CHIKITSA AROGYASEVANCHI

This book is written by my respected colleague Dr Shyam Ashtekar.

It is a well researched, logically thought out book about the problems and possible solutions for improvement of health sector in Maharashtra.

I rate the book very highly in terms of its presentation, scholasticism and timeliness. This is not only due to my personal regard towards Dr Ashtekar. I welcome other persons to read the book and give the review.

The content of the book is very practical and utilitarian- a sort of field guide for politicians, policy makers, observers, researchers and students of health care sector. A superficial reading can also inform the reader about many facts and facets. A deeper reading can give a snapshot of todays reality.

Dr Ashtekar's effort is commendable. Rarely does anybody take so much effort- if taken up early and in the right spirit- the system can really be improved beyond imagination- Yours and mine.

Book details- CHIKITSA AROGYASEVANCHI
Granthali publication.
Available in most book shops in Pune and Mumbai and by order from www.bookganga.com

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