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

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.