Referral System: a call for innovation

Recently I got a patient from Mujjafarpur, Bihar. It is 1000 km from Delhi and it takes long 2 days to reach Delhi from this place if your train is in time. In India, still 70% of population still stays in rural area. The basic needs - ROTI, KAPADA, MAKAN of human beings are fulfilled to 90-95% of our population but what is about the the basic health care? Needlessly we all believe, still it is poor state. If basic health facilities are out of reach for the most of the Indian patients, then what about the second and tertiary care referral system. One can imagine the gaps in the system and patients are still awaiting the best of treatment. 

My patient is a 49-year-old female, suffered from an episode of seizure. For that she was reviewed locally at Mujjafarpur, underwent CT scan of Head and received anti-seizure treatment. Subsequently she did not improve and had recurrent seizures and from there she was referred to Patna. One of the astute Neurophysician at Patna, reviewed the case, he immediately ordered MRI brain for a small lesion which was detected on CT scan. It was suspected as small clot of blood. However, on MRI the disease was not detected as bleed, but report came as a small mass, may be a tumor. With this, patient underwent a series of investigations at Patna and then subsequently she self-referred to SGPGI Lucknow, one of the prestigious medical institute in northern India. She was diagnosed as a case of Brain tumor and she was advised for the treatment. A middle-aged proprietor of her own school, started first symptom in the month of December, started on some medication for seizure. She was not improving with the treatment and now diagnosed for with brain tumor. It look almost five months to reach to a diagnosis. Again, when no improvement with treatment, she again self referred to AIIMS, New Delhi. 

She was evaluated thoroughly at AIIMS and finally diagnosed as Leptomeningeal Metastases. That means disease is spread to brain from some other organ in the body, mostly in females the disease comes from Breast in this age group. When I first saw her she had persistent headache, not able to open her eyes and intractable vomiting. She was in agony and I was also in the same for delayed diagnosis. For this kind of disease, there is no much to offer other than palliation.

After discussion with faculty members, we started her on treatment. Radiotherapy was given to her head. She improved symptomatically. Later with mutational studies in her blood, lung cancer was diagnosed and she was placed on oral form therapy. She is still alive.

Anyway, after discussing this case…. What I feel is, there is so much delay in reaching to tertiary care hospital. For this educated patient it was five months…….. How we as an Oncologist are going to provide the treatment and achieve the best of outcome. It is really saddening for our country till date we do not have referral system for patients. What would have been the perfect system? We all know there is not a perfect system. Now it is a high time that awareness of cancer should be the national public service priority and it should include not only the population as such but it should also include the doctors, nurses and paramedics.