a particular hospital to guarantee that they will be capable. That goes for ALL the hospitals.

I have observed some really excellent care from a large number of (carefully selected) docs at ST Louis, but also run into some substandard care, usually from doing exactly what you describe i.e. seeing someone other than desired for reasons of convenience/scheduling.

Changing hospitals isn't going to solve this problem, I'm afraid. Wherever you go you will need to carefully select and there will be some around you'll want to avoid.

And, as you have done, always seek another opinion if the diagnosis and/or treatment given do not make sense to you or your gut sense is that something important was missed. There is another thread running right now that attests to this; not one but several docs missed a fracture that could have resulted in long term functional impairment. A couple years ago there was a TV member whose wife was diagnosed with tension headaches but actually had a brain tumor -- missed despite having taken the trouble to consult a neurologist. Luckily in neither fo these cases did the patients passively accept the word of their doctors; both persisted and got other opinions which led to the right diagnosis, just as you did. Neither of these occurred at St Louis, BTW.

It would however be worthwhile for you to send a letter or email to the doctors involved with a copy to the Medical Director at St Louis describing (in calm factual terms) the mistakes made. It may help the next patient. Nobody is going to take any sort of disciplinary action but the doctors involved may learn something, and doctors become better doctors when they learn from their mistakes.

[TallGuyJohninBKK]

Thanks for the thoughtful and well-put post, Sheryl....

I don't doubt what you say is true. However, the challenge for all of us is finding some practical means of identifying doctors who have a good reputation for quality care vs. those that don't.

That's particularly difficult in this era of increased medical specialization. It's no longer enough to just be able to identify a good GP. Nowadays especially in Thailand, depending on a person's symptoms, you might need to be looking for a doc in any one of a dozen or so different medical specializations. And doing so perhaps under difficult (illness) conditions where you don't have the luxury of taking the time to do a lot of research.

And then, in addition, there's the difficulty of different people having very different opinions/experiences and expectations. Just from reading here through the years, someplace that's a great dental clinic for one member, for example, is a terrible place for another member. Or a good doctor for one member is the opposite for another...

So it becomes very difficult to make sense out of things or to find any reliable basis for identifying good doctors, except through a lot of personal trial and experience. And fortunately or unfortunately, most of us don't get repeatedly sick with the same ailment and have the need to visit 3 or 4 or 5 doctors for the same malady over time and then have some basis for comparing/knowing who seems to be on the ball.

It's a real challenge...

[Sheryl]

Well that is one of the main things people use this forum for, to get doctor recommendations.

You can also tell a fair amount through the biodatas that many hospitals, including St Louis, post online.

Look for someone with training and preferrably board certif in a western country. That will not only assure a high level of competence (it is no mean feat to get that if you are a non native speaker) but also excellent English and usually an understanding of the expectations of western patients re explanations and involvement in decision making.

A faculty position is also a + sign

On the website www.mythaidoctors.com you can review CVs from pretty much all the Bkk hospitals that offer them, by specialty, which can save time. Not always up to date and not the easiest site to navigate sometimes but still helpful all in all.

Another excellent indication is having published professionally in a peer reviewed journal, this you can get at through a search engine. Not much help for GPs/internists, but very helpful for specialists.

I would like to add that there is also a cultural dimension to what you expereinced, related to loss of face and also "krieng jai". As I read your story the fundamental problem was that in one instance you needed but did not have a specialist and in the other instance had the wrong type of specialist for the problem. In both cases what should have happened is the doctors should have acknowledged that the problem was outsiode their realm of expertise and referred you to someone else. but Thai doctors often feel that doing this will (1) cause them to lose serious face and (2) anger/upset the patient, and being "krieng jai" means never telling people things they may not like to hear (even if doing so helps them in the long run). So, they tried to come up with some sort of treatment, either hoping it would somehow work or that you would later, on your own, go elsehwere and i ngeneral that the uncomfortable probkem would just go away.

Sorry to say this but this is extermely typical of any situation in Thailand where the person you are dealing with cannot do what you need, and doctors are no exception. (I'm afraid "mai ben rai" also sometimes influences medical practice, but we won't go into that here!).

Doctors trained/socialized in the West are much, much less likely to be this way. For one thing, they understand that in the eyes of a western patient, they will not lose face but rather be respected for being up front about their limitations. And they have been inculcated in a medical tradition where it is not only normal to refer patients elsewhere, it is considered remiss not to when indicated.

[TallGuyJohninBKK]

As I read your story the fundamental problem was that in one instance you needed but did not have a specialist and in the other instance had the wrong type of specialist for the problem.

Thanks for the added suggestions on doctor picking, Sheryl... I'll take those to heart...

However, I do need to quibble a bit re your comment I've quoted above...

In the first instance with my wife, the reason we couldn't see a kidney specialist for her at St. Louis on the day we went (which happened to be a Monday) was that they claimed they didn't have any scheduled on that day of the week. Can't say that's a particularly positive indicator for St. Louis.

In the second instance with myself, I was having skin problems (and of course I didn't know the cause) so I went in the first instance to see a dermatologist at St. Louis, who is the one who delivered the faulty diagnosis. The doctor who later correctly diagnosed me at BNH was an infectious diseases doc who'd done his medical training in Germany. My ENT at BNH sent me to him after looking at my throat, skin lesions and suspecting I had contracted an enterovirus, which turned out to be correct.

Under the circumstances, I'd think anyone with those symptoms at outset (sudden onset of skin lesions) would have gone to a dermatologist.... I guess sometimes it takes being a doctor to know what kind of doctor you need to be seeing.

BTW, the doctor I saw at BNH who correctly diagnosed me was Yuthana Budsayavith -- internist, allergology, clinical immunology. Univ. of Erlangen-Nurnberg, Germany. His office hours there are days Sundays to Thursdays. (I'd never heard of him prior to my chance recent encounter.)

Excellent English (albeit with a German accent ) and he clearly answered all the questions I had, both before and after my test results and diagnosis. I was impressed by his thoughtful and deliberate manner and approach, which included having me tested for some other things I'd never have even considered that also could have caused my symptoms.

He also didn't try to pawn me off with a bunch of useless or ill-suited medicines for purposes of either making me think he was doing a better job or helping line the hospital's pocketbook.

If I needed a general internist in the future, I'd certainly give him strong consideration.

Edited February 21, 2013 by TallGuyJohninBKK

[Sheryl]

I was not implying it was you who erred in seeing the wrong type of specialist, but that the dermatologist erred in not referring you to an infectious disease specialist or internist.

[TallGuyJohninBKK]

BTW Sheryl, re one of your suggestions above about ThaiVisa as a source for doctor recommendations, what about creating a pinned thread for that purpose? Recommended MDs...

Right now, that kind of info seems to be spread over all kinds of different threads, and the only pinned thread at present for doctor recs is one relating to urologists.

[Sheryl]

It would be a huge task especially since we are dealing with members living all over the country. Plus docs retire and new ones come in If I ever have time, I will compile one for the main medical specialties in Bkk and also list the best facilities for people upcountry but no telling when that will be. FBN and I both have "day" jobs that are quite demanding....

[TallGuyJohninBKK]

How about if I started a thread just for BKK MDs... Would you be willing to let it run and pin it???

Otherwise, finding the kind of recommendations here in the forum that you referenced becomes very difficult...

[Sheryl]

Most people just start a thread asking for suggestions.

it is easier to give the right guidance that way as we then know something about the problem and the person's priorities. As not only doctor qualifications but also style/personality is sometimes a consideration.

[AyG]

Look for someone with training and preferrably board certif in a western country. That will not only assure a high level of competence (it is no mean feat to get that if you are a non native speaker) but also excellent English and usually an understanding of the expectations of western patients re explanations and involvement in decision making.

Yet the Thai powers-that-be make it virtually impossible for foreign doctors to practise here - even though such doctors will also have a high level of competence and will often (a) be better at communicating with the patient English (or Japanese, or other native tongue), and ( have less of a high-handed approach - not liking to be asked questions, or providing explanations of diagnosis, or offering treatment options.

If Thailand is serious about becoming a hub of medical tourism it really needs to reconsider its attitude to foreign doctors and drop its protectionist measures.

[Sheryl]

Don't hold your breath......

There are at this point still many Thai docs who trained and certified in the west and have been "socialized" into that medical culture. Some really good ones.

This is actually likely to decrease over time as it used to be that docs pretty well had to go abroad to get specialty training. What has happened is that those who did have come back, moved into senior faculty positions, and it is pretty much all available now in Thailand. Which is as it should be, but does mean that over the coming decades there will be more specialists trained exclusively in Thailand.

I frankly would not advise someone planning to travel abroad for medical purposes to put Thailand as a first choice. It is possible to get good care here if you know where to look, but if making an international trip there are often better choices.