THE NEW FRAMEWORK OF PRACTICE

Historically the medical profession has evolved from- faith healers, barbers and 'gurus'. Thirty years ago there was not much specialisation and the average doctor was required to treat all kinds of disorders and patients of all ages. Now is the era of specialisation. We have to become aware of our changing role in this context.

Doctors are supposed to carry on their work sincerely and quietly- active advertising for patients is forbidden. Though many doctors get upset with this rule- it is better that a patient comes out of his/ her own conscious choice. Patients come to doctors with many agendas- least of which is to recover from illness. This may vary from seeking reassurance, wanting certification, making enquiry, expressing concern and sometimes- even to size up the doctor. Doctor should therefore be alert to these undercurrents and not automatically presume that patient accepts everything that the doctor offers. So it is important to communicate clearly and explain to the patient about procedures in clinic- including the process of history-taking and proceed only after patient agrees.

Healthcare is called 'service-industry'. Only a fraction of patients need 'physical' service like injections, physiotherapy, dressing, surgery, etc. Majority of patients only avail of advice. Thus almost all doctors are 'medical advisors'. The doctor advises you about your condition, its treatment and also care to taken at home. The 'management plan' as it is now called- is different for every patient and is arrived at by collaborating with patient. So one patient of diabetes prefers to exercise in a park while another will go to the gym.

This is the essential change in framework of medical practice. A doctor can no longer pretend to be 'omniscient' provider of all solutions. The medical practice is never akin to laundry- where the patient drops his spoiled health and picks up freshly made one for a fee. Medical practice is more like a school where the patient receives guidance about how to solve the immediate problem and also how to prevent further occurence of problems.

Doctors should be conscious of this change and guide their patients about it. 

The Referral Note

The message sent from one doctor to another, requesting an examination/ opinion is called a referral note. The referral note has to be properly written to elicit a proper response from the other doctor.

I have encountered referral notes which are not only incomplete, but grossly offensive. For example- while I was working in CGC at Wadia hospital in Mumbai I used to be called with a note saying ' Dear CGC, Come and see ...... patient, he does not have any problem found by us'. And I have answered with 'CGC building cannot move or cannot sign on this call- there is no person here called CGC- therefore this call is being returned to your Consultant for review'. But one must be careful as patient is the ultimate sufferer in this fight of wills. It is the duty of every medical teacher to properly teach their students how to write a referral note (provided they know it). At least my teachers in B J Medical College, Pune did so with due deligence.

Every Referral note must begin with a proper heading- referred to so and so, Department/ Ward, etc. It should have the date and time of writing referral. It should begin with proper address such as 'Dear Doctor' in case of a colleague, or 'Respected Sir/ Madam' in case of senior faculty/ colleague. Write clearly the patient's name, age and current working diagnosis. Also write for what you are referring the patient. Is it for second opinion, interpretation of reports, taking over- etc? Finally sign off with a legible signature and mention your full name with contact details under the signature. This is important as sometimes the other doctor may need to contact you for clarification. Ward referrals should always be followed by a request to note the referral and write down when the doctor will visit the ward. This helps you to plan to be present when the doctor visits; an invaluable experience of learning.

Nowadays referrals, at least in private practice, are made by email or text message. It is not feasible to write very formal long referrals. But still clarity and politeness should not be compromised.

Young doctors should inculcate techniques of professional communication right from the beginning of practice. Refined communication will make your work easier and efficient and you will gain respect among colleagues- other doctors will appreciate working with you. It also gives a message that you are serious about your work, and communicates an expectation of equally sincere work (from colleague). When you are so thorough about your referral your colleague also feels accountable to you. All this is important to be able to manage your patient properly. Medicine is not only about diagnosis and treatment; it also involves management of case.

Incomplete and improper referrals are confusing and off-putting. They can irritate or even antagonise the other doctor. The ultimate sufferer is the hapless patient. I think we should not make the patient's condition like 'a frog between two stools'

Corruption in medical care

Very good article.
click on
http://www.epw.in/commentary/corruption-indian-medicine.html

Getting doctors to quit cut-practice

eid=31804&articlexml=Medical-council-to-fight-commissions-140520140050714052014005071

MMC has been sending 'do not do cut-practice' letters to all medical associations. That's great.

MMC notice to Kokilaben hospital for cut-practice

http://epaperbeta.timesofindia.com/Article.aspx?eid=31804&articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040#


Please read detailed article on above link.

Great job, MMC!

PSYCHIATRY DURING INTERNSHIP

For the last 15 years interns are posted for one month in Psychiatry Department. They are supposed to do 2 things:

1.       Learn to diagnose and manage common psychiatric disorders

2.       Learn to counsel patients and manage psychiatric emergencies.

Without proper supervision many interns are unable to achieve these two goals.  An intern can inform himself/ herself in advance about the methods of learning and take measures to make sure they spend the Psychiatry posting learning something worthwhile about Psychiatry, even if they do not get proper supervision. This write- up will describe how you can do so. You will not need anyone to teach you if you regularly see patients and try to make sense by reading relevant topics from any basic textbook- there is nothing that is not covered.

The first goal:

Almost all persons (not only doctors) are able to recognize severe psychiatric disorders like schizophrenia. But this is neither a common mental disorder nor is it really so difficult to diagnose (as to spend lot of time learning about it). One should instead try to diagnose depression, anxiety, sleep disorders, alcohol and nicotine dependence and learning problems of children in the outpatient department. Every intern should become expert at treating insomnia, mild to moderate depression/ anxiety, detoxification in alcohol dependence.

The ideal way to learn is to independently work up 1-2 cases in OPD everyday and try to arrive at diagnosis and treatment plan. ‘Hutchison’s clinical methods’ gives an excellent proforma which can be used for the work-up. You can then discuss it with the consultant/ resident. In any department you are likely to find at least one interested person, who will discuss the case with you.

You can work up 1-2 cases in wards similarly and compare your findings during rounds or from notes. Try to read up relevant chapters from a basic textbook such as Ahuja’s textbook or Oxford’s short text book.  Davidson’s textbook of medicine gives excellent coverage about mental illnesses. In the wards try to observe how and when patients recover. It is very important to understand the process of recovery from psychiatric disorders. Don’t miss any opportunity to witness special procedures like ECT, Amytal interview. In every case, read up on non psychiatric disorders causing similar symptoms and non- pharmacological methods of management of symptoms and disorders.

The second goal

Interns should accompany residents to the casualty which is the place where psychiatric emergencies are managed. Most Interns want to know which drug is to be used- that is really of secondary importance and can be read later. (An elegant list of drugs is usually given in every hand-book of medicine- which you will anyway have with you throughout your practicing life). But the real thing is to learn the skill in management. One should learn how to talk and establish a quick diagnosis with appropriate care to rule out organic factors at the same time making the patient feel comfortable. So observe your resident carefully- his tone/ gestures/ postures/ words and questions used, how examination of patient is done. Learn very carefully the ‘performance’ of management- because it is partly a show to demonstrate empathy-competence- safety to the patient. If you learn this essential skill you will be a success in your practice as a doctor.

One must constantly practice counseling by interacting with patients and their families. First learn to listen and find out the patient’s problems and their point of view about the matter under discussion- which may be diagnosis/ symptoms/ side-effects, etc. Then learn the art of communicating empathy and confidence. Then learn to give information to patients and check whether they have understood correctly. WHO gives an excellent booklet about ‘Emotional first- aid’. You may refer to it and learn how to manage emotional reactions. These skills together are called ‘counseling’.

Interns should also learn to diagnose social problems like abuse, domestic violence and marital discord. Every doctor should know about the laws and duties related to management of these cases. They should try to interact with other team members in Psychiatry such as Social workers, counselors, psychologists, rehabilitation managers, NGOs to find out their role in Psychiatric interventions.

Finally interns should get a clear idea about the types of cases to be referred to Psychiatrists. They should also learn the threshold at which common mental illnesses become complicated and need specialist intervention.

No matter what type of medical practice you do, management of psychological problems and mental illness will form a part of your work. In fact, it is a running joke- that those who don’t know anything about mental health will be managing a majority of mental health problems. Managing mental health issues is important and gratifying. Your internship rotation will be the only chance for you to get hands- on experience in Psychiatry.

As a further step-  one can learn specific techniques like- problem- solving methods, Rogerian counseling, breathing techniques, relaxation training, differential reinforcement, sleep hygiene measures, diary maintainence, and use of common rating scales for depression and anxiety and CAGE questionnaire. A smart intern will be able to collect enough data to be able to assemble a small research paper or even make an important discovery in Psychiatry. There is no harm in excelling in internship training, even if you don’t take up Psychiatry eventually. No honest labour ever goes waste.

MMC Notice to Radiologists

n m medical vs mmc case. an update

n m medical registered as n mohanlal and company have approached high and obtained stay on further intervention by mmc. they state that they are a cmpany registered under companies act and not medical practitioner to be regulated by mmc.

the case is now in mumbai high court.one inconclusive hearing occured. all parties are now waiting for the case to reach so that the conclusive hearing can occur.

now delay appears to be inevitable.

HEALTH ISSUES DURING RESIDENCY TRAINING

Post graduate residency training will be a time with lots of work, study, responsibility and most doctors will fall prey to some or the other health problems during this time. If not anything else, poor management of health will lower your immunity and make you prone to frequent mild infections. It is also the most enjoyable time in life and losing out on any fun due to health reasons will be a pity. Therefore every doctor entering Residency training should work out a comprehensive healthcare self-management program and practice it throughout Residency.

Environment modification is out of the question, the poor environment itself is cause of most health problems. So one should work on prevention and strengthening immunity.

Get used to waking up early and having bath everyday- thats the only time bathrooms in hostels are available so that you may have a clean proper bath. Bath is necessary- poor hygiene leads to infections and infestations. Remember all hospitals are dens of very bad infections like TB and malaria. All living quarters and workplaces are full of scabies, bed bugs and lice. One can never over-emphasize the need to be clean and hygienic. Also wearing clean clothes is important. Always wear ironed clothes- heat can kill lots of germs and wash your own underwear. I also used insect repellant cream and spray everyday almost like lipstick and other cosmetics. I regard it as being more important than 'Fair and Lovely'. It is really effective in keeping away mosquitoes and bed bugs.

Never miss breakfast. Always have a heavy and nutritious breakfast. I got used to adding Horlicks to my milk/ coffee- I believed it gave me extra nutrients. Try to go out of the hostel at least once a week to have a good breakfast- all hostels provide pathetic breakfast which is nutritionally very poor. The least we can do is go out a buy something healthy. Always make it a habit to make healthy choices in food- such as idli, paranthas, rice-dal, pulses, sambar, etc. Definitely stay away from alcohol, cigarrettes, drugs, sleeping pills, stimulating pills, excess tea/ coffee. These things will surely ruin your health in the short-term itself and your Residency training will be a disaster.

Most doctors neglect exercise because they believe that hard work is equal to exercise. It is not true. One should purposely exercise, even if it is irregular. I had made it a habit to grab my swimming costume and head to the pool whenever I got a break between 3 and 5 pm. This would be about 5-6 times a month (other than Sundays), which is good enough frequency. Many excellent bending-stretching exercise modules for workplace are easily available on internet and doctors should use one of these. Doctors can always take 10-15 mins break during the day to do these. This helps to tone and strengthen your muscles. This is very important as long hours bending over microscopes, standing in OT or even doing Op consultations can cause lot of unnecessary pain and discomfort.

Although most of your time will be spent working/ studying and rest of it .....resting- do cultivate at least one hobby. You can devote even 1-2 hours a week doing this activity. I have a great passion for needlework and I regularly worked on my pieces during Residency. It helped me to really cool down and feel calm after hectic day of work.

Learn the art of time and people management. These two will help you to minimise the stress that is part of Residency. In every hospital you will meet seniors who will appear to persecute you endlessly and juniors who appear to be lazy and incompetent. Remember that you are not in Residency training to assert labour rights or to avail of human kindness. You are here to learn to deal with problems as they are in the real world. Therefore you are always going to be short of time and help and you are always going to receive critical feedback. So give a thought to how you are spending your days, how you are dealing with people and try to devise solutions that will help you to improve your own situation.

Make it a practice to study regularly on a case-to-case basis. Later during practice, this habit comes handy. It is abnormal habit to work for 2.5 years and then devote the last few months to exam preparations. Ideally you should be ready to face your exam anytime after completion of the second year. This also minimises exam stress- which should be redundant term with respect to MD exams.

A lot of young doctors get married and start a family right away (Particularly Gynecologists). I think it is the foolishest thing to do. Both men and women should realise that parenting is a great responsibility- and you need to put aside proper 5-6 months for it. If you happen to take the plunge, be prepared to delay your graduation by a term. It is unfair on the child to give birth and then dump it on your parents or the maid- when you clearly know that you have to focus on your training and studies. Unplanned pregnancies are a source of severe stress- even to your clinical team. So preventing it is very important. If you must have a baby during Residency, the least you can do is to plan it. Hence knowledge and practice of contraception and safe sexual practices is as important to doctors as it is to their patients.

A lot of doctors do stupid things like riding dangerously without helmets when they have to reach fast, start examining a patient without gloves because he looks very sick or neglecting early signs of ill-health. Being intellectually smart and a having a good knowledge of disease will not protect you from the consequences of your stupidity. It will also not protect you from disease. So is the case about mental health problems. A lot of doctors who attempt to kill themselves will do so during Residency. That is also the peak age for onset of all mental illnesses. Dont be so ridiculous as to deny yourself treatment for depression/ anxiety/ ocd/ alcoholism just because you believe you cannot get mental illness. All hospitals with Residency training programs have at least one in-house Psychiatrist. And all of them will be more than willing to provide you with excellent, confidential treatment free of charge.

I feel very sad when I see that Resident doctors falling sick and wasting some days/ months of the best years of any doctors life. It should not happen. Residency training is a rare and special opportunity to grow into an independent professional. Keep a watch on your health and make the most of it.

PRACTICE MANAGEMENT

One must study and make plans on at least a few points before starting out in private practice. The following must be considered absolutely necessary:

Mission statement

This is a description of what your practice means to you. It should include your aims and objectives in starting practice. An outline of the type of set-up and the materials and resources should be included. Your values and ideals should also be stated. This mission statement should have validity for a fixed time period after which it will need to be revised.

Finances

There will be three financial stages roughly

1.     Starting phase- your earning will be less than expenses and you will make a loss.

2.     Middle phase- Your earning will generate income covering your expenses but you will not be able to satisfy financial commitments required for running your family

3.     Income phase- Your profits will give you enough money to live comfortably.

One has to make a sound plan for all three phases.

You will also have to decide your fees and make a plan a budget of expenses.

Team building

Even if you are a single-person unit, you will need to hire people to assist you in various tasks. This is your ‘team’. You will need a sweeper, cleaner, nurse, receptionist and locum and you must hire everybody very carefully. There is a tendency to hire the person who comes the cheapest. This is the riskiest way to choose your team. Even if it is for a task like sweeping check the person for expertise, regularity, integrity and then fix the remuneration. 

Marketing

In marketing one has to make efforts to inform target audience of your presence and availability. As medical practice is a professional and noble work, one must do the marketing ethically and gracefully. If you have to keep all these things in mind, a marketing strategy will have to be thought out in advance. Think out every minute thing: where you will put your board, what type of board, how will you describe your work to others, what type of stationery you will have, will you advertise (within permitted limits), etc

Initially you will have to visit other nearby doctors, educational institutions, NGOs, etc and introduce yourself. Your good work will advertised by the patients who have benefitted from your expertise.  Even if you do not get patients as soon as you expect, don’t get upset. Medical practice is largely a function of time and your good work. Always do your work with utmost sincerity and competence. This is the most effective marketing strategy.

Administration

A good administration allows you to remain in control of your practice. It adds experiential learning to your practice. Merely by doing your practice administration you will learn as much as no MBA course in the world can teach you. You should be able to have a system of recording and managing your expenses, time and manpower. Nowadays everybody has a computer. You can even use simple excel worksheets. You must maintain data base of expenses, income, travel, time spent, patients, employee attendance and performance, at the least. After getting the data, you will become aware of the assets and liabilities of each domain of your practice in the earliest stages. Then you can plan out how to deal with these intelligently.

Self management

This involves managing both physical and mental aspects of yourself.  Your appearance represents your practice in a concrete visual form.  You are to convey to the patients that you are competent, confident, sincere and reliable in your work. Doctors should decide on a type of dress that is smart, comfortable and culturally accepted. You should learn to speak in the local language and also in reasonably good jargon-free and slang-free English. Practice a polite, soft, clear way of speaking.

Take very good care of your health. A healthy doctor makes for a great role-model; an admiring clientele is the best type you could wish for. Choose a reliable and competent colleague as your family physician, steer clear of the tendency to self treat.

Most doctors are prone neglecting their mental health. Have a regular stress management strategy. Find someone to talk to, or to guide you in times of crises. Learn to deal with difficult situations in a systematic and logical way.

The first few years of practice are extremely stressful- they will test not only your expertise but also your character and human-ness. Plan as much as you can and take care. We need lots of competent, ethically motivated doctors to survive in practice.