CUT PRACTICE ISSUE- A MILESTONE REACHED

Happy to note they have tabled the law and passed it.
So finally cut practice is not merely unethical but also illegal. This is what I wanted.
I understand that implementation is going to be a challenge. But enacting the law changes the whole paradigm and perspective- which is in a positive direction.

So its is a great milestone on Medical Ethics. I hope the international journals give positive coverage to this as well.

Good News!

Consumer is king.....but what about patients?

The Tide of corporatisation of healthcare has swept over India in the last decade. From being sanctuaries in the middle ages to being temples of healing in the last century, hospitals are now evolving into commercial centres. Patient is cast as a ‘consumer’ while healthcare professionals are ‘service- providers’. Today the hospital is designed like a factory with its staff as workers. Unfortunately, health can neither be manufactured nor be bought. In this fact lies the irony- while patients’ narcissism is massaged by advertising spiel- the larger population have not understood what to really expect. 

Consumer- patient

No human willingly chooses to become a patient. (Only exception, being the cases of psychological disorders in which persons are fascinated by doctors and treatments. Let’s leave this category aside.) For illness is an unwanted imposition to be got rid of as soon as possible. In the best cases it is treated as a character- building adversity.  So a person just happens to become a patient. A patient becomes a consumer when he chooses to ‘buy’ healthcare ‘products’. This product maybe an investigation, treatment, therapy, convalescence or palliation.

Service- providers or expert professionals

 The difference between corporate medicine and rest of corporate India is vast. Except few administrators and expert doctors all other staff are either contracted, interns, students or observers. Every corporate hospital runs its own nurses training, post graduate medical training and other courses- the students provide free or cheap labour to run the hospitals. While rest of corporate India enjoys a 5- day week, corporate hospitals work 6 days (the hospitals are manned by rotation duties. These rotations are done every 6 days with one day off). Mandatory 36 days paid leave, maternity leave, on site child care, medical facilities- are not usually given.

The problem is the problem

Common complaint against corporatisation is high expenses. This is a genuine problem and activists are working on it. Bigger concern is changing framework of illness and its treatment. The reality about illness and treatment is this- one cannot choose the illness, its timing or intensity. Similarly no patient can hope to recover by mere administration of treatment without an interest or effort on part of the patients. Corporate healthcare is trying to actively hide these facts.

Advertisements make tall claims about prevention of illness by undergoing battery of diagnostic procedures. No tests can prevent illness. If you become ill at an inconvenient time, the corporate hospital promises to give you treatment without a break in your commitments. A part of this is the active encouragement given to patients to arrive late for appointments and to not be compliant towards treatment recommendations which get in the way of their life (eg alcohol use during treatment). Has anyone ever heard of a running car being repaired? But corporate healthcare promises that to humans.

As stated earlier, health is a commodity that can neither be manufactured nor bought. A few lucky people are born with good health and continue to enjoy its benefits without much effort. Many of us are able to cultivate healthful habits. Yet for most of us illness is inevitable. Patients have to approach for help. The responsibility of arriving on time, reporting problems honestly, taking treatments as advised- is completely with the patient. Going to a corporate hospital with excellent quality ratings alone, never helps. Patients should learn to differentiate between hospital and hospitality and between treatment and pampering. In this lies the difference between a common patient and a wise one.

Conclusions

The trend of corporatisation has given a false sense of security that they will be assured of good health with payment of steep charges. But no illness can be treated just from the outside without participation of the patient. Patients should be willing to do their part of the hard work to recover, merely throwing money will get them nowhere.

MENTAL HEALTH PROFESSIONAL AS A LIFE COACH

Lately I come across a number of business cards of my colleague Psychiatrists where they mention their work as being ‘Life Coach’. In general, I have been sceptical of the concept of life coach- I think it’s just a modern version of ‘Guru’, ‘Baba’, etc. It appears that talented, accomplished people cannot trust their own judgements at some point of their lives and the above category of persons fill the need so created. I wonder if there are any courses to become a life coach and I have heard of highly questionable methods like ‘whats your favourite colour today?’ being used to guide the person by life coaches. Anyway, this post is not about life coaches- but about mental health professionals functioning as life coaches.

Mental health professionals like Psychiatrists, Psychologists or Psychiatric Social workers are trained in the diagnosis and treatment of mental disorders. During training, their exposure to problems of ‘normal’ life is limited- at least in India. Most of the times the number of mentally ill is in such excess to the people dealing with problems of daily living- so critical and professional evaluation of persons with functioning lives is quite rare. Professionals in private practice may have a greater chance, but again I have my doubts. Psychiatrists spend about 5 mins with one patient, while psychologists have simultaneous tests running in 3 cabins. Very few professionals actually see their patients for long durations. And then there is the problem of doctor- shopping by the capricious patient, because of which the drop-out rate of patients in therapy is considerable. So I doubt how many mental health professionals are really doing therapy and have accumulated the diverse, rich and deep experience to be able to contemplate on the problem that is ‘LIFE’.

So when I see life coach printed on the business card- I am prone to be sceptical- particularly if the professional is young, has a busy practice and not known to be contemplative (through lack of writing/ presenting/ researching).

TIME MANAGEMENT IN PRACTICE

http://bmjopen.bmj.com/content/4/5/e004679.full

This is a continuation of my previous piece about time management in medical practice.

There is a lot of anger among the public over waiting in the doctor’s clinic. As  patient is in discomfort and pain, there is an expectation of relief at the earliest. When this expectation is not met- anger is likely. Some doctors do not care to organise their practice leading to time mismanagement and delays. The worst offenders are doctors who call all patients at the same time, so that they can arrive after a sizeable number assembles and then proceed to rush through the que. This is wilful waste of the patient’s time which is completely unforgiveable. Some doctors have given up on time management thinking it is a hopeless attempt and just announce their working hours. Any patient arriving within that time is seen on a first come first served basis. So essentially there is no appointment given. In all these scenarios the doctor has designed a schedule which is heavily weighted in the doctor’s favour and in favour of a patient who is disorganised consumer. Yes, some patients do feel reassured taking treatment from a busy doctor who makes them wait for hours- these patients are welcome to wait.

Working by appointments is by far the best way to work. It is good for the doctor as well as for the patient. It is the doctor’s responsibility to implement a system that ensures time management. The most important intervention to reserve the first two slots of the day to patients who are known to be punctual. Work must BEGIN ON TIME.  Second important intervention is to turn back and reschedule appointments of patients who come late. Patients should be accommodated for reasonable delay which may be upto 15 mins. Beyond that appointment stands cancelled. Thirdly, after every 4-5 appointments, an empty slot should be kept to accommodate delays and extended sessions. On certain days, when time- consuming interventions like therapy are to be done , patients come prepared to wait because I inform them in advance- so that is okay by them. I keep my side of the deal by not charging patients if I make them wait excessively, irrespective of who is at fault. Majority of patients appreciate the doctor’s punctuality. There are some patients who cannot understand all the fuss- but well the doctor has to take responsibility for clinic management not the patient.

After doing this for 15 years, I have a beautiful practice which allows me to start my day as planned and end it on time. 

MCI, PLEASE OBLIGE

When we were students, we had to learn medicine, surgery, obstetrics and gynecology, ophthalmology, ear-nose-throat diseases, orthopediacs and paediatrics as separate clinical subjects. Psychiatry was dealt with in 1-2 lectures, 15 days in the second year and about 15 days of posting in internship. The medicine paper was supposed to have a question on Psychiatry which was usually a short note on one of five favourite topics (which unfortunately did not include depression).

This was 15 years ago. Now when I meet my classmates, irrespective of speciality or area of practice or even if some of them have switched their professions- all my classmates rue the lack of special training in Psychiatry. Most of my non- psychiatry colleagues have told me how a significant portion of their practice is actually psychological intervention or psychiatric treatment. One family physician joked to me that he will have very minimal practice left if he begins to refer patients with psychological problems to Psychiatrists instead of treating them himself! Considering all these experiences, it is very clear that a special training in Psychology and Psychiatry would have been indispensible.

All things cannot be covered in undergraduate medical education because of the vast and changing nature of medical science. Invariably, some amount of learning happens on the job when the doctor actually settles down to start work. So some authorities have argued that psychology and psychiatry will be ‘automatically’ learned by doctors when they need it. So we see a good attendance at CME programs of medical associations when the topics are related to psychiatry. But what about clinical skills? CME programes are only lectures and I don’t know how doctors will learn the clinical skills of mental health care.

Unless the MCI mandates that clinical skills have to be learned, the students will not be able to do so during MBBS. After MBBS, even if they want to pick up these skills, who will teach them? Technical knowledge in psychiatry can be picked up in the CMEs but clinical skills have to be learnt during undergraduate clinical training only. So our MCI should include testing of clinical skills in psychiatry and psychology during exams. Then there is a higher probability that students will imbibe these skills. Leaving market forces to create motivation for this learning is not the right approach. I hope the MCI will oblige.

Writing for a news-paper

Nowadays I am writing a regular column for the newspaper 'Loksatta' and my colleagues want to know more about this writing process.

About 3 years ago, I wrote my first article for a newspaper and it was on 'depression in menopausal women'. I think my first boss, Dr Harish Shetty refered my name to the editor. I was very hesitant to write in Marathi. So the first time I sent the material in English and she translated it for me. The article came out very well. My concepts and her translation- an excellent combination.

Thereafter slowly I began to get requests to write more articles. But now I had to write in Marathi itself- another challenge. I speak Marathi very well but writing and typing was another thing. Generous use of dictionary and Google transliterate solved the problem. And the excellent editing inputs- 'kept the technical points at the same time maintaining the readability of the article' (in the words of one of my colleagues who was kind enough to review and give feedback).

I get a small honorarium for my efforts. I have never had to pay for getting articles published. In the initial years I did approach some newspapers with articles; but I learnt that writing is their job and they really dont need any articles from us. So I stopped sending such requests.

After writing articles, many persons and patients have contacted me for their troubles. This works both ways- I get some work and patients get to know where to find the person who can understand their problem and give them treatment. Somehow it adds to my credibility, so just by writing articles now I am supposed to be a better doctor also. Maybe now, that my thinking and knowledge are public- the judgement about my competence is easier. Or that the public is counting on the newspaper to have chosen 'only a competant doctor' to write.

I take my writing very seriously. I read all material on the subject. I review all patient histories relevant to the topic. I am meticulous about sticking to deadlines and word- limit. And I check what I have written. But of course I am not a writer- and my editor always manages to give a wonderful makeover to the article, putting the most appropriate words and phrases. Journalists are wordsmiths- and I have been lucky to have been guided by the best of them in writing my articles.

I feel it is a very good opportunity to revise the topic, learn new things and a different way of serving patients. I have really learnt a lot and will continue to learn from this experience. And I really agree that the written word has the unique power to communicate, impress, give relief and bring change.

Responding to 'Private healthcare providers.........revenue generators' in BMJ

http://www.bmj.com/content/350/bmj.h826/rr

TREATING 'CELEBRITIES'

Whenever my classmates hear that I practice in the Western suburb of Mumbai, they are keen to know which celebrities I have treated. This is because most of the Bollywood live and work in the Western Suburbs of Mumbai and there is a higher than usual probability of any doctor encountering one as a patient.

Well the first point is: I have to disappoint my classmates as I cannot name any patient due to my very uncompromising stance on patient confidentiality. Secondly, they get disappointed to know that famous people are not very different from 'non famous' patients in any way. Like all other groups 70% are just usual people who need treatment while 30% are unnecessarily troublesome. And that they suffer from much the same illnesses, side effects and concerns.

 I prefer not to treat famous clients generally. The main problem is: my time-management goes for a complete toss. Famous clients have round the clock comitments and they though they try hard to maintain control- sadly it is never possible. So the 6 o clock appointment becomes 7, then 8 then 9 and so on. Then for being able to accomodate their crazy schedules I have to reschedule other appointments- this I hate doing as I value all my patients equally. Well some famous folks feel very bad- and as they feel that everything can be set right by money and that is one thing they have in plenty- they try to pay the therapist an 'hourly charge'. But really its not about the money- the genuine therapist is also like a performer- I set an agenda for consultation and am eager to do it at assigned time. Waiting is like a 'false- start'- it causes me to lose the sharpness and interest in intervention.

Some famous people are pitiably foolish. They want their doctors and therapists to be in awe of them and wait at their beck and call. But this is very counter productive as medicine is a profession which requires human judgment based on objectivity. Maybe the famous person gets easy access to the therapist, can bully the therapist- but this causes subtle and sure harm. So we read about doctors who have been prescribing ever higher doses of sleeping pills because patient demanded, or got into relationships with patients because they were not able to assert their limits. The danger of thinking famous people are different is very real- both for patients and their doctors.

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

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.

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.

APPOINTMENT MANAGEMENT

I follow an appointment system in my clinic. I believe that my patient’s time is as precious as mine, and try to ensure that they do not have to spend too much time waiting in my clinic. I also feel that as my patients are emotionally distressed, waiting could worsen their condition. I try to ensure that no patient waits more than 15 minutes in my clinic. The maximum time a patient has waited in my clinic is about 1 hour.

 

About 50% of patients, who are scheduled to see me for the first time (New patients) don’t turn up. And they do so without informing me, which means I wait for them and after half an hour of ‘no show’, conclude that they will not come. About 40% patients coming for follow up are delayed by at least 15-20 minutes. Around 10% patients schedule appointments repeatedly but fail to make it with/ without informing. A small percentage, walk in without appointment and insist on being seen.  Another (surprisingly common) patient is the one who arrives in clinic after I have reached home and then phones me requesting me to come back to clinic or that the patient will come to my home for consultation. Their logic is: now I have the time- see me. I never entertain such requests.

 

To ensure proper time management, I never schedule anything else near my clinic timings. I ensure that I leave home early and always arrive on time. I prepare in advance for my therapy appointments and long review appointments. I schedule the patients carefully, so there a few who require more time and few who require shorter consultations. I always schedule regular and punctual patients in the first slot. No matter what time the patient arrives, I always end my consultation at the same time. (Yes, I do charge full consultation fee, why should I not do so?) If there is not enough time left, I reschedule the appointment. For habitual latecomers, I do not give appointments, but tell them to walk in a range of timings and wait. Due to the large numbers of new patients coming late (cant estimate commute time?) or not coming at all, I never schedule appointments but ask them to attend the walk-in clinic on weekends.

 

I often feel that the appointment system is counterproductive for me. The no-show and latecomers throw my schedule out of gear and it is quite unfair on the patients who arrive on time.  Some patients who arrive on time, don’t understand that the earlier patients had come late and so their appointment is getting delayed. Another set of patients who come late just want to be seen right away, without realising that the next patient who is likely to arrive on time, will get delayed because of them. I feel I should detain the first type of patient and make him/ her explain to the second type- but both usually fight loudly with me.  Patients who come late are seldom remorseful and never care to mend their ways. This way everybody is a loser.  Meanwhile, I am paying for the overheads, I don’t get to express my disappointment and my family always has to see me home later than expected.

 

I sometimes feel, that I should abandon the appointment system as it affects me badly. I can tell all patients to come and be prepared to wait indefinitely and see them on a first-come-first –seen basis. This is followed by most doctors. It clearly places the doctor at an advantage as the doctor does not waste time waiting for the patient. But I feel it is not fair, to make the patients wait like that. I don’t know how much longer I can act with regard this principle of propriety and stick to the appointment system.  

 

But of late, I do turn away patients who habitually come late, or are delayed by more than 30 minutes. I charge full fees for the second missed appointment. This way I feel I can control my schedule as well as have some sense of justice for my efforts.

 

THE WORLD AROUND YOU

I have worked in private practice as well as in an institute. My impression is that the amount of work a psychiatrist gets does depend on the setting of work.

In an institute, I have observed that the threshold for asking a Psychiatrist to get involved is rather low. We get referred any case and every case. Hence the workload is considerably high. Whereas, in private practice the referrals are slow to come. Even serious and purely 'Psyhciatric case' like suicide attempts and psychoses are retained by doctors from other specialties. Thus cases are fewer.

One explanation for this is due to the desire to work less and also to make more money; both being at the cost of the patient's welfare.

 In the first instance, the patient would benefit from continuing care of the Physician/ orthopedician, etc. But the salary remaining constant, this doctor has nothing to gain from keeping the patient in the wards and increasing his/ her workload. This doctor also has a culture of concrete thinking, where seeing ONLY is beleiving and quality of life has no meaning. But if patient is not accepting his explanation that everything is ok, and the relatives refuse to take the patient as he/ she is still distressed or troublesome, the doctor bounces off the patient to the Psychiatrist. No Psychiatrist can refuse to take care of a patient who is obviously uncomfortable. So the patient with many medical problems, and just mental symptoms (not mental illness) gets shifted to the Psychiatry ward. Now the Psychiatrist and the patient have to keep begging the referring doctor to come  regularly and have a look to maintian the physical status. This gives the additional incentive of 'ego massage' to the referring doctor, who believes that Psychiatrists are lesser mortals and anyway dont have any work to do.

The scenario is much different in private practice. Every doctor believes that Psychiatric disorders are not disorders at all and counseling will set everything alright. They are scared to use psychiatric drugs in proper doses, but since they are so intelligent they will open some book, find a few names of psychotropics and discharge the patient with a scolding and 'good advice' (which is their version of counseling). After all by treating the patients themselves, and keeping them ill as long as possible, there is money to be made. When the patient becomes fed-up or very ill, they will, very reluctantly refer to the Psychiatrist. By this time the disease has progressed to such an extent that it is a tuff situation even for a Psychiatrist and the improvement proceeds slowly, partially or not at all. Then they confirm their delusion that 'Psychiatrist know nothing and do nothing' and malign them.

I feel every professional should spend some time educating themselves about the thresholds for referral to Psychiatrists. They can just make it a habit to talk to the Psychiatrists about the cases they have referred; over the years they will learn. Of course, one can do nothing aboout unscrupulous persons who dont want to refer patients.

I am sure this discussion applies to referrals between other specialties also.

WHAT THIS BLOG IS ABOUT?

This blog is for doctors and about doctors. It will contain topics about the medical profession, and about psychiatry.

WHO PAYS THE DOCTOR?

Following are some of the beautiful reasons people give to evade payment of doctor's professional charges:


1. I am very poor, so I cannot afford you
2. I am a celebrity (and anyway have done you a favour by consulting you)
3. I dont agree with the philosophy of paying money for such a 'sacred' service
4. I work in a Government office, so I am entitled to everything and am deluded that I am being underpaid (inspite of sixth pay)
5. I am a CEO and I expect to be served
6. I am a senior citizen and would rather pay the SOTC to visit rare places on earth, so I dont have money to pay you
7. I am your relative
8. I am a doctor myself
9. I am a doctor's relative
10. I am a friend's friend
11. I am like your family member
12. I am a holy man/ astrologer/ spiritual person
13. I am your neighbour
14. I just wanted to talk to you, and find out some things. Does it amount to a consultation?
15.It will not matter to you if one person does not pay you
16. I forgot my purse
17 I went to all the faith healers/ babas/ etc and now I am broke and in a serious condition. It is your legal and moral duty to treat me, even if I cant pay you
18. I was among the first few patients you treated
19. I was your school teacher/ music teacher/ art teacher/ etc
20. You failed to save the patient, so why should we pay you?
21. Please dont bother me, ask the insurance company/ my employer/ etc to pay the bills
22. I was not satisfied with your consultation as you merely talked to me and actually did nothing (to a psychiatrist-what else should we do, actually?)
23. You delivered a female child, we wanted a male child (to a obstetrician)
24. I will surely come back and pay you (a patient caught leaving hospital secretly)

All others pay the doctor.
And also pay for the above.
As doctors have to make up for the costs of working for all these non-paying characters, the fees of paying patients get hiked.

GENDER SENSITIVE TRAINING

A recent report about the number of 'working' MBBS doctors was found to be much lower than the number of rgistered doctors. In case of nurses, it was found that 63% were not working currently. During my interactions with various doctors' organisations I find that a significant number of women doctors are not working actively in their professional capacities. This is a worldwide phenomenon, and the reasons are variable.

One of the reasons,in India, could be that the training is gender insensitive. While the doctors are experts in theory of disease and medicine, their training about the practice of medicine is completely hopeless. Take the very simple example of the type of dress a doctor wears to work-this has more more significant implications for female doctors than for male doctors. There is no discussion regarding personal safety during practice-a very significant concern for women doctors in most parts of India.

Women enterpreneurs receive different types of encourgement in terms of training in enterprise management, cheaper loans, etc. But women doctors (for that matter any women with professional qualifications) are barred from these schemes.

The lack of good quality, adequate and round-the-clock childcare facility is the most difficult and common problem that women healthcare professionals face. Each female doctor or nurse is left to her own means to 'figure it out' once she becomes a mother.

Our training does not take timely and realistic view of these challenges. No wonder most women quit. By the time their children grow up, they are out of touch and have lost the confidence to work.

To counter this problem, I feel the training program should have a module on gender issues in medicine. Government needs to adjust the rules to allow women to re-enter the profession. Maybe they can have a refresher course and re-entry exam? All hospitals should have large-capacity daycare centres for children upto 14 years of age.

ACCOUNTABILITY OF MEDICAL TEACHERS/ COLLEGES

was at the IACAM conference in Blore recently and they were having a symposium on training in Child Psychiatry. I raised the issue that the current training is sound in (clinical) theory but gives no thought to the context of work. Where we are talking of Individualised Education Programs for our patients, we have missed that point completely for our own workforce. Further, most child psychiatrists are going to be women, who really have not much say in where they will work. Eventually you will create a psychiatrist who is full to the brim with psychiatric knowledge but very unprepared for the 'practice' of psychiatry in the real world. With the result that people get intimidated by the prospect of working in India, and take the easy way out-that is migrate abroad. I told the audience that it is sad to see that more that 80% NIMHANS alumni work abroad-and my reasoning that this is because they have not been inculcated the thought of 'career-planning'.

I suggested 2 things for this

Firstly, to divide syllabus into two parts-A). core competence which includes everything about psychiatry and B). electives, which includes subjects like enterprise development, financial managment, health care systems etc. these could be managed by visiting faculty and students can choose which subjects to take up. Even things like social marketing, documentary film making, etc can be helpful while working as a Psychiatrist

And Secondly, an active engagement with alumni-they can give a feedback to adjust the training in keeping with 'market' requirments' and also maybe teach the others what they have learnt. they can take up mentoring also

I also told them that the teaching in IITs and IIMs is dynamic and along the above lines, these institutes support their alumni not only to become engineers; but also to become employers and enterpreneurs and contribute to the development of the country. So we also need to emulate their practices, and also because we also deserve to get good education AS WELL AS encouragement. I am very ashamed to say that the alumni of these institutes have created more value for our country than we have. They also may work abroad, but their work is such that it has caused development for us. Personally, I want to get aboard the gravy train and feel part of national wealth-only I have no idea how to do it except for being a medical 'labourer'!

All I want to say is: If you are sitting in a national institute and 80% of your alumni migrate abroad and are not happy about it-then does it not worry you? Mostly the reason to go abroad is to 'stay there for few years' because the propspects here are not good enough, right now. In my private discussions, most faculty and medical teachers blame migration to personal factors-like not getting alongwith elders at home, lure of easy money, lack of research atmosphere, gender issues,etc

The national institutes and medical colleges are using the taxpayer's money to impart subsidized education tailored to their (a few government doctors') idea of the 'perfect child psychiatrist'. But is it not their duty to think of how this manpower may be retained and used for the good of the taxpayer? How can they abdicate this responsibility by holding each person (the migrating doctor-student) responsible when the large majority of theirr alumni are leaving? Either their selection process is faulty, or their training is-in both scenarios something has to be done by these institutes only.

I am really very upset about this smugness and that our education policy is in the hands of people whose psychological boundary ends at the threshold of their inpatient wards. To change the healthcare system we need people who may really not be very good at psychiatry, but maybe need to be visionaries with the aim of transformation. Good psychiatrists may be hired to teach psychiatry and leave, which is just what they seem to be eager to do. I wonder if has anything changed between when the previous generation of Psychiatrists did their MD and now;  in terms of practice skills of fresh MDs and opportunities available to them? -I am now accusing that generation of not doing enough