THE CONSULTATION ROOM
A SYNOPSIS OF SOFT SKILLS TO MEDICAL PRACTITIONERS PREMIER ON PUBLIC RELATIONS TO COMPLEMENT ACADEMICS
Prof C M K REDDY
DSc FRCS (Glas & Ire) FRSH FICS FICA
General & Vascular Surgeon
HALSTED SURGICAL CLINIC, APOLLO & LIFELINE HOSPITALS Honorary Surgeon to the Vice President of India Emeritus Professor, TN Dr MGR Medical University President, TN Medical Practitioners’ Association & Indian Chapter, Royal College of Surgeons in Ireland Formerly President, TN Medical Council & Honorary Professor of Surgery, Stanley Medical College Recipient of Dr B C Roy National Award as Eminent Medical Teacher from the President of India CHENNAI
THE CONSULTATION ROOM Prof C M K REDDY
Halsted Surgical Clinic
306, Poonamallee High Road Kilpauk, Chennai – 600 010 Phone : 95434 5999 / 98843 13344 eMail : email@example.com Web : allindiatf.com
Published in India by Tymes Multiple Services L515, Amarprakash Templewaves, Kundrathur Chennai – 600 069, Tamilnadu, India
Phone : +91-7550 259 856
Email : firstname.lastname@example.org 1st Edition : February 2021 Pages : 136
price : `150
THE CONSULTATION ROOM Prof C M K REDDY
What is the need for this book ?
“Practice of medicine is more an art than science”.
“The time I spend in my office is more taxing on my expertise, than when I’m in the operation room.”
- Prof J M Zimmerman, Johns Hopkins University.
Though every Doctor reads the same books and passes the same examinations, how is it that one Doctor becomes very popular, resourceful and much sought-after, while many others remain average ‘run-of-the-mill’ type, with no appreciable recognition in the society? Obviously there is something very important, missing in the curriculum nor taught by the teachers, i.e., the art of practice of medicine. To be a successful Doctor, besides medicine, one should also master psychology and philosophy in dealing with patients. Lay people say it’s ‘kai raasi’ or ‘hastha vaasi’, but in reality, it’s sincere patient-friendly application of our knowledge and skill. Hence instead of getting jealous about successful Doctors, we should try to learn their ‘techniques’ and implement.
There are 3 ingredients in the medical curriculum. First is to know all the facts and figures of medical science, like anatomy, physiology, pathology etc, secondly to acquire various skills required to make diagnosis or to treat and lastly, most important, to nurture proper attitude towards our patients. It’s only for the third, we are called ‘Doctors’, otherwise like BSc Zoology, Chemistry or Physics, probably we would have been called as BSc Medicine.
We see many well qualified, knowledgeable and highly skilled physicians not being able to satisfy their clients, to the extent expected, entirely due to poor attitudes towards public relationship (PR) and scant realization of customer psychology.
3 THE CONSULTATION ROOM
As Charles Darwin put it : “it’s not the strongest of the species who survive, nor the most intelligent, but those most adaptive to change”. Then it became apparent that the young Doctors need to be oriented to the changed mindset of the present society, by finding out where generally the patients are disappointed, dissatisfied and unhappy about the total set up.
The aim of his work is to prime a practitioner to adapt himself to the ideal wave length to satisfy a patient, who may be sinister, insinuating, half-baked, outspoken, litigant, troublesome, criminal-minded and in short, most undesirable individual.
I am certain that many things said in this book are too familiar to the senior practitioners, but had to be reiterated for emphasis and comprehension. I hope this book written with an experience of 5 years of training abroad and 50 years of active practice in a cosmopolitan city, would serve the purpose and if, after reading this, the attitude and the mindset of a junior Doctor towards handling their customers, has changed for better, I feel, the effort taken is worth while and the time in compiling the book is well spent.
Lured by the hitech diagnostic and therapeutic devices around us, let’s not lose sight of the ground rules of clinical assessment and basic bedside manners, taught to us as graduate students. Also nothing in our professional conduct should override humane considerations, fondly expected by the suffering fellowmen. Unless we collectively try to preserve or restore the nobility of our profession, we will be passing on a highly hostile and litigating society to our next generation.
The statement that ‘individually we are very strong, but as a group, we are weak’, is very unfortunate, but true. Though most of our patients are sincere, cooperating and respect our profession, because of very few undesirable, troublesome elements, we are forced to view every patient as a potential litigant. It should be realized that most of the guidelines suggested here are applicable to Indian conditions, with some varations from state to state.
4 Prof Sudha Seshayyan
Vice Chancellor, The TN Dr MGR Medical University Member, Editorial Review Board of Gray’s Anatomy Former Director & Professor of Anatomy and Vice Principal, Madras Medical College Chennai – 600 032
ractice of Medicine is indeed an art. Though facts and figures of medicine and healthcare are often considered to be factors of science, practice and implementation of the policies and procedures related to all healthcare
activities call for a sensitive mind and an empathetic heart. If education has to be ‘learner-friendly’, gadgets have to be ‘user-friendly’ and governance has to be ‘people-friendly’, a practicing medical doctor needs to be ‘all of these’ and may be more too.
Prof CMK Reddy, himself a compendium of all such ‘friendliness’, has now put it all to paper for the sake of proper use by the younger generation of doctors. Half a century of experience as an active practitioner and ardent teacher, is encapsulated into an artiwork.
Starting from the often-forgotten rule of punctuality to the critically sensitive issue of discussing one ‘patient’ in front of another, Prof Reddy has attempted to enlist every single factor that a practitioner should focus on. The author appears to be at ease while dealing with ‘seemingly’ small matters like pleasantries & chats with attendants, on one hand and difficult issues like gender precaution, interpre- tation of investigations and medicolegal issues on the other as well.
Soft skills are an essential part of professional development and backbone for doctor-patient relations. Prof Reddy has added a touch of class to his idea of extraordinary theme. The book is well studded with illustrations that show-case the author’s ability to appreciate delicate humor.
In toto, the book makes for an interesting read to those who are already in medical practice and for a learning experience to those who are entering into it. In fact, there is quite a lot to implement for every type of healthcare professional. Practicing doctors, consultants in various specialties, hospital administrators, laboratory personnel and medical educators can all learn many things from this ‘seemingly simple-strongly supportive’ synopsis.
As I wish Prof Reddy more and more of such fruitful endeavors, I also appeal the younger members of the medical fraternity to imbibe the values that have been well documented by an outstanding teacher of teachers.
– Prof Sudha Seshayyan Prof B Krishna Rau
MS FRCS(Eng & Edin)FIAMS FACG FICS FIGSC
Surgical Gastroenterologist & Interventional Endoscopist Chairman, 21st Congress of International Society for Laser Surgery and Medicine 2015 Honorary Fellow, American Surgical Association B C Roy National Awardee Past President, World Federation of Society for Laser Surgery and Medicine & Association of Surgeons of India (ASI) Formerly Honorary Professor of Surgery, Kilpauk Medical College
NOTE OF APPRECIATION
t is indeed a pleasant task to write about an innovative booklet that Prof CMK Reddy has written, titled The Consultation Room. This is meant for doctors,who have just embarked on their private practice after completing
their medical graduation and junior consultants in various specialties. Unfortunately the medical curriculum is silent on this important aspect in the doctor’s career.
Prof Reddy has conceptualized, elaborated and put down the difficulties, when he had to establish his practice. In this booklet, newly graduated doctor in any specialisation will find the methodology to set up his practice in private, small clinic, multispeciality hospital, Government hospitals and in corporate settings.
As an ardent teacher, I can appreciate his zeal to distill the knowledge he has amassed in his six decades of medical knowhows, that he has met and tackled the problems and share with his juniors. He has dealt with medicolegal, patient handling, talking to the relations, medical ethics, above all to be straight forward in the outcome of the treatment proposed. He identified areas in our practice requiring improvement, to strengthen doctor-patient relations, which is at stake in the recent times.
Equally he has emphasised to offer the patient a second opinion if required. To make the book reader-friendly, he added medical cartoons in several chapters, to bring out his inherent sense of humor. I am confident that this publication will be wholeheartedly welcomed by young medical graduates and if followed by the letter and spirit, their outlook towards the patients would certainly change for better, ultimately to their own benefit.
- Prof B Krishna Rau THE CONSULTATION ROOM
- Why growing public dissatisfaction about medical profession?
- Why clinical diagnosis ?
- Ambience & attire
- Qualifications, certificates & photos
- Reception desk
- Furniture & equipment
- Assistant (ante) room
- Consultation room at residence
- Appointment system
- Patient comes to your clinic by mistake
- Patient without appointment
- Social engagements
- Consulting hours
- Patient reporting morning with evening appointment
- Language issue
- Making notes & plans
- Reliability of history
- Physical examination
- Gender precaution
- Investigations & interpretations
- Diagnosis & surveillance
- Scheduling a procedure
- Informed consent & refusal
- High risk consent
- Overlapping specialties & systems
- Documenting conversation
- Seed and soil theory
- Breaking a bad news
- Expressions to be avoided
11 12 13 14 15 16 17 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 37 38 40 42 43 44 45 47 48 50 51 52
7 THE CONSULTATION ROOM
- Well informed patient
- Technical explanation
- Medical Council guidelines for a prescription
- Remembering names of drugs
- Selection of drugs
- Generic vs brand names
- Dosage of drugs
- Prohibited drug combinations
- Advice on lifestyle modification
- Referred by a Doctor
- Referral to another consultant
- To get another letter from family Doctor
- Collection of fees
- Patient left without paying fees
- Doctor as patient
- VIP as patient
- Your relative as patient
- Prescription by phone
- Medicolegal procedures
- Accident register & wound certificate
- Request for postmortem examination
- Visit of law enforcing officers
- Visit by social friends
- Visit by medical representatives
- Attitude towards co-practitioners
- Issuing certificates
- Updating CMEs & Workshops
- Periodic recertification
- Media statements & interviews
- Licence from statutory bodies
- Mass casualties
- Prescription pad by pharmacy or diagnostic centre
8 THE CONSULTATION ROOM
- Family practice & house visits
- Death in residence
- Death in consultation room
- Injection reaction
- Details of attendant
- Indicate report to be mailed to patient
- Remembering quotation
- Social media
- Community service
- Free service
- Getting lab reports by SMS
- Alternate power supply
- Sharing consultation room with others
- Doctor going on leave
- Professional confidentiality
- Supporting professional bodies
- Pediatric patient
- Geriatric patient
- Pregnant or lactating patient
- Psychosomatic disorders
- Psychiatric patient
- Noncompliant patient
- Clinical trials
- Preventive healthcare
- Humor in medicine
- Twelve Commandments
- Etiquette & ethics
- Japan’s secret for success 105. Concluding philosophy
95 96 97 98 99
100 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 121 122 123 124 125 127 128 129 131 133 134
9 THE CONSULTATION ROOM
1 Why growing public dissatisfaction about medical profession ?
Though medicine is advancing leaps and bounds, ironically patients’ dissatisfication is also on the rise. There are many reasons for this unfortunate situation :
High expectations, in view of the scientific advances, specialization and superspecialization of Doctors.
Increased awareness of their rights and privileges.
Ready access to information in various media and internet.
Corporate phenomenon & aggressive marketing.
Suboptimal communicative skills or lack of diplomacy.
Consumer activism and low threshold of the society for litigations.
As in any profession, we also have a few ‘black sheep’, though vast majority of us do honest, sincere job.
I tried to analyse some of these issues and suggest practical solutions, in an earnest attempt to reverse, or at least slow down this trend.
“Our hospital has the very best technology. I’ll be using GPS to locate your appendix.”
11 THE CONSULTATION ROOM
Why clinical diagnosis ?
Even in this era with high tech diagnostic armamentarium, there is still a place for clinical diagnosis, to :
Short list the differential diagnosis.
Minimize the investigations, save time & expense.
Derive emotional satisfaction by the clinician about his clinical acumen.
Make a physician expedient and cost-effective.
Boost patient’s satisfaction and confidence, by detailed systematic physical examination.
Improve Doctor-patient relations
“It’s just a new patient security system to verify your identity before we are allowed to give you any medications or discharge instructions.” 12 “Dress makes the man”
THE CONSULTATION ROOM
The tranquility the patient gets, as he walks into a neat, hygienic, tastefully decorated environment is of immeasurable value, particularly if he is under distress and emotionally charged because of the illness and anxiety of its cost and outcome.
There is no need for exuberant appearance nor ugly exhibition of wealth in the architecture, beyond a certain point. Sometimes it may create a negative opinion, under the fear that those overheads might reflect in the ultimate cost of services.
A warm reception with a smiling face, by a neatly dressed Doctor, preferably wearing a white apron, inviting him into the room by his name, is very refreshing and puts any one at ease, for further proceedings.
“I would be a lot healthier if you’d stop finding things wrong with me!”
3 Ambience & attire
13 THE CONSULTATION ROOM
Qualifications, certificates & photos
“Sometimes we have to see to believe, when happenings are unanticipated”
To discourage unqualified ‘Doctors’ (quacks) from practicing, it is prudent that every qualified practitioner displays his academic qualifications, Medical Council registration certificate, as well as any other awards and appreciations received in profession, in the consultation room or the waiting hall.
Whenever there is dissatisfaction or distrust about the management of a patient or the conduct of the Doctor, the patient or his family would certainly be reassured to see the qualifications for themselves and any apprehensions about the bonafides would be dispelled.
Recently, to weed out quacks, Medical Councils of Tamil Nadu and few other states have installed a dedicated software, that by sending the Doctor’s Registration number (displayed in the office) by SMS to a specified number (it’s 56767 for TNMC), a prompt automatic reply will be received, mentioning the name of the Doctor, reassuring the patient about the status of the Doctor he’d seen or going to see.
If the Registered number displayed by the ‘Doctor’ is ‘bogus’ or belongs to some other Doctor, the response will reveal the name of the Doctor, to whom the number belongs. Now it’s obvious that we should exhibit our Medical Council Registration certificate in a prominent place in our office, for ‘our own good’.
“It seems all Doctors agree with you, but I’d still like to get a 5th opinion.”
14 THE CONSULTATION ROOM
“First impression is the best impression”
In my opinion, next to the expertise of the Doctor, this is the most important area in the entire set up. A neatly-dressed, pleasant- looking receptionist, capable of communicating in the language of the patient, is an asset. If he also has some medical knowledge, it certainly helps.
It should be realized that the patients may put up with rough behavior of the consultant, but certainly don’t tolerate unwelcome conduct of the staff working with him, including junior Doctors. She has to maintain the Day’s Schedule on Doctor’s desk, to indicate details of patients waiting to be seen, whether they have appointment and new or old.
If you want to reduce your ‘over heads’, the receptionist or secretary at the front desk should be ‘omnipotent’, i.e., capable of handling many fuctions, such as giving appointments, streamlining those came with appointments, retrieving patients’ records & putting them back in place afterwards, fixing appoint- ment with other consultants, scheduling scans, attending to patients requiring
immediate attention, keeping the waiting patients informed in case you are delayed for some reason, assis- ting you in examining a female patient, doing dressings or suture removal, collecting fees and of course, oversee the total upkeep of your office etc.
5 Reception desk
15 THE CONSULTATION ROOM
Furniture & equipment
An elegant table, Doctor’s chair, chairs for the patient, an examination coach of proper height with a thin foam bed, a 3- seater sofa for attendants (and also to examine patients, who can’t climb the examination coach), and good lighting, are desirable in the Doctor’s chamber.
Basic equipments such as a stethoscope, thermometer (standard, digital or infrared), blood pressure (BP) measuring apparatus (standard or digital), tendon hammer, torch light, tongue depressor, measuring tape, room air freshener and emergency light, may be available in most of the consulting rooms.
A hand sanitizer dispenser, either manual or sensor-triggered, has become a necessity nowadays, to prevent cross infection, soon after you had examined a patient. But it would be highly desirable to also have the following gadgets, especially if the Doctor is a surgeon in any speciality :
Digital pulsoximeter, ophthalmoscope, nasal/ear speculum, rectal gloves with lubrication, a sterile dressing tray (with a tissue forceps, 2 hemostats, suture removal scissors and a few pieces of sterile gauze), a wide-bore needle (to aspirate a suspected abscess or hematoma) and a roller bandage. Any more, such as an ECG machine, suction apparatus, hand-held Doppler, transillu- minoscope or personal protection equipmet (PPE) etc. are optional.
Gastroenterologists perform endoscopies, both diagnostic and interventional, in their offices. A foot stool about 25 cm (10”) height is very useful for the patient to climb the examination coach and also to examine patient’s feet, legs, scrotum or groins, in standing position. A wash basin and a clean toilet facility are of course, essential.
16 THE CONSULTATION ROOM
7 Assistant (ante) room
Besides the equipments mentioned, facility to administer injection, IV fluids, passing an NG tube or giving a glycerin enema (practoclys), should be available in Ante Room, where the Assistant Doctor or Duty Nurse sits. The Assistant or Nurse may also give some injections to provide symptomatic relief, till the Doctor is able to see the patient.
This is important, since the patient will be happy that someone attended on him immediately and made him comfortable, while waiting for the Doctor to see him. Having a cable TV installed at a vantage point in the patients waiting area is optional, but there’s always a risk that a women seriously watching a TV program, when her turn of seeing the Doctor comes up, requesting the receptionist to send some other patient in, since she didn’t want to miss the program !
Emergencies are bound to occur in our profession. Facilities to give first aid and resuscitation, at least with an ambubag and emergency drugs, such as steroids, adrenaline, deriphyllin, nitropatch, analgesics (ketorol, tramadol, diclofenac, buscogast), PPIs, antiemetics etc. should be available.
Of course, CPR facilities, including laryngoscope (in working condition), endotracheal tubes, long (spinal) needle for intracardiac injection etc. are optional. Availability of a wheelchair for patients who can’t walk is definitely appreciated by the families.
A CCTV unit, to keep track with the movements in and out of your office, has become a necessity, in view of the increasing security hazards in recent times (vide infra).
Keeping an automatic vending machine for soft drinks, a snack bar or a book shop is purely optional, but may be helpful to patients, who have to wait for longer periods in the office, for various reasons.
17 THE CONSULTATION ROOM
Financial logistics may decide, if the Doctor should house facilities, such as a pharmacy, clinical laboratory, physiotherapy unit, an x-ray or an ultrasonogram unit, within the office complex. If the office is located in a hospital building, duplication of these services will be redundant.
Otherwise, the volume of Doctor’s work, to feed these units without the outside support, may be a deciding factor, besides the available financial resources.
Additional equipment may be needed in various speciality areas, such as Gastroenterology, ENT, Ophthalmology, Orthopedics, Diabetology, Dental surgery, Cosmetology etc.
“Hmmm … no health insurance. Take him to Intensive I don’t care unit.”
18 THE CONSULTATION ROOM
8 Consultation room at residence
It may become a necessity for many Doctors, especially for those in Govt service, getting relocated from time to time, to improvise a consultation room in the residence itself. This has both advantages and disadvantages.
The advantages are, minimal overheads, no additional rent, no commutation time (sometimes, Doctors spend hours to travel back and forth), available all the time and if there’s no work, one can attend to any ‘home work’ required or spend time with family and children.
All that’s needed is to keep it clean with some domestic help and one assistant to help you during the consultation times. Being a part of the residence, someone in the household can remind you about taking the medications required, on time (through intercom) and send you some beverages for ‘intermittant’ hydration, during your long consulting hours.
The drawbacks are that you may be disturbed by patients during odd hours and may have to compromise on the ambience, equipments and parking facility within the available space.
“I can’t read a word of this essay of yours. Excellent work.”
19 THE CONSULTATION ROOM
Many of our patients (especially from rural area) may not be acquainted with appointment system and they need be primed to your system in a sympathetic manner. But many general practitioners or even consultants, don’t give appointments to individual patients, they only have ‘consulting hours’ and ‘token’ system.
Under such situations, the patients, sometimes have to wait for long hours to see the Doctor, which is not fair. A genuine emergency, such as an accidental injury or cerebral/cardiac event, may be exempted from our ‘formalities’, meant for routine patients. The appointments may be requested or given on phone, SMS, WhatsApp, Email, as convenient. It is better they give sufficient advance request, if they want to see the Doctor on a particular day, provided the Doctor is available on that day.
How much time to be given for each patient to be seen by the Doctor, depends on several factors, whether it’s general practice, speciality, what speciality, how expedient is the consultant etc. New patients may require more time whereas less for review patients. In our experience, on an average about 8-10 min for each patient is sufficient, which works out to 3-4 patients in every 30min slot. In special situations, such as pandemic, more time may be needed to observe all the precautions by the medical personnel, against the infectious disease.
To avoid doubts about the genuineness of the urgency, it’s better the patient brings a letter of reference from the Doctor, who had seen him earlier. Or still better, a phone call from the referring Doctor to either the consultant or the reception, requesting for an urgent appointment, which is invariably obliged. If the Doctor is not in the office, when the patient lands, the receptionist should try to contact the Doctor to get immediate instructions, till he’s able to see him.
20 THE CONSULTATION ROOM
Under such situation, it’s highly desirable that the consultant himself directly talks to the patient or attendant, to get the first hand information about the ‘urgency’ and decide the immediate plan of action. It not only reassures the patient, their reverence on the consultant mounts up considerably.
When we give appointments to patients, we should note their contact numbers, so that they may be informed, if there’s any changeintheschedule. ThiswillalsogivefreedomtotheDoctor, if he has to leave town, at short notice.
Patients generally prefer to see a ‘busy’ Doctor, but ironically, expect or demand an early appointment and minimum waiting time in the office. You should keep in eye on the person giving appointments, so as not to do unscrupulous business out of it by offering special favors. Beware, if we keep the waiting time to get an appointment too long, the patients may get well and cancel their appointments.
“I was so tired at work, the other nurses had to revive me with C.P.R. – Coffee, Pepsi and Redbull”
21 THE CONSULTATION ROOM
Patient comes to your clinic by mistake
If a patient by mistake comes to your office, with reference letter addressed to another consultant from his family Doctor, it’s ethical to explain this to the patient and advise him to go to the Doctor, to whom he was referred, even though you may also belong to the same specialty.
But inspite of it, if the patient insists in seeing you, then you are justified in entertaining his request. It’s in order, after the consultation process, to give the ‘usual’ reply to his family Doctor, adding an explanation, under what circumstances he saw the patient.
“You are suffering from a new syndrome : REMOTE CONTROL THUMB.”
22 THE CONSULTATION ROOM
11 Patient without appointment
If it’s genuine emergency, it’s only fair that the Doctor attends (condoning the lack of prior appointment) on him at the earliest and plan for appropriate course of action, depending upon whether the problem is medical or surgical, whether you are the right specialist and whether he requires admission to a hospital or not.
If there is no true emergency problem for the patient, the Doctor has three options, refuse to see him or try to see him at the end of the day’s work or the assistant may order necessary investigations and arrange for an earliest appointment with the Doctor. First option is most logical, if the patient is a habitual defaulter in this regard, but the assistant may give him an interim prescription (preferably in consultation with the senior) and some fees is collected from him. If the Doctor chooses second option, additional amount may be collected over the regular fees, as a penalty, to discourage him for repeating the same mistake in future. In all situations, where the consultant hasn’t seen the patient, it’s advisable that some interim treatment is given (by the assistant), to satisfy the patient, to some extent and also to justify collecting some fees.
Some patient coming with an appointment, at the end makes a request to see another person accompanying him (without an appointment), who may be having some problem. Under such situations, if you feel his (other person) problem requires immediate attention, you may advise him to see the reception, to go through the standard protocol, so that you may see him as early as possible. If you feel the matter is not urgent, you may ask him fix a regular appointment, for a detailed evaluation. Best way to avoid such unwanted intrusions would be by politely telling them ‘I don’t like to see any patient in a hurry, inviting the possibility of commiting a mistake’. Same procedure may be followed, if the patient reports late, after the reasonable ‘grace’ time. We have to be lenient to a patient who claims he’d taken an appointment, but it’s not recorded in your offce, since it’s possible that your secretary failed to note it in the book.
23 THE CONSULTATION ROOM
This is an important asset for any Doctor, to be credited with ready accessibility and availability. The happiness the patient derives when he’s able to talk to his Doctor, whenever required is immeasurable and it over compensates the inconvenience, the Doctor may experience.
If the Doctor is preoccupied at the time he gets a call, the patient may be asked to call back at a convenient time or to send an SMS if it’s urgent. If the Doctor needs to verify the records to give a proper reply, the patient may be asked to call his secretary during working hours, to retrieve his records and place them on the Doctor’s table for review. If the Doctor feels that the patient has to be seen by a Doctor immediately, the patient may be asked to come to his office, if the Doctor is able to see or asked to go to a hospital of his (or Doctor’s) choice, where some Doctor can see and discuss with you about the management, till you’re able to see him.
We have to remember that we may have ‘consulting hours’ according to our convenience, but the diseases have no ‘manifestation hours’ and our prompt service at critical times, goes a long way in our professional credentials.
A highly duty-conscious, dedicated Doctor was living with his wife and a child. His wife always wanted him to take her out for eating, movie or some entertainment, but he couldn’t spare time. Even the day they planned to go to a movie, he got cought in an emergency and had to cancel their program, at the last minute. She was terribly annoyed, depressed and got dejected over these incidents. The ‘eye-opener’ for her came one day, when the Doctor was out of town and their child was taken seriously ill. She had tough time finding a Doctor to attend on the child, during odd hours on a holiday. Then she realized the importance of availability of Doctors for medical emergencies and never complained about his commitment to profession, later.
24 THE CONSULTATION ROOM
13 Social engagements
We get invitations to many functions, weddings etc. from friends and relatives, some of them may be so important that we have to attend. Unless we maintain a separate planner for outside engagements, we are likely to forget and miss them, only to regret later.
Another problem is misplacing the invitation card, not able to find when required, to know the venue, time etc. It’s very useful to maintain a ‘monthly’ planner (for the current and next month), displayed in a prominent place and preserve all the invitation cards (which you decided to attend) in seven ‘pigeon holes’ in a cupboard, one for each day of the week, making it easy to locate.
A Doctor is considered an important person in that area and his attendance for a function would certainly make the organizers very happy and every one appreciates your social outlook, inspite of busy profession. We must realize that man is a social animal and can’t live in isolation.
“Testifying against another Doctor would violate my ethics, so I’ll have to charge double.”
25 THE CONSULTATION ROOM
Most of the Doctors work late hours in the night. We must remember that it’s our life profession and not a hobby. If you have school-going children, it’s better you program your activities, so that you can spend some time with them, otherwise they miss you. For example, if you’re a surgeon operating early mornings, kids go to school by the time you come home after surgery.
If you start seeing patients in your office early afternoon, you’re not home, when your children return from school. Suppose you work late, they may go to sleep by the time you reach home. So they never get to see you at all on week days. There is a possibility the kids may tell their mom, when they see you on a Sunday ‘mom, uncle has come to see you’.
Till the kids grow up, it’s your responsibility to spare time to interact with them, at least by returning home early in the evening. This will give you an opportunity to assess their intellectual growth and also to attend some important social engagements.
Improper scheduling of working hours is the main reason, why we don’t find many Doctors in social gatherings. Doctors working in Govt service, may plan private consultations during late hours. In fact, those in Central Govt service are not allowed private practice.
“Hospital regulations. You gotta wear the strips while I read the bill.”
26 THE CONSULTATION ROOM
15 Patient reporting morning with evening appointment
If the Doctor has visiting hours in two sessions, morning and evening, some out-of-town patients with evening appointments, may report in the morning itself. It’s very advantageous, if possible, the Doctor can briefly see them and order for necessary investigations.
They will be ready with those reports by evening, when the Doctor can see and dispose, so that they don’t have to stay ‘over night’, at additional expense. If some lab reports are awaited, if they are very important, there is no choice for the patient, except to stay on, till the next day.
Otherwise, they may be permitted to leave, make a call next day about the reports, any additional instructions required, may be given by the Doctor on phone and the reports mailed to the patient. By this arrangement, the patient will be fully satisfied about the efficiency and expediency of the whole set up, which is the ‘bottom line’ of all of our efforts.
“Considering the obvious lies on your information form and my tendency to misdiagnose, we should get along just fine.”
27 THE CONSULTATION ROOM
‘Those who come late are not busy, but lazy’
Respecting the value of time of everyone, we should try to be as punctual as possible. An anxious patient tends to be more and more emotionally disturbed, if he has to wait for hours, to see the Doctor. If the Doctor is held up in an emergency, the reception should brief the waiting patients about it and indicate the approximate time Doctor is expected to be in the office.
It’s nice for the Doctor to express, when the patient is called in, a word of regret for the delay, mentioning the reason. If you are a surgeon, best way to maintain punctuality in office is to schedule surgeries not during consulting hours, say early mornings.
Other advantage in early morning surgeries is some unexpected and more important assignment during day time, may dislocate or disappoint patient scheduled for surgery or their attendants, upsetting their plans for the day. Patients definitely appreciate our ‘time sense’ and commitment to stick to the schedules.
“Conventional medicine says take Aspirin. In the incence of tort reform, defensive medicine says MRI and Cat Scan.” 28
-Mahatma Gandhi THE CONSULTATION ROOM
“Smile on your face is an inexpensive way of improving your looks”.
Doctor should receive the patient into his chamber, with an attitude depending upon their earlier relationship. After the usual pleasantries, it’s better to start with some nonmedical subject (other than the patient’s illness), may be related to the attendant.
For example, if patient’s daughter is accompanying him, you may ask her what she’s studying. Suppose she says ‘I’m doing MSc Physics’, you might say ‘Oh ! Physics was my favorite subject, I used to get centum. In fact, I wanted to become an engineer, but somehow, I became a Doctor’. Such conversation puts them at ease, tends to identify with the Doctor, before actually going to the subject.
It’s also nice, if any major event in the patient’s family, such as graduation, marriage, child birth, major accident/illness or death, is brought to your notice, to make some enquiries and offer your feelings about it.
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Of course this gives you the most important information, to arrive at the probable diagnosis or at least short list the differential diagnosis. Attentively listening to what all the patient wants to say, would give you some valuable clues whether it’s organic or functional and also very vital to gain their confidence.
If you feel he is drifting away from the main subject, you may put a leading question, to bring him back on the right track. A study revealed that now a Doctor spends 30-40% less time with his patients, compared to 40-50 years ago, which is responsible for eroding into the all important ‘Doctor-patient relationship’. Losing emphasis on clinical diagnosis is a very important reason for escalating the cost of medicare.
Best way to gain confidence of the patient : maintain good eye-eye contact, keep the external interruptions (on your mobile or the intercom) to minimum, review all relevant records patiently and ask pertinent questions in eliciting history.
It’s better to ask all the attendants including the nurse, to leave the room, to ensure strict privacy, before asking personal questions, such as sexual history (marietal or extramarietal) or erectile dysfunction etc. or any other confidential matter, he may want to disclose. We should remember, they may even hesitate to talk about their smoking, alcohol or other unhealthy habits in the presence of elders, out of respect.
As you are doing physical examination, you may ask more questions, initially overlooked or felt necessary in view of certain findings. History related to incidental diseases discovered, such as a thyroid nodule, umbilical/inguinal hernia, hydrocele, sebaceous cyst, lipoma, phimosis, halux valgus etc. which may or may not be related to his primary problem, has to be noted for future reference.
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It’s very annoying to the Doctor as well as the patient, if their conversation is getting repeatedly interrupted by phone calls or assistant’s visit to the Doctor’s chamber. It’s important to create an impression to the patient that his matter is the most important at that point of time and the Doctor is giving his ‘undivided’ attention in that respect.
We should keep such interruptions to minimum, preferably to the short gap ‘in between’ patients. It’s also undesirable to discuss on phone about a patient, critically ill (in ICU) or expired, which may generate negative thoughts in the patient sitting in front of you. Of course, the patient and the attendants should be instructed to switch their mobile phones to silent mode, before entering into Doctor’s room.
Continuous noice of an AC unit may be disturbing, unless it’s a split type or there is central air-conditioning unit. Similarly we should avoid external disturbances from the adjacent room or the neighboring areas, which will disturb the tranquil ambience and requires louder voice, to make the conversation audible.
“We have two options. I can open you up again or I can report the watch stolen and split the insurance money with you.”
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“If you talk in a language which one understands, it goes to his head, but if the same is said in his mother-tongue, it reaches the heart”. -Nelson Mendela
If you have problem communicating in their language, request any of the attendants to assist you, or get an interpreter, who knows both languages (yours and patient’s). It’s advisable that the consultant makes an attempt to learn those languages, mostly required to improve the efficiency of his professional work.
After my return from USA, I started practicing in Chennai in 1970, when I didn’t know a stroke of Tamil. My elder brother, a graduate of Kilpauk Medical College and a leading general practitioner, whenever he sent a patient to me, he used to send an ‘intelligent’ interpreter along, with instructions about what to (I should) tell the patient, regardless of what I might say, since he felt I couldn’t communicate well !
You have to put all your efforts to ensure there is no communication gap because of language issue and the patient should leave your room with a satisfaction that he conveyed everything he wanted.
In city practice, patients belonging to various languages come to us, it’s important to make a note in his record the language(s) the patient can speak, so that you can converse in a language comfortable to both on future occasions.
“The Doctor just finished his rounds.
I better go soothe the patient’s psyches.”
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21 Making notes & plans
The consultant’s memory is fresh about the entire picture, soon after the initial interview. Subjected to the results of the investigations, that is the best time to formulate a tentative prescription in his notes. When the patient returns with all the reports, if they are found to be normal, prescription can be simply copied from the notes, if necessary with some modifications.
Any future plans for more studies or consultations may be noted in the file and accordingly patient briefed, so that he’d come prepared for them, if necessary. Important health events in the past have to be noted for future reference or correlation with the present illness.
History of co-morbidities, relevant family history and known allergy to drugs have to be written in bold in the patient’s file, to attract our attention every time we write a prescription for him.
“Yes this is a family practice, but you’ll have to make separate appointments.”
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Reliability of history
By and large the history given by the patient or parent/guardian, can be taken for granted and any wrong information given is usually by oversight and not intentional. However there may be some situations, the Doctor has to be very cautious.
We all know the story of Munchausen, a laparotomophilic malingerer, who presented to various hospitals at various times, with ‘typical’ symptoms and signs of surgical diseases, luring them to carry out multiple laparotomies, for no organic illness, before the days of noninvasive imaging technology.
Besides this, deliberate misleading history may be given in medicolegal matters, insurance coverage reasons, workmen compensation purposes, parental disharmony (as in battered child syndrome) and so on. In such situations high index of suspicion is necessary, especially if you have to issue any certificate, so as not to allow yourself supporting unscrupulous elements.
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23 Physical examination
When any patient voluntarily walks into your consulting room, it implies that permission is given to elicit history and perform physical examination on him. However, it’s prudent to delibera- tely ask for permission and record the consent. Special permission may be required to examine pectoral region / breast / axilla of women, genitalia and do digital pelvic (vaginal) or rectal examination. It’s logical not to perform vaginal examination in a virgin (or unmarried) woman.
The physical maneuvers that impress the patient most about the ‘thoroughness’ of your examination are : tongue & throat, eyes for pupillary reflex (or even fundus, if you have an ophthalmoscope and trained to do), auscultation of chest (to pick up respiratory adventitious sounds or cardiac murmurs), & neck (carotid bruit), tendon reflexes and digital pelvic & rectal examination.
This approach is very useful, if you are dealing with a psychosomatic disorder, to gain confidence of the patient, which makes your prescription work. Most of them are easy to perform, may be a bit time consuming in the midst of a busy clinic, but worth the effort, if you have to score over other Doctors, who treated the patient earlier.
‘If you don’t want to put your finger in the rectum, you may have to put your foot in it’ – Hamilton Bailey
Surprisingly, women don’t hesitate to undergo pelvic (PV) examination by a male Doctor in the consultation room, provided you are ‘senior’ enough and have a female assistant with you. During our training in USA, our teachers impressed upon us the value of pelvic examination to a ‘general’ surgeon, since for any patient referred to us for evaluation of vague unexplained abdominal pain, our opinion as to its cause, should be final, hence our examination had to be comprehensive (literally no stone unturned). Of course, we should always do PV before PR, if we have to do both, for hygienic and esthetic reasons.
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Remember the saying ‘don’t insult vagina, by doing rectal examination first’. If prostatic carcinoma is suspected, it’s advisable to have the patient’s blood sample collected for the estimation of serum acid phophatase (SAP) and prostate specific antigen (PSA), before carring out PR, since they may be elevated (transient) after prostatic massage even in benign conditions.
The examination coach should be so placed in the room, so that the patient can be examined standing on his right, however if you are left-handed, you have to stand on the left of patient. Certain clinical tests are better avoided; examination in knee-elbow position (inconvenient) and Kocher’s sign for tracheomalasia, in long standing large goiters (risk of producing acute airway obstruction).
This was how physicians used to hear lung and heart sounds before Laennec invented stethoscope in 1816. Doctors over centuries never forgave him for his invention.
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24 Gender precaution
Male Doctor should have a female nurse or attendant, while interrogating and examining a female adult or while a female Doctor examining a male adult.
Of course, parents or some elders in the family may be allowed with their children of any gender.
Not observing this precaution has been a common cause of litigation, arising in consultation rooms.
If you can provide a screen or curtain, isolating the exam coach in your room, any male attendant of a female patient may be allowed to stay in your room. Sense of security is maximum for a woman being examined by a male Doctor, if her husband or father is with her in your chamber, of course with a female assistant standing by you.
“She allowed this when we told her that this is antiviral software.”
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Investigations & interpretations
There has always been a public hue and cry that too many unnecessary investigations are being done by the Doctors, with some unholy nexus with diagnostic centres. Over the years, a few Doctors have given room for such criticism against the ‘noble profession’, though many still observe strict ethical values in ordering investigations.
To say that this is a universal phenomenon, is of no relief to an individual patient, who spends twice the amount for any scan, as against it’s actual cost nor is an excuse for an individual Doctor. An investigation, which doesn’t influence the management (either in diagnosis, treatment or prognostication), is considered academic and only adds to the cost of medicare.
Unfortunately, there is no law preventing a Doctor doing any investigation, but he may be questioned if a particular investigation wasn’t done in time, which would have identified the disease earlier. This has become very convenient in a corporate set up, which believes in carrying out ‘thorough’ investigations for any patient, even apparently with a common ailment.
Consumer activism also played its role in encouraging commercially-oriented Doctors to over-investigate, so as not to miss a disease, which may occur in one out of hundred such patients. This is the main reason why in most of the western countries, especially in US, the medicare is very expensive and by and large considered cost ineffective.
It’s very useful to have the urine sugar of a known diabetic patient checked by your assistant or nurse, at least by the stick test, before he is allowed to see the Doctor. Any alteration in the anti-diabetic treatment may be made accordingly. As a rule, less expensive and noninvasive investigations have to be done first and resort to more expensive or invasive ones, only if the earlier tests couldn’t clinch the matter, to proceed with treatment.
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We should avoid carrying out investigations, which are considered non-reproducible. A test giving different results in the same patient at different times, such as random plasma glucose or gastric analysis, have limited diagnostic significance.
Nowadays, we don’t ask for motion examination as a routine, for aesthetic reasons and the inconvenience involved, unless we are looking for something specific. It’s very important to establish tissue diagnosis in cancers, before offering treatment.
One elderly patient came to us, after getting discharged from a ‘teaching’ hospital, with a label of advanced cancer of lung, diagnosed by a CT scan. Since his daughter’s wedding was to be performed a month later, they just wanted my help to keep him alive till the ceremony was over.
While perusing the hospital records, to my surprise, I found the diagnosis was not clinched by histopathology. On careful examination, he had a palpable supraclavicular node; we did excision biopsy, reported as tuberculosis. Now, after 5 years, the patient is well, playing with his grandchildren. While looking at an x-ray or scan, always verify the name and date printed on it, to avoid studying the report of a wrong patient.
“When it comes to bustin’ a kidney stone, the old methods are still the best.”
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Diagnosis & surveillance
It’s said ‘three important things in the management of any disease are, Diagnosis, Diagnosis & Diagnosis’. ‘If you make a rare diagnosis, you may be rarely correct’. But it’s also said ‘if we don’t diagnose rare conditions, they become still rarer’.
External conditions such as skin diseases, lipoma, dermoid or sebaceous cyst, Dupuytren’s contracture, parotid swelling, cleft lip, torticolis (wryneck), hemangioma, varicose veins, phimosis, hydrocele (in the scrotum or neck of a child), inguinal or ventral hernia, hemorrhoids, prolapsed rectum or uterus etc. known as spot diagnoses, can be identified by mere inspection.
Some minimum investigations are required for many diseases and more elaborate studies needed for a few. Most of the time, the diagnosis can be reasonably arrived by good clinical examination, radiology (imaging), biochemistry, microbiology, immunology, cytology or histopathology (tissue diagnosis). Immunohisto- chemistry (IHC) gives us further confirmation and sub classification of lesions.
‘The abdomen is a temple of surprises’, once a very popular adage, has become an ‘open book’, with the advent of noninvasive imaging and fibreoptic endoscopies. For deeper, inaccessible lesions, image-guided biopsy may be required to establish diagnosis.
Diagnosis and staging malignancies have become very easy with Positron Emission Tomography (PET) scan, which gives us both anatomical and functional details, also used to monitor response to therapy. Biochemical tumor markers are very useful for post- therapy surveillance, in conditions of thyroid, ovary, prostate, neuroendocrine tumors etc.
Giving full account of the applications of various diagnostic tests is beyond the scope of this book, suffice to say that with the availability of more and more advanced, sophisticated studies in
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various fields, the number of undiagnosed (enigmatic) conditions become less and less. It should also be cautioned at this juncture, we should be aware of the limitation of every test, in terms of its sensitivity and specificity, before we can draw inference.
A test is more sensitive, if it gives few false negatives and it’s considered more specific, if it gives few false positives. . A negative needle biopsy has to be viewed with caution, due to possible errors of sampling and interpretation.
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Scheduling a procedure
Minor procedures, such a drainage of a superficial (subcutaneous) abscess, suturing a minor laceration, punch biopsy of an ulcer tongue, cheek, cervix uteri, rectum or skin, core (tru-cut) needle biopsy of a not-so-deep, >3cm sized mass, placement of secondary sutures, paracentesis of abdomen or chest, suture/clip removal etc. can be safely done in an office set up.
Major procedures requiring admission and anesthesia, have to be scheduled in hospitals, where the Doctor has privileges. However the choice of the hospital depends on the infrastructure required for the particular procedure, availability of room and operation theatre, tariff structure, presence of insurance cover and of course, the patient’s preference, if any.
The patient has to be adequately counseled, all his doubts cleared including approximate total cost, number of days required to be in the hospital and any relevant preoperative instructions. Under instructions of the Doctor, this process is usually carried out by an experienced receptionist, including collection of some advance amount from the patient for the service of the Doctor.
It’s also important that the co-morbidities of the patient, such as anemia, diabetes, hypertension, ischemic heart disease, COPD, hypothyroidism, convulsive disorder, azotemia etc. are properly addressed.
“Your health Insurance doesn’t cover heartburn. You need fire insurance for that.”
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28 Informed consent & refusal
This is usually required for patients to be admitted for surgery and not for out-patient care. Since it’s a legal document, all the prescribed formalities have to be followed, properly recorded and signed by the patient/guardian and some relative/attendant as witness.
All those who signed, have to be properly identified in capital letters and the document kept in safe custody. However, if the patient refuses admission or a particular investigation as advised, it is also recorded in his file and signature for ‘informed refusal’ obtained, to avoid future litigation.
Since there are no hard and fast rules, we always have a dilemma, how much to inform the patient, regarding his illness, the proposed operation and the complications. As a general rule, only probable (and not possible) complications need to be discussed, before getting the consent. If we narrate all ‘possible’ compli- cations of an operation to the patient, many may hesitate or refuse to give permission.
The wisdom and judgment of the Doctor, dictated by his experience, should guide him how much to ‘disclose’ to the patient. In any event no guarantee should be given about the outcome of any major illness or procedure, since ultimate result depends on so many factors, beyond the control of the Doctor.
If the patient is a minor, parent or guardian should sign the consent form. In an emergency situation, such as an accident, requiring immediate intervention, if no one who has the legal authority to sign, is available, a second opinion from a senior Doctor may be recorded, before proceeding with the ‘life-saving’ procedure. The family members, however, should be contacted and the critical situation explained on phone and oral permission obtained, which may also be recorded.
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High risk consent
This is obtained when the outcome of a procedure is uncertain, but it has to be done to save life. It may be due to age, co- morbidities or the nature of the procedure. It is preferably hand- written in patient’s own language, outlining the reason for the additional risk and the need for the procedure.
Besides the patient, at least two of his close relatives should sign and identify in capital letters. Not only it provides additional legal safety, it also prepares their mind to accept some adverse outcome, if such a contingency arises.
Before leaving this subject, it’s important to realize that obtaining a ‘proper’ consent for a procedure does not provide immunity against litigations, arising out of professional negligence, incompetence or deficiency of service and so on. However, if a procedure is done without a proper consent, it may become a criminal affence, hard to defend.
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30 Overlapping specialities & systems
In Indian scenario, this is unavoidable to overlap into areas other than ones specialization. Most of the specialists do some family practice as the situation warrants and some maintain two clinics, in one as a GP and in the other as a consultant. Many general surgeons are ‘all rounders’ depending upon their training background and force of circumstances.
Hysterectomy and Cesarean section are the classical such examples, which are commonly performed by general surgeons, family physicians and of course by gynecologists. In moffusil practice, spinal anesthesia is usually given by the surgeon himself, monitored during the procedure by one of his assistants, due to nonavailability of anesthesiologists.
We know one General Physician (MD-Gen), while working in Railway service as Medical Superintendent, started doing closed mitral valvotomies (CMV), that he was honored by awarding ‘Padma Sri’ by the Govt India for doing large number of those operations successfully.
According to the Medical Council rules, there is no bar for even MBBS (Bachelor of Medicine & Bachelor of Surgery) Doctor to perform any ‘not-so-complicated’ operation, provided he has had the necessary training and expertise and the hospital has the required infrastructure, to justify in the event of developing some complication.
It is also common knowledge that a General Physician (Internist) overlaps into various specialty areas, out of sheer necessity, in his practice. Similarly many ENT surgeons do head & neck surgery, including thyroid and it’s still an unsettled issue, who is the preferred specialist to do disc surgery, neuro or ortho surgeon. Excision of cervical rib ‘enjoys’ maximum overlap of specialties : neuro, ortho, vascular, thoracic or a confident general surgeon (trained in vascular surgery).
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These lines of specialization are strictly drawn in major tertiary care centres, but not so in primary and secondary care hospitals. Many teachers in non-clinical departments such as anatomy, physiology, biochemistry, pathology, forensic medicine etc. do family practice, during their spare hours.
I know one postgraduate (MD) in Social & Preventive Medicine (SPM), had a very busy practice as ‘General Physician & Cardiologist’ in Chennai, by just omitting to put SPM in brackets after MD, on his name board and prescription pad.
The Supreme Court had clearly stated that a Doctor qualified in any system of medicine, is prohibited to practice other systems. However there are many ayurvedic or herbal products (used in liver disease, urolithiasis, prostatic disease etc) ‘adopted’ by allopathic Doctors and are available in regular pharmacies.
Further, in an attempt to encourage Doctors of alternate systems of medicine, the Govt of India has decided to give them more privileges. When the physiotherapists started putting ‘Dr’ before their names in the past, the medical fraternity vehemently opposed and successfully prevented it.
We have to wait and see the developments regarding the recent decision by the Govt to allow Ayurvedic Postgraduates to perform ‘minor’ general, ENT, ophthalmology, dental and orthopedic surgeries (total 58 operations listed), how the Govt is going to push the idea forwards and how the medical (allopathic) community is going to react.
The way Govt looks at it is, when the qualified allopathic Doctors are not keen on settling in rural areas, allowing mushroom growth of quacks, this may be a better option, besides promoting Indian medicine. However the logistics of anesthesia, pre and postop care, use of antibiotics, intensive care, treatment of postsurgical complications for such procedures done by Ayurvedic ‘specialists’ haven’t been clearly defined, throwing the debate of the issue wide open.
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31 Documenting conversation
In busy consultation time, recording the conversation with the patient/attendant, is not always possible in our set up, but this is routinely done in some western countries, to avoid misunder- standing later. In some centres, the entire proceedings are video recorded and preserved, to be reviewed in the event of a dispute. The office secretary transcribes the conversation dictated by the Doctor, prints it in the file. The patient, while leaving, reads and signs it, to indicate his agreement with what transpired.
For example, the consultant had suggested the patient to undergo gastroscopy, on some suspicion of a gastric lesion. The patient was not prepared at that time and said he’d undergo the endoscopy during his next visit after a month. He never reported for review as scheduled, but after a few months, when his symptoms worsened, he went to some other Doctor, who performed endoscopy and detected cancer stomach.
If the conversation with the previous Doctor was not recorded, there is a possibility that the patient could complain that the disease would have been picked up much earlier, had the Doctor suggested endoscopy last time.
Another simple viable option is, to make a note on one corner or on the reverse of the prescription paper, any important investi- gations or consultations suggested to the patient, but not done. This will serve as a proof that you advised, in the event of a dispute.
“Reflexes seem normal. You kept him waiting over two hours.”
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Since many diseases are self-curable, ‘medicine is an art of entertaining the patient, while nature cures him’
This is an integral component of our daily activities and requires, besides grip on the medical science based on a strong rational foundation, astute communicative skills and diplomacy. A diplomat is one, who tells you ‘go to hell’ in such a manner, that you actually look forwards for the ‘trip’.
An American Psychologist did a study to find out why public litigates against Doctors, interviewed several persons involved and concluded that the main culprit was inadequate or inappropriate communication. In Indian scenario, another factor, self-centered behavior of some Doctors such as, lack of empathy towards co-practitioners and the so-called one-up-manship (vide infra), may be added.
It’s suggested that certain antisentimental words, such as cancer, malignancy, TB, death, mortality, fatality etc, to be avoided, as much as possible, during counseling. Instead terms like bad tumor (or it may turn into something bad), bad lung infection or unfavourable outcome, may be used respectively.
To a patient, who came with advanced malignancy, beyond the scope of surgery, it’s much better to say that ‘you don’t require surgery’, than to say ‘your disease is too far advanced that surgery can’t be done’ or ‘surgery is useless’. The colloquial term ‘current’ treatment for radiotherapy, also to be discouraged, instead ‘x-ray treatment’ is more acceptable.
If you are planning for surgery, the pros and cons of nonsurgical options, if any, also have to be discussed. We must remember that the patients sometimes wait for days or weeks to see us, just for a few minutes and every word we say will have profound impact in his mind and influences his emotional balance.
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It’s said in lighter vain that if a patient refuses surgery for his symptomatic hernia, inspite of adequate counseling, you ask him ‘go to hell’. But make sure he goes only to hell, since there may not be any ‘good’ surgeon in heaven, if he wants to get operated there.
Two questions, often asked by patients before surgery, difficult to answer :
1) will I be alright after surgery ? We should tell them, no guarantee would be given and ask them, if they could give 100% guarantee to go to Central station and return. ‘We surgeons only cut and stitch, god (nature) heals’
If so, to expect total assurance for a major surgery is unfair and we decide for surgery, since the risk/benefit ratio is in its favour.
2) Next question is if the patient should write the Will (for his properties), before surgery. This is more sensitive issue, suppose you say, ‘yes, I think it’s a good idea’, in all probability, the patient may not come for surgery. If you say, ‘no, it’s not necessary’, it may turn out to be a wrong advice, since no one can be sure of the outcome of any procedure.
I found an answer, ‘your surgery is scheduled for next Wednesday, is there a guarantee that you will be alive till then’. To diluteit,youmayadd’willIbealivetillthen? Surgeryisonlyone event, but there are many risky situations in daily life, such as going by flight, travelling by train, crossing a road etc. which we accept and carry on. Hence if there’s a need for writing a Will, do it immediately, but not necessarily for the operation’.
You have to realize some cancers, such as papillary ca thyroid in young women, lymphocyte predominent Hodgkin’s, ca prostate, seminoma testis, carry best prognosis, where as some, such as anaplastic ca thyroid, ca gallbladder, acute myeloblastic leukemia (AML), glioblastoma multiformi (GBM) of brain are so bad and considered as oncological disasters.
“Heads, you get a quadruplicate bypass. Tails, you take a baby aspirin.”
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Seed and soil theory
Doctor should be prepared to answer even intricate or insinuating questions raised by the patients, keeping scientific facts in the background. When a patient is diagnosed to have a rare disease, generally he’d ask ‘why me ?’.
It’s a human tendency whenever one is faced with an adverse situation, but strangely no one would put that question, when something good happens, say when you win one crore rupees in a lottery or when you become the President of the country. One may call it as luck, but science may not accept it.
Remember the Chinese aphorism : ‘Luck favors the one who doesn’t believe in it’.
Most of the diseases develop as a product of genetic makeup (nature) and environmental factors (nurture). Of course the former is not modifiable, but the later certainly is. One can choose his father-in-law but not the father. This is where ‘seed and soil’ theory comes handy.
Suppose a few friends met and had some soft drink together. Only one of them develops gastroenteritis, due to suspected food poisoning. When everyone took the same drink, why one person gets it ? Does it mean all the germs got into a single glass ? No, though the seed is sowed in every one, only one fellow’s inner soil is fertile or conducive to accept it.
Medicine is a science of uncertainties and art of probabilities, since a drug which can cure some one, may kill another and many aspects of biological behavior of humans are still beyond comprehension to our present knowledge.
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34 Breaking a bad news
There may be many sensitive situations, when a Doctor has to disclose a bad news to the patient or relatives and it requires very high level of communicative skills. It may be simplified as ABCDEF :
Build a suitable ambience Communicate facts & figures Deal with emotional reaction Encourage free communication Final summary of plan of action
Of course the intellectual level of the patient/attendant also largely determines the extent of technical discussion and the type of questions expected from them. It’s very common for the close relatives of a patient with advanced malignancy, to request us to give them an idea about his life expectancy; it’s wise not to commit, since we had seen surprises and miracles. Best answer would be to say that since the genetic make up and biological behavior of each patient is different and the response to the proposed (palliative) treatment is unpredictable, a specific time frame could not be given. However they should be advised to ensure that the patient executes whatever documents required, with regards to transferring properties, business etc. as early as possible, while he is fit.
Ever since my heart transplant,
I always think of sex, money and more sex. Have I grown young?
No. Actually, the heart belonged to a prostitute! THE CONSULTATION ROOM
Expressions to be avoided
(preferred expressions in brackets)
Some expressions may generate negative thoughts in the patient or may have legal implications :
Cancer or malignancy (bad tumor or growth)
(bad lung infection or Koch’s disease)
(chronic skin infection or Hansen’s disease)
Death or mortality
(unfavorable outcome or results may be bad)
(95% of them do well)
Situation is hopeless, nothing can be done
(science is so advanced, let’s see if something can be done)
Disease is too far advanced
(never too late, but you may not require surgery)
Postop incisional hernia (ventral hernia)
(stomach upset or some thing you ate, didn’t agree with your stomach)
Drug-induced renal failure (kidney dysfunction)
(opportunistic infection, when the resistance is low)
Spinal (anesthesia) headache or shock (low or unstable BP)
(nerve irritation or pain)
(abscess due to some infection)
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Similarly, never guarantee a cure, especially on statistical grounds. For patient with a problem requiring surgery, which carried 90% risk, nobody was willing to operate.
One surgeon ‘confidently’ agreed to do it and assured the skeptical patient by saying ‘it’s true that 9 out 10 don’t survive, but since previous 9 patients for whom I did the same operation died, statistically you should be alright’.
Earlier days, Doctor could ask the patient putting irksome questions, ‘who is the Doctor, you or me ?’ But now an informed patient will shoot back, ‘of course, you are the Doctor, but you’re planning surgery on me, I have to know the score’.
“Apparently you contracted a virus from your computer,
so we had to erase your memory. I trust you had a backup copy?”
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Well informed patient
With increasing level of literacy and the plethora of information in various media, it’s no surprise, many patients do lot of ‘home work’, before coming to us and we have to carefully watch our words, while interacting with them.
We should also be prepared to face some insinuating or uncomfortable questions such as, ‘how many such operations you’d done before and what were the results, immediate and long term’? Is the Hospital you’re suggesting, sufficiently equipped to handle postoperative care ? Are you planning for conventional bypass(CABG) orbeatingheartsurgery?’
One patient came to me from a remote place in another state for lap cholecystectomy. I knew that there’re many good surgeons in his town, so I asked him why he all the way came to us.
He said ‘yes sir, I know there are many surgeons, but they’re all laparoscopic surgeons and not competent ‘open’ surgeons. I wanted some one who’s also a good ‘open’ surgeon, if conversion is required, for some reason during the procedure’.
“Here is the mood elevating medication that your Doctor prescribed. The less costly generic version is called chocolate.”
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37 Technical explanation
It’s better have some pictorial anatomical charts of various parts of the body in the office, so that the patient may be properly explained about the disease, it’s probable complications and proposed treatment.
Otherwise, the Doctor should draw a sketch diagram of the concerned part and explain the matter. Readymade pictures of the area of Doctor’s specialty, would be very handy in such situation and the patient may carry it to show to his people, if he wishes.
The level of their capacity to understand has to be assessed, before we decide the depth of meaningful technical discussion with them. Sometimes, it may be better that they don’t understand at all, than to misunderstand.
It may be difficult for the Doctor to explain certain exercises required to patients for some conditions, such as cervical spondylosis, thoracic outlet syndrome, low backache with sciatica, postpartum excercises of abdominal muscles, post- mastectomy shoulder exercises etc. Best method is to record them as videos in your mobile phone and show or forward to them, to follow.
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Obviously this is the fruit of our medical science, ultimately the patient is going to eat. As already indicated, it’s much better a tentative prescription is formulated soon after the first visit, when the memory is green, about all the details. Suitable alterations may be made, after reviewing the lab reports.
Giving an appropriate and comprehensive prescription, covering all aspects of the patient’s ailment, is an art, choosing from plethora of options available. Many Doctors, who may be academically sound, but fail in the application of their mind, while formulating the prescription.
It has been our experience that out of ten patients we see in office, 1 or 2 may require surgery, unless the Doctor strictly sees only patients referred by Internists. It has also been observed that more experienced you become in profession, less number of medicines are prescribed and indications for surgery also become more strict.
Barber (1995) recommended that we should consider four important aspects, while prescribing a medicine :
- minimize cost,
- minimize harm,
- derive maximum therapeutic benefit and 4. respect patient’s choice.
Let’s remember that ‘remedy should not be worse than the disease’.
The prescription should be legible, best written in capital letters or printed, to avoid pharmacist giving wrong medicine, for which the Doctor also shares the legal responsibility for the damage that might occur. If any of the drugs prescribed has a sedative property, the patient should be so cautioned and advised to avoid
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driving a vehicle, for a specified period, after taking that medicine or still better, to take it at bed time. You all know the story about a Doctor while on tour, wrote a letter to his wife and she had to take it to their pharmacist to read it. Of course, with the advent of social media, nobody writes letters any more.
The patient should also be cautioned about change in urine color that may occur with some common drugs :
isoniazide, sulfasalazine, nitrofurantoin, metronidazole, paracetamol
rifampicin, warfarin, phenazopyridine (Pirydium), ibuprofen
Blue or green :
amitriptyline, indomethacin, cimetidine, metoclopramide
mepacrine (antimalarial), riboflavin
Motion may turn black with preparations containing iron.
‘Every patient has to recover twice, once from illness and again from the medicines’
“Cause of death was an unexpected post-surgical complication. His wife caught im flirting with a nurse.”
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Medical Council guidelines for a prescription
With the recent notification of the Govt of India and the MCI, indeed many medical practitioners have been left confused on how to go about writing their prescriptions. Yet Doctors also need to keep in mind that there are many essential, sometimes legal requirements, that are mandated in writing a prescription, a routine, but most significant task. Here are the very elaborate guidelines :
Minimum sizes of the Prescription pad :
Depending on the requirement, two sizes of pads are suggested, they are either 21×14 cm (A5 size) or 11×11 cm.
Details of the Doctor :
Doctor’s full name, details such as qualifications, address, consultation timings, telephone numbers, Medical Council Registration number (& Registering authority), should be printed on the letterhead.
Only those degress or diplomas received through convocations should be mentioned. At the bottom, Doctor’s signature and date in indelible ink, are required to verify the authenticity of the prescription, in order to prevent misuse. Use of ‘Rx’ superscription, not a legal requirement, but most often used as a matter of practice, which comes from the Latin ‘Take Thou’.
Details of the Patient :
Patient’s full name, gender, age, weight, address and telephone number, to be shown at the top.
Details of the Medicines :
Name of the medicine – write the Generic Name in CAPITAL, with the brand name/Company or any other name in brackets. Strictly avoid abbreviations or scribbling the name of the medicines.
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Strength or potency of the medicine, form and dosage – eg : capsule, tablet or syrup etc. dosage & dosing instructions, total quantity & Refill information. If the Doctor wants the prescription to be refilled, he should clearly write the number of times it may be refilled. This is very important to deter patients from repurchasing medicines (on their own), from the same prescription, again & again, which may be potentially harmful. A rubber stamp, containing Doctor’s full name and Reg no. should be affixed below his signature, also to prevent abuse.
It’s a pity that the process is made so cumbersome, for which our Doctors are not primed, though it may be necessary, it hasn’t yet become a routine exercise by many, thanks to the inefficient monitoring system. Unfortunately, the law makers overlooked the plight of a general practitioner, especially in rural or suburban areas, who sees (has to see, rather) more than 100 patients in a day, with poor education and paying potential.
“I already diagnosed myself in the Internet. I’m only here for a second opinion.”
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Remembering names of drugs
It’s always difficult to remember the names (both generic and trade) of newer drugs entering the market. When you are impressed about a newer molecule or drug, found in the literature or when the medical representative details about it, it’s better to note it down in a booklet, including the name of the manufacturer, indication, prescribing information and the price.
Of course this booklet is only for your private reference, may need to be periodically updated, removing those, you have already become familiar, from the list, so that it would be succinct and easytorefer,whenyouaresittingwithapatient. Tomakeitstill easier to refer, we can put them in a classified manner, system- wise, by the indications. This will certainly improve your prescribing efficiency, utilizing some very useful latest drugs available in the market.
You may also refer to any Drug Info Book, such as Current Index of Medical Specialities (CIMS) or Physician’s Desk Reference (PDR), for prescribing guidance. If there’s internet facility in the consultation room, you can browse ‘medplusmart.com’ and go to ‘pharmacy’, askformedicinesprescribedforaparticulardisease and select from them, to get the generic formula, brand names, dosage, price and the manufacturers.
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41 Selection of drugs
Some drugs, which may have duel effect, may be conveniently used, if the patient has both the symptoms. We can give several examples : for a young girl with persistent vomiting of functional nature (such as anorexia nervosa), you may choose chlorpromazine, a powerful antiemetic as well as psychotropic agent.
For a women who needs to be treated for amebiasis, urinary tract infection (UTI) and pelvic infection (PID), a combination of a quinolone/imidazole, may be considered. For a man with mild BP and features of prostatism, prazocin or tamsulosin may be useful and for someone with bronchiectasis and small aortic aneurysm under observation, long term use of doxycycline may be appropriate.
If you had chosen to start an antibiotic for any infection and the patient is improving, don’t change it, just because the bacteriological report is not supporting your selection. If you wish, you may add another antibiotic based on the report and don’t allow the lab report override your clinical judgment.
If a patient calls few days after taking your prescription, says the medicines didn’t agree with him, developed ‘allergic’ symptoms and wants to know what to do. You might have given 4 or 5 drugs in the prescription and it may be difficult to identify the ‘culprit’.
Best course of action in such situations is to advise to stop all the medicines and take some antihistaminic or antacid, as the case may be. Then, after a few days, ask him to restart the medicines, one by one, with a gap of 1-2 days for each. By this method, most of the times, we would be able to identify the culprit, for which we can prescribe of a suitable (hopefully, less troublesome) substitute.
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Generic vs brand names
There are positive and negative points in both, but the Govt always focuses on the economy to the patient, even taking chances about their quality and difficulties of the profession. Unfortunately, except the cost (which is not always true), all other factors are not in favor of prescribing by generic names.
Firstly, for generations, the medical fraternity is more acquainted and familiar with the brand names, than their generic formulae.
Secondly, writing generic names of all the ingredients in multidrug combinations becomes very tedious and time consuming.
Thirdly, even it’s a single drug, when it’s prescribed in generic, the pharmacist chooses the manufacturer, naturally who ever offers him maximum margin of profit, even if it’s substandard.
Finally, some patients prefer branded medicines, made by time- honored standard companies, familiar to them. Best solution is the strict drug pricing policy of the Govt, especially over the multinational companies and bring down the maximum retail price (MRP) of the branded products, to a level, almost on par with those of generics. This gives the Doctor to choose the ‘best’ brand for the molecule, without much financial burdon on the patient.
Patient is out of Anaesthesia, He is moving his limbs…
… Relax. It is just
an Earthquake … carry on…
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43 Dosage of drugs
Our Indian patients may not require or tolerate the dosage schedule, prescribed in western literature. Meticulous care has to be exercised while calculating the dose of medicines to patients in extremes of age and those with compromised renal, hepatic or cardiac functions, especially those drugs with a narrow therapeutic index (maximum tolerable dose/minimum effective dose).
The website mentioned to select drugs (medplusmart.com), can be very useful to find the dosage of some rare drugs, if you have internet in your office. Of course, as indicated CIMS or PDR may be referred.
“I specialize in referrals to specialists!”
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Prohibited drug combinations
In 2016, Govt of India prohibited manufacture and marketing of more than 340 fixed-dose drug combinations. To give some examples :
Antihistaminic with anti-diarrheals.
Penicillin with Sulphonamides.
Vitamins with Analgesics.
Tetracycline with Vitamin C.
Hydroxyquinoline group of drugs with any other drug except for external use.
Corticosteroids with any other drug for internal use Aceclofenac + Paracetamol + Rabeprazole Nimesulide + Diclofenac
Nimesulide + Cetirizine + Caffein
Nimesulide + Tizanidine
Paracetamol + Cetirizine + Caffeine Diclofenac + Tramadol + Chlorzoxazone Dicyclomine + Paracetamol + Domperidone Nimesulide + Paracetamol dispersible tablets Paracetamol + Phenylephrine + Caffeine Diclofenac + Tramadol + Paracetamol Diclofenac + Paracetamol + Chlorzoxazone
“We can’t find anything wrong with you,
so we’re going to treat you for Symptom Deficit Disorder.”
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45 Advice on lifestyle modification
‘Hospitals and graveyards are filled with those who ignored and insulted nature’.
World health Organization (WHO) says health is not mere absence of diseases, but some thing more and calls as ‘comprehensive positive health, which includes physical, mental, social, environmental and spiritual wellbeing’. ‘Just because you are not sick, doesn’t mean you are healthy’.
You all agree that many of the problems we see in day-to-day practice are directly or indirectly related to the inappropriate lifestyle of the patients, such as over eating, obesity, lack of physical exercise, consumption of tobacco, alcohol or drugs, high stake gambling or horse races, extramarietal affairs, undiplomatic communicative habits, lack of self confidence & positive thinking, getting tensed up for insignificant issues and so on.
Besides prescribing medicines, the Doctor has to spare extra time to counsel them against these unhealthy habits and how they make the drugs ineffective in providing permanent relief.
We have to go into full details of what they eat from morning to night and suggest practical modifications and assure them that the body will get adopted to the new diet regime very soon, without getting (or feeling) weak.
But it is very important, to have the moral right to advise the patients, we should set good examples for them to emulate. We should maintain optimal body weight and refrain from smoking or alcohol consumption during consulting hours (preferably quit the habit).
Remember that tremendous moral boost to a smoker is a smoking Doctor. ‘We should eat to live and not live to eat’.
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There is a saying that ‘if a man eats one meal a day, he is a yogi. If he eats two meals, he is a bhogi and if he eats three meals a day, he is a rogi’.
‘A health conscious society impoverishes the local Doctor’.
He who takes medicine and neglects the style of life, wastes the skill of his Doctors.
Don’t take health for granted. You will realize this only when you get sick.
Risk calculation of smoking :
If one smokes 10 cigarettes/day for one year, on an average life expectancy is reduced by a month. It means, 20 cigaretes/day for 12 years, life is reduced by 2 years.
Remember the popular statement we make to a smoker coming with chronic limb ischemia – ‘you can have either your cigarette or the leg, but not both’.
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46 Referred by a Doctor
It’s important to extend due courtesies to patients referred by a Doctor and the patient appreciates that because of that, some extra attention was given. This is not to say proper attention need not be given to other patients, but such gestures would keep the referring Doctor in ‘good humor’, though ultimate treatment may not change.
It’s equally important that a proper reply is sent to the referring Doctor, giving details about the investigations done and the probable diagnosis, including future plans for further studies, if necessary. If surgery is advised, it’s nature, risks, preop preparations and other relevant facts, including any nonsurgical options available, to be indicated.
For example, if surgery (stripping) of varicose veins is planned, the other options, such as laser or radiofrequency ablation or foam sclerotherapy, have to be mentioned. Similarly for patient requiring inguinal hernia repair, the pros and cons of open vs laparoscopic approach have to be explained.
This will provide necessary information for proper counseling of patient by the referring (family) Doctor, in whom he may have more confidence. Besides being educative, the referring Doctor also appreciates that he’s kept in the ‘loop’ of the overall management of the patient.
Alternately, if a letter can’t be prepared in time, before the patient leaves the office, it may be mailed as soon as possible, or the referring Doctor may be briefed about the details on phone, by the consultant. At the time of discharge from the hospital after surgery, a detailed discharge summary, indicating the procedure and postoperative pracautions, has to be given to the patient.
It’s very important and ethical that the referring Doctor’s name is included in the discharge summary, which will be appreciated by him, as well as the patient.
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Referral to another consultant
If you don’t want the patient go through the ordeal of fixing appointment with another consultant, it’s better either the Doctor himself or his secretary fixes the appointment and gives a letter of reference. This will make the matter easy for the patient, who may be already troubled with his ailment and concerned about the cost and outcome.
If the patient has to be seen by more than one specialist, the primary Doctor should liaison between them and make them come to a ‘considered’ conclusion. For want of such a coordinator, there should be no communication gap, delaying the decision making or carrying out an investigation by one consultant, which is felt not needed by another specialist.
We should realize the importance of communication or conference between the various consultants attending on a patient, to avoid ‘catchy’ headlines in news papers: ‘Doctors differ and patients suffer’.
Same procedure may be followed, if the patient requested for a second opinion or the Doctor himself decided to get a second opinion, before planning a major procedure or for a patient, who is critically ill.
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48 To get another letter from family Doctor
Some patients initially referred to you by his family Doctor for some surgery, want to continue seeing you, even after the immediate postop period, for all their ailments. In all fairness, after the surgical matter is over, the patient should be advised go back to his family Doctor, for any other problem (unrelated to the operation).
If the patient insists on seeing you in future, then he should be asked to get another letter of reference from his family Doctor, so that the Doctor won’t think that you had ‘taken away’ the patient from him. Otherwise, there is a risk that the particular Doctor may not refer another patient to you, a justified decision from his angle.
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Collection of fees
To give a good professional look, it’s better the Doctor doesn’t collect fees directly from the patient. As the patient walks out of Doctor’s chamber, the secretary or receptionist may be instructed through intercom, the amount to be collected. Even counting the money given by the patient in his presence (to verify if it’s correct), doesn’t give a ‘healthy’ feeling to both, but this is an inevitable embarrassment, if the Doctor has no assistance.
There is a possibility of the patient paying less (by oversight) or with counterfeit notes. The Doctor has to monitor closely, if the fees is collected by the secretary/receptionist, to avoid any fraud by them, of collecting more from the patient, which will go unaccounted.
This can happen even if a Receipt is given for the amount paid; the counterfoil will show lesser amount than the actual Receipt given tothepatient! It’dbenicetoprovidefacilitytoacceptpaymentby a credit card, the swiping equipment may be easily installed in any office, but the money transfer into our account has to be closely monitored, to ensure proper functioning of the gadget.
If you are in Govt service and planning to admit a patient in your Unit (in Govt Hospital) for treatment, for financial reasons, it’s ethical that no money, not even the consultation fees is accepted from him, on moral grounds.
“Wake up Mr. Jones! It’s time for your sleeping pill.”
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50 Patient left without paying fees
The same procedure of noting in the record, can be followed, if the patient leaves your office, without paying the fees (most of the time by mistake, but occasionally intentional) or requests to allow him pay it at the time of his next visit. This is very useful, even if the patient reports to you for some other problem, months or years later.
Some extra fees (as fine) is collected, if it’s proved that he deliberately avoided paying the fees last time, especially if he is a habitual ‘offender’. Sometimes patient argues that he had paid the fees during his previous visit, but the secretary should convince him that there’s no appeal against the personal notation by the Doctor.
As a matter of additional precaution, such patients are allowed into the Doctor’s chamber, only after clearing the ‘arrears’. If we waive fees for a patient, it’s a gesture or goodwill on some special consideration, but not if they behave smart and want to take us for a ‘ride’.
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Doctor as patient
‘Doctors make worst patients’, but may not apply to all. Medical etiquette dictates that an early appointment be given to a Doctor or at a time convenient to him, if possible. As a matter of courtesy to a fellow practitioner, he may be called in as early as possible, keeping the waiting time to minimum. Similar privilege may be extended to a Doctor, if he is accompanying a patient, who may or may not be related to him.
If a Doctor (or any VIP) brings a patient to you for consultation, it’d be nice to pass a remark to the patient, ‘Dr/Mr……. is such a busy person, how did you manage to bring him along with you?’. This will be appreciated by the Doctor as a compliment, about his involvement with his patients. It’s quite in order that we don’t accept consultation fees from a Doctor or his dependents. All possible concession may be arranged for him in carrying out investigations or surgery, if required, especially for professional services.
One Doctor remarked in a lighter vain, when his colleague offered to pay him the consultation fees for seeing his wife, “dog eats all kinds of flesh, but not dog’s flesh”. Being a medical person, counseling a Doctor is easy and technical pros and cons of various options in the treatment may be frankly discussed.
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52 VIP as patient
VIPs demand early appointment and ‘zero’ waiting in reception hall, when they want to see a senior consultant. It’s sensible to respect their ego and cooperate as much as we can, because of two reasons.
Firstly, when a VIP visits as a patient, the value of the Doctor goes up in public eyes. This is true also with other legendaries in film field, sports etc.
Secondly, no one can predict, when he suddenly becomes a very influencial person in politics or government and may be useful to you at some point of time.
It’s also wise business that we don’t expect consultation fees from this group. Certain amount of maturity and balance of mind is needed to treat a VIP, like any other patient and not to be tempted to create a ‘VIP syndrome’.
Some VIPs are so humble and ‘down-to-earth’, they don’t throw their ‘weight’ around and very pleasant to deal. On the other hand, some ‘ordinary’ people are so egoistic and hostile, behave so arrogantly, taxing the diplomatic skills of the Doctor and his staff, but ‘it’s all in the game’.
‘Every client is a VIP for us, he’s not a trespasser but very much partofourbusiness’ – MahatmaGandhi
“Good News. Your cholesterol has stayed the same, but the research findings have changed.”
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Your relative as patient
You may know him well, may be studied together or might have helped you in someway, during your early days. They may rightfully expect and deserve some special attention and concessions in various services such as labs, scans or for surgery, if they’re required.
Your helpful nature, beyond the call of duty, will definitely be appreciated and publicized at appropriate gatherings, indirectly boosting your image among your close relatives and friends. The similar courtesies, may be more, have to be extended if your teacher (in school or college) or his dependents, come to you for medical help, not forgetting the ‘ladder’ on which we climbed and reached the present position.
More than honoring them, it reflects on our culture to acknowledge their services and to utilize the opportunity to invoke their blessings, by touching their feet.
A senior doctor asks a young lady to go into the exam cubicle. When she hesitates and requests if her husband could come with her, he remarked, ‘Don’t you trust me ? You know me for so long’.
She says, ‘No, no, I have full faith in you, but I don’t trust my husband alone outside, with the good looking Receptionist’
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Maintaining patients’ records is very important and has several advantages. Firstly, very often patients don’t bring their old records, when they come for review. Having their records with us is a big help to proceed further.
Secondly, patients develop emotional attachment with you, since they feel that you have all their records.
Thirdly, when any of your patients calls you or writes to you for some clarification, we can give them ‘intelligent’ reply, if we can peruse their records.
Fourth point is for legal or insurance purposes. You may get a letter from a lawyer or an insurance company asking for some details of the diagnosis/treatment given to a patient, whom you treated some time (or even years) ago.
You can give an authentic reply with all the dates and what was his condition when seen last, only if you have the old records of the patient for reference. Later on you may be even summoned by the Court to give expert evidence, to help disposing the case.
As long as they are readily retrievable, you may choose any form of records that is suitable to your set up, it may be as Cardex system, in the form of a file or computerization. The former two requires manual retrieval, may be time consuming and occasionally unsuccessful, because of the large number of patients with similar name.
Though it’s the best, computerization has some problems; cost of installation & maintenance, skilled manpower requirement and possibility of data corruption or ‘virus’ infection. Other problem with the computers is unless you key the exact spelling, it will not oblige you. For example, name Satagopan may also be spelled as sadagopan, sadakopan, satakopan, sadhagopan, shatagopan, satagoban, sadagoban and so on, posing problem to retrieval.
16 17 18 19 20
21 22 23 24 25 26
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This may not be cost effective for smaller establishments. When we use retrieval by manual mode, those staff can by utilized for many other purposes, during other times. Taking photographs (of course with the permission of the patient, especially if the face is shown) and preserving them in the patients records, may be useful in areas like cosmetic or reconstructive surgery, hair transplantation, limb gangrene (before amputation) or orthopedic correction of deformities, for future comparison.
A simple card we deviced and found very useful, explaining the various check lists and codes, is shown below. If the patient has undergone surgery, salient details are entered in the card by the Doctor himself, obviating the need to peruse the discharge summary at every visit. (Size of the Card is 135mm x 115mm).
1 2 3 4 5 6 7 8 9
Acid Peptic Disease Diabetes
19 Divorsed 20 Insurance 21 Telugu
25 Kannada 26 Malayalam
4 5 6 7 8 9 10 11 12 13 14 15
11 Cardiac Disease 12 Asthma
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55 Prescription by phone
It’s also advisable not to prescribe medicines on phone, more so, if the Doctor had not seen the patient recently. In an urgent situation or for a patient, who was recently seen by you, prescription by SMS, WhatsAp or E-mail may be safer and foolproof, till the patient is able to see a Doctor.
Unfortunately, during the pandemic situation, since we are unable to see many patients directly, we are forced to send telephonic prescriptions to them, even for ‘routine’ ailments. Of course, the patient should be advised to see you or some other Doctor, if the he had not improved with the treatment suggested by you within a specified time, for further evaluation.
Patient may also call you for some clarification in the prescription or a particular drug prescribed, not available or for some drug ‘reaction’. If a drug is not available, it’s best to ask the patient to call you from the pharmacy, so that you could talk to the pharmacist directly and suggest a suitable available substitute.
If a postop patient calls you for a stitch abscess or wound infection, you may ask him send a picture, so that proper advice can be given.
If the combination drug you prescribed, is not available, you may ask the pharmacist to give both the ingredients separately and
advise the patient accordingly. discussed elsewhere.
The subject of drug reaction is
Patient : Dr What happens after we die?
Doctor : hmm we clean the bed and admit a
Note : Don’t ask your doctor philosophical questions
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There is no bar against a private practitioner to treat accidents, poisonings or other medicolegal cases, provided prescribed procedure is followed. As mentioned already, the Doctor has to exercise extreme caution in taking history given by them for granted. Proper recording of history, physical findings and initiate immediate treatment required.
At the earliest opportunity, Police has to be informed as to the nature of the incident, either by phone or a letter of intimation. The time, date of phone message, name, designation & the service number of Police officer received, has to be noted. If a letter is delivered, an acknowledgment of time received on the counterfoil, with the seal of the Police Station, is essential.
When a Police officer arrives to take statement from the patient &/or attendant, the Doctor has to certify that the patient is in a physically and mentally fit condition to make the statement to the investigating officer. After the first aid, the Doctor shall decide if the patient requires hospitalization, for further management.
If the patient is critically ill, with uncertain outcome, the investigating officer may invite a judicial officer to record dying declaration from the patient or if a judicial officer is not immediately available, he may decide to record the declaration himself and proceed with further investigation. In any case, you have to certify that the patient is physically and mentally fit to make the declaration.
We all know that ‘an apple a day, keeps Doctor away’ but in the present scenario, it’s more important for the Doctor to keep the ‘lawyer away’. Fortunately in Indian law, if there’s a complaint against a ‘qualified, registered’ professional, the burdon of proof lies on the plaintif.
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In USA, it’s the other way, the professional has to prove that he’d done the right thing, which makes all the difference.
The Supreme Court of India clearly stated that saving a patient’s life is more important duty of the Doctor than the legal formalities and provided immunity against any subsequent harassment by the investigating officer.
These are some examples, when complaints against doctors are commonly leveled by the public or the government :
Professional negligence, incompetence or deficiency of service.
Performing additional procedures without patient’s consent. Deliberately issuing wrong or misleading certificate. Unlawful behavior with patients of opposite gender.
Performing procedures, such as prenatal gender determi- nation, abortion without valid medical indication or for female genocide, organ transplantation with commercial interest etc.
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Accident register & wound certificate
Accident Register is more relevant in Govt institutions, otherwise the method of recording usually followed by you may be acceptible, but in a more detailed manner. On the written requisition of the investigating officer, the Doctor has to give him a summary of history and treatment details, including a proper wound certificate of the patient, as early as possible.
The accidental wounds are classified by their severity and risk to life, as simple, grievous, dangerous or fatal. Dangerous implies, without prompt treatment, the wound may be fatal.
When I was doing residency in US, working in emergency room, a 5-yr child was brought with an injury to forearm. Finding no fracture in the x-ray, I called the consultant for advice.
To my surprise, he asked me to take x-rays of all the limbs for the child. The reason given by him was shocking; after leaving the hospital the father might intentionally break the other forearm or leg of the child, get an x-ray in some other hospital and sue this hospital for ‘missing’ a fracture. Unfortunately, we are living in materialistic world and such atrocious things can happen.
Doctor gets a phone in the midnight. ‘Doc, can you come immediately please, I think my wife has appendicitis’. Doctor says ‘Impossible,
I removed your wife’s appendix last year, I’ve never heard of second appendix’. The man asks ‘Doctor, have you heard of a second wife ?’ 80 THE CONSULTATION ROOM
58 Request for postmortem examination
If the patient expires in the consultation area, with or without treatment, the matter has to be reported to Police and request for a postmortem examination. Such forethought would avoid much afterthought, in terms legal formalities and responsibilities.
The sequence of events from the time the patient came or brought into consultation room, have to be noted in detail and preserved for future use. Another advantage of requesting for an autopsy is, it gives a clear indication of transparency of your action, besides being educative.
Inspite of your written request, if autopsy was not done for some reason (at the discretion of the investigating officer), it’d serve as a strong point of defense, in the event there’s any litigation against you later.
“Your X-rayshowed abroken rib, but we fixed it with photoshop.”
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Visit of law enforcing officers
Any Govt. officer belonging to Police, Local Administration, Pollution Board, Labor, Income Tax, Professional Tax, Electricity Board, Water & Sewerage dept. may visit your office. It’s prudent to cooperate with them, offer them coffee to keep them in ‘good humor’.
If they find any deficiencies or problems, you can request them to suggest remedies and assure them that those suggestions would be complied as soon as possible. Most of the issues arise out of improper documentation. Of course if the problem is so gross that may invite penal proceedings, you have to face them as best as you can, with the help of your lawyer or auditor.
It’s important to know the Labor laws, in giving minimum wages, other allowances and benefits for your staff, including weekly leave, paid maternity leave, provident fund (if the total number of staff exceeds 20) and retirement benefits. Different Registers have to be maintained to show your compliance to the rules, which will be periodically perused and endorsed by the visiting Officers.
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60 Visit by social friends
A system has to be evolved to handle someone coming on a personal matter, such as a friend coming to give invitation card to a marriage, a function or dropping in for a courtesy call. Since it’s unfair to make them wait for too long, the receptionist has to be instructed to bring such cases to your notice as soon as possible and dispose them early.
Also it’s important that the Doctor doesn’t spend too much time in casual chat with them, in the midst of busy consultation time, forcing the waiting patients to become impatient. Sometimes after they come in as a ‘social’ visit, they start talking about their illness. The matter has to be dealt diplomatically, without hurting their feelings and give them an early appointment to see them in ‘detail’, asking them to bring their old medical records for review.
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Visit by medical representatives
Specific time may be allocated to see medical representatives, to avoid interruptions during regular times. It’s ethical that we don’t make them wait inordinately in our office, since they are considered as ‘paramedical’ professionals.
It requires a restrained mindset, not to accept ‘gifts’ from them, who expect some ‘favors’ and the Medical Council strictly prohibits such ‘transactions’. It requires some level of maturity, not to be influenced by such ‘gestures’ in your prescription pattern.
Often the other way is true, since we are already supporting them by prescriptions strictly by professional considerations, they may want to show their gratitude. To request them to bring sample medicines for personal use is very tempting and may not be very objectionable. Similarly asking them sponsor a medical conference or CMEs, is also not desirable, but may be better than asking for personal favors.
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62 Attitude towards co-practitioners
This subject of giving appointments to a Doctor coming as patient or accepting fees for professional services has already been discussed. In Indian scenario, one of the common causes of litigations against medical profession is the attitude of ‘one-up- manship’ by the Doctors. A loose, uncharitable remark made by a Doctor, about the treatment given by another Doctor, sets the ‘legal ball’ in motion.
This kind of attitude is often seen in consultants practicing in large or corporate hospitals. It’s neither ethical nor good ‘business’, sitting in ‘ivory towers’, to pass an unfair judgment on the practitioner treated the patient earlier (or who might actually have referred the patient to the hospital, you’re working), not realizing under what working conditions the Doctor might be practicing or gave such treatment.
In legal parlance there’s an expression called ‘benefit of doubt’. It means, when there is a doubt if a particular witness should be relied upon or not, the benefit of such doubt has to be given to the accused. But it’s a pity that we don’t give that kind of benefit to our own colleagues (due to professional jealousy), not realizing that tomorrow we may be at the receiving end, in this free world.
When a patient puts very insinuating questions about the treatment given by the previous Doctor, in all wisdom, it’s best to brush them aside by saying ‘he had done what he thought was best, under those circumstances and no point in discussing it now, let’s see what has to be done further’.
A generous minded Doctor may even go one step above and say that ‘under those circumstances, I also might have done the same thing’. This statement should put all their doubts and possible legal thoughts to rest. Certain expressions to be avoided during counseling of a patient or in discharge summaries, are indicated in Chapter 35.
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Any Registered Medical Practitioner (RMP) has to be extremely careful while issuing a medical certificate.
The common purposes for which a medical certificate is required :
illness, fitness, disability, old age pension, vaccination, estimate for treatment/surgery, leave from work, court attendance, accidents, medicolegal matters, death and postmortem.
Medical certificate is very valuable that utmost care has to be exercised without falling prey to helpful temptation, monetary consideration, compassion, humanitarian feelings or any extraneous pressure.
Best way of asserting the identity of the person is to make him sign (before you) at the bottom of the certificate and duly attested by you.
Our teachers cautioned us that while issuing a certificate, at least verify for yourself, if such a person exists at all, the question of illness or other details mentioned, can always be debated.
Secondly, since no one can question your judgment, once a certificate is given and you honestly think it’s true and just, stick to your opinion, to any level.
A Professor of Forensic Medicine was called to court, to give expert evidence. The opposition lawyer pointed out that some opinion expressed by him (Professor) was contrary to what was given in a standard text book (Modi’s Jurisprudence).
The professor replied ‘what I said was my opinion, what’s in that book was his opinon. Only differene is, that guy had the time to write a book. You take whatever you want’.
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64 Updating CMEs & Workshops
It’s said that every year, 10% of scientific information we have, becomes outdated or obsolete. Hence if we don’t often keep updating our knowledge and skills, after some time, what we think or what we do, may not be acceptable scientifically or legally.
Further, we are living in the era of evidence-based medicine and we should restrain treating patients out of our anecdotal experience. With the mind-blowing information technology, you can access any subject any time.
It’s really astonishing how the Google has compiled so much information about virtually anything and everything under the sky and may be beyond. Of course, other venues of knowledge updating is by standard books, monograms, scientific journals and continuing medical education (CME) programs. It takes profound determination by the Doctor, to adopt evidence-based protocols at all times, overriding strong personal beliefs and convictions.
Generally patients prefer Doctors who have academic bent of mind, interested in attending conferen- ces, give lectures, contribute articles in journals, give TV interviews on health matters etc. If a Doctor can strike a ‘healthy’ balance between academic inte- rest and delivering expedient service, tailored to individual patient, he will be very success- ful. Someone explained why they’re called Workshops : if there is no work, we can do shopping !
Patient ran out of operation room, before a minor surgery could be done. His friend outside asked him, ‘Such a small operation, why were you scared ?’. Patient says, ‘Inside nurse also said the same thing’. ‘Then why did you come out ? ‘Patient : ‘She didn’t tell me, she was telling the doctor’. THE CONSULTATION ROOM
The Govt of India, on the recommendation by the Medical Council of India (MCI), had passed a rule in 2002, that every Medical Practitioner should renew his licence to practice once in 5 years and during this period, by attending minimum 30 hours (one hour every 2 months) of CME, preferably in his specialty, conducted by a Medical Organisation, recognized by the State Medical Council, for the purpose.
Unfortunately, neither the 10 lakh-odd Practitioners in India nor the State Medical Councils have made serious attempt to implement it, though it’s for their own good in improving the quality of medicare, especially in rural and suburban areas. It’s an irony that we can’t drive a car without renewing licence, but we can practice medicine, with the knowledge acquired in the medical school, even after 50 years.
If the State Governments are sincere in implementing this, first they should provide regular CMEs in Districts, with the help of nearby Medical Colleges, to encourage Doctors to update themselves. This is the first step the Govt and the Medical Councils should have taken, before insisting on minimum attendance of CMEs and periodic recertification for the Doctors, who may be interested, but have no access to updating facilities in their areas.
The public and law makers, who make hue and cry, if a Doctor is found to be inefficient or deficient in knowledge, don’t realize their responsibility to create facilities for updating their knowledge and skills, especially for Doctors practicing outside the cities. With the unutilized funds lying with State Medical Councils, the Govt can easily provide such services to medical profession, ultimately for the benefit of public at large. Respecting the seniority, this condition has been waived for Doctors over 70, but they have to send communication to their State Medical Councils that they are ‘still alive’, to keep their records updated. Blissfully, thanks to the complacent Medical Councils, our Doctors are not put to ‘hardship’, trying to enforce the rule of recertification.
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66 Media statements & interviews
The media, both print and electronic, may request for a ‘short clip’ from you on some current medical issue, more so if you are a senior Doctor, holding a position in some medical organization. If the subject doesn’t directly concerns you or if you are not the expert in that subject, you may decline to do so.
As far as possible, it’s better to avoid subjects, in which you are not very familiar. Alternately, you may opt to ‘co-operate’ with media, make some preparations on the subject and give the statement. If you wish to utilize the opportunity to project yourself as a leader or thinker or to give an impression that you’re an ‘all rounder’, necessary ‘home work’, has to be done as the occasion warrants.
Extreme diplomacy is required to answer some insinuating questions against the Govt or some other leader in the subject, realizing the media is ‘notorious’ to show your statement ‘out of context’ and drag you into a controversy.
During an interview by a leading TV channel, after I received a national award, a very sensitive question was put to me by the interviewer. At that time the Doctors in the state were on strike, to resolve some issues with the Govt. He asked me, ‘doc, as one of the leaders of medical profession, do you agree with the Doctors going on strike ?’.
Tremendous diplomacy is required to answer such questions, since we can’t say yes or no. I told him, ‘our profession is considered noble and essential, so normally we shouldn’t go on strike, putting public to hardship. But for a minute, let’s look at the issue in Doctors’ angle.
It’s not a lightning strike, they would have served notice to the Govt, at least a few weeks in advance. Out of their 10 or 15 demands, the Govt could have easily conceded at least 2-3 ‘reasonable’ demands and ask for more time to look into the others.
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The Doctors would have certainly agreed to it and called off the proposed strike. But on the contrary, the Govt ‘sleeps’ over the matter ignoring them, till the strike actually commences. Then they ask the leaders to ‘call of the strike and come for negotiations’.
What were they doing all these days before the strike started? If only the Govt handled the matter tactfully, the strike and the resultant public inconvenience, could have been avoided. There is no point in blaming the Doctors now’. Finally I concluded by saying ‘in any case, Doctors shouldn’t have gone on strike, since their services are essential and life saving’.
The Doctor asked me to spend at least one hour per day on the treadmill.
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As a rule, we are not supposed to advertise achievements in our profession, to ‘attract’ clients. But under the Corporate phenomenon, where nonmedical persons own or manage hospitals, who are not bound by ‘Hippocratic oath’, such barriers are broken and we often see ads about many hospitals in various media.
But it’s a double-edged weapon, while it may attract some patients, they come with high expectations and if we don’t live up to their expectations, they get disappointed and resort to litigations. Medical Councils can only initiate action against a Doctor for unethical practice, but unfortunately have no powers on hospitals or diagnostic centres. Hence it’s better that any particular Doctor’s address, phone number or his capabilities are not focused in media.
However you may author books, contribute scientific essays of public importance or take part in panel discussions or debates on matters related to medicine or public health and thereby share your experience with public.
You are also allowed to publish news when you start new practice, mentioning the specialty, change of address, if you sell or buy a practice or when you may not be available for consultation for a considerable period. Under the pretext of facilitating the patients carrying all the records safely, a subtle form of advertising is by giving a File or Folder with your details printed on it (either free or at nominal cost), to the patient.
The other advantages for such a file are, if the patient loses it, some good samaritan who finds it, may send it to you and it serves as an easy reference, if the patient wants to send any of his friends, for your consultation. Remember delivering ‘good professional service is the best and most ethical way of promoting our ‘business’ which is the main objective of this book.
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Licence from statutory bodies
Of course no Doctor can practice allopathic medicine without registering with Medical Council, either the State or MCI. If you migrated from one State to another, you have to Register with the new State, within six months of relocation, with a ‘No Objection’ certificate (of good standing) from the Medical Council of the previous State.
If you are practicing in an independent consultation office (not attached to a Hospital), proper licence from the Corporation (or any Local Body) authorities (for the building permission, house tax etc) and State Pollution Control Board (to verify the management of bio-hazardous waste generated) are required.
It’s funny, that we have to pay annual ‘licence fees’ to the Pollution Board, to grant us ‘permission’ to pollute air and water around us, the logic is beyond anybody’s comprehension. The Labor department will periodically inspect the premises to verify if working hours and holidays are being followed and minimum wages and other allowances are being paid to be employees as prescribed by law.
Interestingly they also want your weighing machine and thermometer to be ‘checked, calibrated and certified’ periodically, for reasons best known to them. Let’s comply with their rules and not enter into an unproductive argument with them.
“You can see the Doctor now. Don’t ask him anything too medical”
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69 Mass casualties
Mass casualties may occur in situations, such as bomb blast, tsunami, building collapse, food poisoning in a school or a marriage function etc. The unfortunate victims have to be given first aid by the medical team, their seriousness sorted out and arranged to be shifted to various willing hospitals for further evaluation and management.
If yours is an independent consultation office, the role in mass casualties may be limited, but if your office is located within a hospital, the directions given by the hospital authorities have to be followed, which are generally guided by the ‘disaster & triage’ team of the town or city.
The total operations would be supervised by some senior Admi- nistrator (IAS) and higher officer in the Health department, coordinated by an officer of the Local Body.
It’s the bounden duty of every Doctor and paramedic available, to extend helping hand to the medical services, in such circumstances, on humanitarian grounds.
Doctor comes out after successful open heart surgery, to talk to his wife. She asked him ‘Hope you’d seen thoroughly in his heart and everything ok ?’ The doctor assured her ‘I’ve seen everything, there’s no other problem’. Suspicious wife asks the doctor ‘did you find there anyone else other than me ?’
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Prescription pad by
pharmacy or diagnostic centre
It’s better the Doctor avoids using prescription pads printed by a pharmacy or a diagnostic centre, which may instill some doubt in patients’ mind about Doctor’s nexus with that concern. But the all- too-common practice, especially in rural areas for economic reasons, is difficult to eradicate and the public also have come to accept it as a ‘matter of fact’ and don’t draw serious inferences from it.
Very often, Doctors also use such pads for some miscellaneous scribbling purpose and not as a prescription pad. It may be alright if the name of the pharmacy or lab is printed at the bottom of the pad and not at the top in bold letters, above the Doctor’s name.
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The main reason for the quacks (unqualified Doctors) to proliferate and flourish, is the maldistribution of qualified Doctors in our country and their unwillingness to settle down in rural areas.
While 70% of our population live in rural areas, only 30% of Doctors work and 90% of quacks ‘practice’ in rural areas. Out of necessity, rural population patronize the quacks, mostly for first aid and sometimes for total care.
On the face of it, it may look cheaper than going to a qualified Doctor. But when the disease is allowed to get worse, due to ‘half- baked’ treatment, then going to a higher centre will ultimately turn out to be more expensive.
Further, since the public is unaware of significance of qualification, any mistakes committed or complications arising out of the treatment given by the quacks, reflect on the quality of entire medical profession.
Unfortunately the law enforcing authorities have a ‘soft corner’ towards quacks, since the qualified practitioners don’t ‘wet’ their hands periodically and they don’t want to kill a ‘golden duck’. It may not be surprising that many Doctors encourage quacks, since they advertise and bring them patients and of course get ‘commission’ from both, for their ‘service’!
One of the reasons given by the Govt. of India to allow Ayurvedic ‘surgeons’, is to discourage quacks, but the allopathic Doctors are unable to digest the logic behind it and they feel substituting ‘educated’ quacks for the ‘uneducated’, may be more harmful.
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Family practice & house visits
One can recall in old movies, when some rich man falls sick, the family Doctor comes with a ‘medicine kit’ and gives him an injection and some tablets. With waning of Family Practitioner concept, we don’t see such scenes any more and the house visits by Doctors have virtually vanished.
There are many reasons for this unfortunate scenario, such as personal safety (especially to women Doctors), Doctor’s lack of confidence in making a clinical diagnosis (without lab support), legal issues arising out of some drug (injection) anaphylaxis, unwilling profession to be disturbed during odd hours and lastly Doctors’ calculation that it’s not remunerative commensurate with the time spent.
Young Doctors (and their parents) don’t want to stop with MBBS and they want to become ‘specialists’ by acquiring some postgraduate (or even superspecialty) qualification, for academic pursuit, as well as for better ‘quality’ of professional life.
A family Doctor is more than a Doctor, friend, guide and philosopher to the family, charges ‘affordable’ fees, accessible during odd hours, makes arrangements for his patient to see the ‘right’ consultant when required and follow through the further treatment.
He also counsels and arbitrates on nonmedical issues in the clients’ families. In olden days, Doctor became a GP by default, but now it’s the last resort, if there’s no option. The present society certainly misses ‘his’ 24/7 services, for which changed public mindset has to be blamed.
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73 Death in residence
One situation when it’s most appropriate for a Doctor to make a house visit may be to certify death occurred at home of a patient, who is under your treatment. But, before certifying, ensure that there’s no doubt of any foul play and it’s indeed a natural death.
The real dilemma is if you’d not seen or treated the patient before. Going by the family statements, perusing the medical records or circumstantial inputs, may not give you the whole truth. One option is to talk to the Doctor, who treated the patient last, if he’s available and get first hand information about probable cause of death.
Knowing the family earlier may be of some help, but also puts you in a situation where you can’t refuse issuing a certificate. Note that there is a separate Form meant for non-institutional (home) deaths, prescribed by the authorities.
As in the case of any death, if there is an element of doubt about the cause, it’s safe to inform police, whether family likes it or not, and allow the law to take its course. You can also convince the unwilling family members, that it’s for their own good, in the event some one contests about the nature of death, later on.
“We have made a major breakthrough. We have developed an artificial heart that runs on cholesterol.”
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Death in consultation room
The problem is very similar to a death in the residence. The situation is different if he’s brought alive in a critical state, some resuscitation was unsuccessfully attempted. On the other hand, he might have been brought dead. In either case, if the Doctor knows the patient, his previous medical history and is convinced that it’s a natural death, a certificate can be issued to that effect.
But even if there is an element of doubt of some foul play, the police has to be informed and postmortem advised, which will be done only at the discretion of the investigating officer, after some preliminary enquiry. The detailed history and the sequence of events have to be properly recorded and a copy of it is given to police, for the use of the Doctor performing autopsy.
The matter becomes more sensitive and complicated if the Doctor was not available in the office, when a critically ill patient was brought in. Assistant Doctor or senior nurse has to give first aid and contact the Doctor to decide further management or shift him to a nearby hospital. If the consultation room is located within a hospital, the patient can be conveniently wheeled to the emergency area for further evaluation and treatment, without much delay.
“It’s a simple stress test – I do your blood work, send it to the lab, and never get back to you with the results.”
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75 Injection reaction
If injections are given in the Doctor’s office, it’s essential that all the emergency drugs to combat anaphylactic reaction, such as adrenaline, hydrocortisone, deriphyllin, avil, atropine, IV fluids and infusion set etc. are kept readily available. The patient should be asked to sit for at least 15-30min after the injection, before leaving.
It’s advisable not to administer IV medication to a patient, if the Doctor (or his assistant) is not in the office. It’s to be realized that neither giving a test dose nor history of taking the same medicine earlier by the patient, provides guarantee against anaphylaxis, but it may provide some legal protection.
In any case, it’s also wise not to use drugs commonly known to cause anaphylaxis (on parenteral use), such as penicillin, amoxicillin, carbamazepine, low molecular dextran, iodine containing contrasts etc. Of course, police has to be informed and postmortem to be performed, as per the prescribed medicolegal procedure, if the patient succumbs to the adverse episode.
We should also remember that sometimes it may just be a syncope of a vaso-vagal reaction to pain or anxiety, related to the injection, typically associated with hypotension and bradycardia. All that is required is to make the patient lie flat, allow good ventilation around and if necessary, IV atropine. They usually recover in a few seconds.
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There is no better example than Covid-19, which devastated the entire world and many healthcare workers (over 500 Doctors and 2,000 nurses) lost their lives in the process of carrying out their noble services to the victims. As much as it’s our ‘god-given’ duty, it’s more important to protect ourselves, by all means possible.
Since the morbidity and mortality of the pandemic is higher in elders and those with co-morbidities, many senior Doctors closed their offices and carry out only ‘on line’ consultations. However, attending to genuine or life threatening emergencies can’t be avoided by a conscientious Doctor.
Precautions such as, taking plenty of rest, doing regular exercises, eating healthy wholesome food, supplementation of micronutrients, wearing a face mask, frequent hand wash and maintaining social distance should not be difficult for any Doctor to practice. Using a face guard or personal protection equipment (PPE), setting up special isolation chamber to the Doctor in the office, while interviewing or examining the patients, offer additional safety.
Patients should be allowed observing full precautions into Doctor’s chamber,i.e., with full mask covering nose and mouth, both hands sanitized and infrared temperature screening of forehead. It’s better not to allow patients suspected (or diagnosed) to have Covid, into the Doctor’s room. Instead, an attendant may go in, to show the records and take instructions for further management of the patient.
Other option for additional safety to senior Doctors, is interviewing through video calls, fortunately such a facility now readily available with most of the patients. Of course, Doctor can’t do physical examination, but can ask his assistant or the referring Doctor, to discuss the findings and request for the relevant investigations, before arriving at the final conclusion and further management.
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In any event, as a matter of precaution, senior Doctors and those with co-morbidities (obesity, diabetes, hypertension, ischemic heart disease, COPD, dyslipidemia, thrombophilic state, smoker, alcoholic, those with compromised liver or kidney functions) are advised to restrict the appointments for personal visits to bare minimum, to very essential or life saving situations.
Fortunatelymostoftheviralinfections,includingCovid, canbe prevented by appropriate vaccination. Though the safety of the vaccines available is a cause for concern, it’s advisable that senior doctors to get vaccinated, as we did for hepatitis-B, if they wish to resume active practice.
Our ancient scriptures and the present law of the land affirm, ‘nothing is above self’.
“I didn’t get to see the Doctor. The office closed before I finished filling out the ‘New Patient Forms’.”
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Details of attendant
It’s very useful to note down the name, occupation and contact number of the attendant, who accompanies the patient. During subsequent visits, you can appreciate the glow in their faces, if you address him (attendant) by his name. Not only they’d be impressed about your ‘memory power’, but feel very comfortable with the idea that you are trying to get close to the family.
It also helps you to decide at what ‘wave length’ you can communicate with them. Lastly, if he (attendant) is in some important position in a Govt office or an organization, he may be useful to you in some form or other, at some point of time (of course, if they’re satisfied with the care given to the patient by you).
Keeping in touch with the attendant is also very useful, if a critical development to the patient during treatment or after surgery has to be discussed. He will also give you moral support, if the ultimate outcome of your treatment is unfavorable.
Nurse answers phone, while doctor is examining a pretty girl with stethoscope. She says ‘Sorry, Doctor is busy on the other line’
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78 Indicate report to be mailed to patient
We have to innovate some procedure by which we don’t forget sending the reports to the patients, as promised. If the report is received next day or a few days after you had seen the patient, normally it would be brought to the notice of the Doctor, report entered in his record, but no one will remember that it had to be mailed to him, often causing embarrassment to the Doctor, when the patient points out during his next visit that he hadn’t received the reports.
It’s very useful to put some code or symbal ( I put x ) in the area in the record, where the lab reports are usually entered, to draw their attention, that it had to be sent to the patient (or communicated in some form). Needless to say, the patient would be greatly elited to promptly receive the reports from the Doctor, with appropriate advice and develops full confidence in the foolproof system in your office.
If a reply to the referring Doctor was not given to the patient, when he was leaving the office, this is the best time to enclose that letter also in the same envelop, with instructions to deliver it to his Doctor, at the earliest. The date of mailing the letter should be recorded for two reasons : firstly it’d ensure that your staff did the job and secondly if the patient, during his next visit says he didn’t receive it, you can show him when it was mailed.
Doctor : Your liver is grossly enlarged. You have to quit drinking Alcoholic patient : Glad to know that. Now my liver can accommodate more alcohol’ 103 THE CONSULTATION ROOM
This is more relevant to patients undergoing surgery. Surgeon’s fees is bound to vary depending on the economic status of the patient and many other factors (such as if the patient is related to a Doctor or some important Govt servant or if the bills are paid by a third party or whether he is having adequate insurance cover etc).
Sometimes patient may report for surgery after a few days or weeks and the Doctor may not remember the earlier quotation given to the patient, leading to unwanted difference of opinion and argument.
Some patients (who may not be very honest) would deliberately make a wrong statement about the earlier quotation, for their advantage. To avoid such confusion, it’s better to indicate the quoted figure in a specified place in the patient’s record (may be coded), so that it can be remembered and resolved easily, in case of a dispute.
This also creates a positive impression in the patient’s mind that the Doctor always ‘sticks to his word’ and is ‘trust worthy’. If they are acting funny, sometimes I mention a higher figure than originally quoted, then they will reconcile to the correct amount.
Patient : ‘I’ve been suffering for several years, seen so many doctors, spent lot of money, but no one could relieve me. Finally I decided to commit suicide, then someone advised me to see you sir’
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80 Social media
This will help you to keep updated on various issues, during your busy professional preoccupations. It’s also very easy to pass on a message very fast (almost instantaneous) to a very large ‘like minded’ group, including pictures, obituaries, anecdotes, videos, conference notifications etc.
The facility to be able to talk ‘face-to-face’ with friends or relatives, especially with children, if they’re abroad, is a heart-warming feature of the modern video communication systems. Agreeably there are certain drawbacks in the present high-tech era, but if judiciously used, the benefits far outweigh the probable risk of abuse, since the scope of its applications in day to day life, is virtually unlimited and by and large free of cost.
It’s advisable not to post or forward any objectionable or offensive matter related to a public person, to avoid inviting legal proceedings. Also, in view of over crowding messages, we should avoid posting matters which have no news value, such as pictures of deities, flowers, sceneries, ‘good morning’, ‘happy weekend’ etc. otherwise we may miss useful messages, drowned under the plethora of such postings.
“I’m sorry – I’m a left-foot podiatrist”
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It’s very important that the Doctor gets involved in some community service activity, especially for those practicing in rural and suburban areas. Medical profession has maximum opportunity and potential to carry out humanitarian service.
It may be to improve or establish a school, temple (any place of worship), play ground, library, instituting scholarships, public park, hygienic toilets, mass vaccination, community hall, main road, drainage system, recreation club, burial ground etc.
This gives an impression to the public that you are not just sitting in the ‘four walls’ of your clinic to ‘earn money’, but also interested in public welfare and leaves little room for litigations against you. If you can’t personally contribute, you may collect donations for some good cause, using your influence or become an office bearer to undertake such projects in the community.
Invariably, in the process, you will develop more like- minded contacts in the town, indirectly promoting your practice, besides the goodwill it gene- rates. Our social status, popularity and wealth are the ‘gifts’ of god. He expects a ‘return gift’ from us by way of human service, to settle the score.
Ayurvedic Ortho Surgeon
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82 Free service
In every profession there are three aspects, public or community service, job satisfaction and remuneration, in varying proportion, the first two may be considered as ‘outcome’ and the last one as ‘income’.
It’s natural that most of the Doctors in their initial period, focus on the latter two and start thinking about the first one, after they comfortably settled down in practice. Very few born with a ‘silver spoon’ have the privilege of thinking of public welfare, right from their early days, unmindful of the income.
Senior Doctors may designate one day in a week or fortnight, to offer free consultations to poor patients, following the same protocols as other days, carrying required investigations and give a proper prescription. By our influence, some concession may be arranged for this group in lab tests, scans and for surgery if necessary.
Such noble service shall go a long way in building up the image of the medical profession in general and the Doctor in particular. Imagine the impact and credibility of our profession, if all the senior Doctors emulate such gesture and will certainly reverse the trend of deteriorating public reverence on Doctors, to a large extent.
The public will be less inclined to litigate against such Doctor, since he would earn a reputation that he’s not ‘money minded’. After all, we are not losing much, except we are giving our time to the underprivileged population. Our regular clients won’t leave us any way, they will certainly come to us on other days.
Other areas where we can extend free service are orphanages, oldage homes, homes for physically or mentally challenged or destitutes. They deserve consideration by every citizen, especially our services are very essential and may be life saving to them.
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Getting lab reports by SMS
Most of the labs, especially pathology or microbiology, take a few days to get the report ready and it may take another day or two before it reaches you. Or the patient may collect it and see you next day. We can make an arrangement with the lab, to send you the report by SMS or WhatsAp, as soon as it’s ready.
It’d be nice to call the patient and inform about the report and outline further management. Needless to say that the patient would be immensely happy to get your phone call and hear ‘his master’s voice’, that you’re taking time to ‘keep track’ with his case, in spite of your busy preoccupations.
You can have similar arrangement with the radiologist, so that he’d discuss the findings of CT/MRI/angio with you, well before the patients receive the typed report. You may initiate appropriate treatment immediately, especially in emergencies like a head injury or acute abdomen. This will certainly project yourself as an expedient Doctor, ‘right on the ball’ in the management of a ‘sick’ patient.
Doc : Hello brother, why are you here ?
Man: Well, I tried to kill a person, caught by police.
What about you Doc ?
Doc : I’m the one who tried to save the life of that guy, but not
successful. I was booked for deficiency of service
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84 Alternate power supply
In the midst of busy consultation time, sudden darkness filling up the atmosphere, is very irritating and dislocates the chain of serious thoughts flowing with the patient sitting in front. It’s advisable to install emergency lights in your chamber and at the reception counter, which get switched on automatically, so the work process goes on without interruption.
Of course it’s ideal, if the entire building is equipped with a power generator, that goes on automatically, when there’s a power failure. Otherwise, you will find your secretary running around in search of candle and match box, but in the meantime, with presence of mind, the patient in your room switches on the light in his mobile phone, so that you could continue writing the prescription. At least, it’s sensible to keep some candles and match box handy in the office.
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In today’s crime-ridden society, it’s very important to protect yourself, your staff, cash (day’s collection), other property and equipment in your premises, against violence, robbery or burglary. A single woman Doctor, working in an isolated area, towards the conclusion of her day’s work, when there may not be anyone in the waiting area, will be a soft target for antisocial elements.
If the consultation room is located within a hospital complex or in a ‘polyclinic’, their security personnel, close circuit television (CCTV) etc, should take care of your requirements. Otherwise, we have to employ security staff and install a private CCTV, to monitor the movement of people in and out of the premises. In the event of an untoward incident, the investigating officer can use the footage recorded in the CCTV (the socalled 3rd eye for them), to identify the culprits and understand the modus operandi.
It may be wise to transfer the cash on hand, towards the end of the day, to some safe place and not to wear expensive jewelry or watch, during the consultation time, unless you have enough manpower in the premises, for protection. This is also a main reason why Doctors, especially women, are reluctant to make house visits.
In view of some unfortunate incidents of Doctors being physically harmed by the public for flimsy reasons, it’s important to keep some alert assistant in your room, especially for lady Doctors, during consulting time. It’s advisable not to enter into heated arguments with any person with aggressive or provocative behavior and exercise extreme diplomacy to ward off confrontation. If you sense a hostile situation, never use aggra- vating phrases, such as ‘keep quiet’, ‘shut up’, ‘nonsense’, ‘get out’, ‘who are you to ask me’, ‘don’t dictate me what to do’, ‘do what you can’, ‘I don’t care’ and worst of all, ‘go to hell’.
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86 Sharing consultation room with others
This arrangement is irksome, but inevitable, in larger establishments, with several visiting consultants, coming at various times. The available consultation chambers are efficiently allotted to the ‘outside’ consultants, at different time slots, to accommodate maximum number, in their limited facility.
Sometimes (or often rather) you may have to face embarrassment of waiting outside ‘your’ chamber, since the consultant of previous time slot is holding it. As the hospital administration has no control over such matters, there is little use by complaining. Best solution is to develop a symbiotic relationship with the consultant over-shooting his time and politely request for cooperation and respect the ‘time slot concept’.
You will be lucky to get the time slot for the room, first in the morning, but be considerate, avoid overshooting your time and make the next Doctor wait outside.
“Your medical records are safe with us. We take patient privacy very seriously”
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Doctor going on leave
If you’re going on a planned leave for a considerable period, say weeks or months, it’s desirable you request one of your colleagues of same specialty to look after your patients during that period. Your secretary has to redirect the patients requesting for appointments, to the Doctor taking the calls, if they can’t wait till you return. This system is well stream-lined in the western countries.
It’s ethical that the Doctor taking calls handles only those problems that can’t reasonably wait and ‘handover’ the practice to the primary Doctor, as soon as he rejoins duty. If any active intervention, such as a surgery or angiogram is required, the Doctor on call should discuss the matter on phone with the patient’s primary Doctor (in whom the patient may have more confidence) and decide the course of action, including the choice of another specialist, if required.
The Doctor who attended on your patients during your absence, is entitled to charge for his service, but not to steal your practice.
“Insomnia is very common. Try not to lose any sleep over it.”
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88 Professional confidentiality
We are bound by the Hippocratic oath to maintain strict secrecy of all the medical or personal information related to any patient, disclosed to or discovered by us.
Theexceptions whenweareallowedtodisclosepatient’smedical information are :
the investigating officer or the court of law (as expert witness), the insurance company, the employer, the Health authorities, when a violent patient may harm others and finally to any one with the consent of the patient.
These are put as 5-Cs for easy remembrance when the Doctor may disclose confidential information :
with the consent of the patient or a legally authorized surrogate decision maker, such as a parent or guardian
Court Order :
upon the receipt of an order by a court of competent jurisdiction
Community Health :
necessary to the Health authority, in the interest of protecting the community or epidemiological statistics
Comply with the Law :
in order to comply with mandatory reporting statutes (e.g., child abuse or domestic violence), law enforcement or authorized investigating agency
Communicate a Threat :
this exception to confidentiality involves the clinician’s duty to protect others from violence by a patient.
Sometimes, a would-be spouse (fiancé or fiancée) or in-law may want to know about someone’s health issues. They can’t be disclosed without the consent of the person concerned.
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Supporting professional bodies
It’s very important that every Doctor becomes a member of a professional organization of his choice, preferably his specialty. It provides you regular updating facility, circulate important news and events, protects you against hostility by any individual or social threat in discharging your duties, it fights for the rights and privileges of the members and makes you feel that you’re in the main stream of the profession.
On the other hand a Doctor has certain responsibilities towards the organization : participating in programs related to public health (eg : polio, malaria, tuberculosis, leprosy, pandemics), supporting any protest against injustice done to a member or to the entire fraternity, contributing to the welfare schemes or to the ‘think bank’ of the profession etc.
Greater the strength of any medical organization, better the negotiating power with the Govt. or with the insurance companies, on genuine issues or whenever unjustified decisions are taken by them against the interests of medical profession.
In short, if we support our Associations, they will come to our rescue when we are in trouble. In elections, it’s your duty to elect people with clean track record to run the organization, weeding out any ‘black sheep’, so that we can expect dedicated, honest administration from them. Beware, most of the organizations earn ill reputation in handling money matters.
“Quit chewing tobacco? But that’s the only source of fibre I get.”
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90 Pediatric patient
Doctors working with children should have a good knowledge of child psychology and normal developmental milestones. It is important to have established rapport with parents and the child when taking the history. Assure the child that you’re not going to give an injection. Keep some chocolates and some (unbreakable and not sharp) toys in your room to make the children feel at home and to distract their attention.
Even a pen torch, ear speculum or calling bell can be a useful distraction. The approach to the examination will be determined by the age, level of development and level of understanding of the child. Avoid waking up sleeping children. Approach the child at their level; if necessary, kneel on the floor. It may be impossible to examine pyrexial, irritable children without provoking crying and they should be carefully observed before attempting closer examination.
Start examining peripherally (hands and feet), as this is less threatening. Make sure the child is comfortable in cold climates and that your hands, stethoscope and other instruments are warm. Ask parents to assist with dressing or undressing children and be aware of sensitivities about this. Inspection and observation are the most important aspects of the examination.
Observe the child’s behaviour and level of awareness and corroborate with the parents’ statememts. Consider if the child’s appearance is unusual and if there are any recognisable anomalies. If there are any bruises, note their color, shape and positions. If they are of suspicious nature, consider the possibility of being non-accidental.
Avoid examinations such as rectal examination, as it may cause discomfort, unless it’s essential. If a child requires x-ray of a limb for suspected fracture, it’s better to take normal side also, for comparison, since unfused epiphysis may cause confusion.
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Doctor has to face additional problems in the evaluation of diseases in very elderly for several reasons. They may be frail and not very ambulant, have impaired hearing or sight, multiple organ (cerebral, cardiac, renal etc) dysfunction, may be away from children or spouse leading to emotional problem, may have some property or financial issues, may be living in an old age home, may be already taking several drugs and so on.
It will be convenient to have a 3 or 4-seater sofa in the consultation room (meant for the attendants), on which the patient may be examined, if he can’t climb the examination coach. Eliciting history may be difficult, in view of the hearing problem or dementia. Special attention to be given to identify and address common diseases in elderly, such as constipation, cataract, prostatic disease, malignancies, insomnia or cognitive disturbances.
Most of the investigations may reveal age-related organ dysfunction, about which very little can be done. If surgery is required the risk/benefit ratio of anesthesia and surgery has to be assessed, keeping non-surgical options also in mind. Morbidity or mortality in very elderly is better accepted by the family by omission rather than commission by Doctors.
Drugs which may be potentially risky, such as NSAIDs, anticoagulants, antihypertensives, hypoglycemic agents, antiparkinson drugs, psychotropics should be used with caution and their dosage to be adjusted according to the age and co- morbidities.
In view of the various drugs they consume, periodic monitoring of renal, hepatic, cardiac, pulmonary or cerebral functions, may be necessary. Keeping in touch with their kith and kin, who may be abroad, will make them very grateful and satisfied.
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92 Pregnant or lactating patient
It’s a complex subject, to know the mechanism how molecules cross placental barrier or lactiferous system and list of such drugs may be very lengthy. As a rule no drugs should be given during 1st trimester, when the formation of various structures and organs in the fetus is expected to take place.
Since the teratogenic potential of several drugs haven’t been fully studied, only essential drugs should be given even during 2nd and 3rd trimester. Some drugs, having low molecular weight, high lipid solubility, high protein binding property and low polarity (molecular charge), readily cross the placental barrier.
Actually there is no ‘true’ barrier in the placenta, it’s a semipermeable membrane, only reduces the amount of chemicals diffusing through it. It’s interesting that the hyperemesis gravidarum seen in the 1st trimester is actually nature’s design to reject foods that may be harmful to the developing embryo.
Some drugs, such as codeine, nasal decongestants, amiodarone, statins, anti-mitotic agents, radioactive iodine, extended release or long acting formulations etc. have to be totally avoided while a woman is breast-feeding.
Drugs are preferably taken once a day, immediately after feeding, giving a long gap for the next feeding. There is a big list of safe and unsafe drugs, both during pregnancy and lactation; you are advised to consult experts or larger text books, for more detailed account on these two subjects.
“The Doctor will see you now. Here’s your medical jargon dictionary.”
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‘It’s more important to know what kind of a patient has the disease, than what kind of a disease the patient has’.
Beware, ‘there are more mental patients outside than inside the asylum’. The human diseases may be broadly classified as somatic, psychosomatic and frank psychiatric disorders. The first and last categories may not be difficult to identify, but the second is the most difficult to diagnose and requires the expertise of an astute physician. To name a few such conditions : hyperacidity & heartburn, irritable bowels or constipation, tension headache or vertigo, cervical spondylosis, hyperhidrosis (increased sweating) or palpitation, chest pain or cardiac neurosis, insomnia etc.
A patient with these disorders, typically comes with a big file, seen by so many consultants (hopefully you are the last), undergone several investigations, but not satisfied and exhibit a sense of insecurity. If we carefully observe the way he narrates the history, laying emphasis on unimportant matters and the pattern of symptoms not fitting into any known entity, refractory to conventional treatment, we have to suspect a ‘functional’ component and deal accordingly.
Generally the patients don’t accept that their problem is functional (or ‘supratentorial’, as our teachers used to put it) and we have to convince them that symptoms of an organic disease are getting aggravated by some emotional stress. At that stage, they generally admit some incident in the background causing stress. There can be innumerable causes for stress in life, listing all of them is beyond the scope of this booklet.
The statement, ‘man is under stress from cradle to coffin’ has been expanded in modern life and modified as ‘from womb to tomb’. However the threshold point for breakdown for any stress varies from person to person, depending on a combination of genetic (nature) and environmental (nurture) factors.
‘There are many people in this world, who spend so much time watching their health, that they haven’t the time to enjoy it’. ‘Treat the entire patient, not just his liver’.
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94 Psychiatric patient
We should realize that ‘all psychiatric patients die of organic diseases’, hence every symptom they have should not be brushed aside as functional. It taxes our clinical acumen and experience to filter an organic disease out of functional manifestations and successful Doctors had mastered this art.
It’s also advisable to avoid surgery on them, unless it’s absolutely indicated and life saving, because anytime after surgery, if the patient goes to another Doctor with a problem, the Doctor promptly advises him to go to the ‘Doctor who operated’ and ‘washes’ his hands.
Subsequently, it becomes very difficult to disown the patient, even if his problems are not related to the surgery. The Doctor must be aware of any possible physical harm a violent or aggressive patient may do to him.
We should keep enough manpower with us, when we are examining such patients and exercise extreme restraint against using any affensive or abusive language with the patients, who may have very low threshold for criminal violence. But at the same time, it may be necessary to take him into confidence in absolute privacy, to get some important clues from him.
A person after an ‘unsuccessful’ suicidal attempt, including a post-burn patient, requires intense counseling, since they have a high incidence of repeated attempts. The family also has to be cautioned to eliminate any possible stressors in his life, as much as they can.
Another very important and sensitive matter is the ‘unwanted’ gossip about a ‘mental’ patient, which can aggravate the patient’s original problem. If someone has stomach or leg pain, no one, not even the next door neighbor, thinks about it. But if someone has a psychiatric problem, entire town talks about it, adding their own anecdotes.
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Hence it is very important that utmost confidentiality is maintained not only by us, but also by their family members, especially in ‘borderline’ psychiatric problems.
The fact a person consulted a psychiatrist, leaves a permanent stigma on his personality and may create additional issues. To maintain absolute secrecy, I request the psychiatrist to see the patient in my office and use my prescription pad, to write the treatment.
Lawyer : Doc I’ve a bad news for you. My client wants to include your parents also as accused.
Doctor : How come ?
Lawyer : He strongly feels they shouldn’t have sent you to medicine
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95 Non-compliant patient
It’s said in lighter vain that ‘the patients who don’t take our advice seriously, are our assets’. For a patient who doesn’t quit smoking or drinking, that provides you with best explanation, why your medicines were not working as expected. Similarly for a patient who doesn’t lose weight, that gives you a good reason why his musculoskeletal symptoms were not resolving.
That’s why, one smart Doctor had put up a board outside his room, which says ‘if every patient sincerely followed my advice, I wouldn’t have been able to build this building’. This message is expected to reach deep in the patients’ minds.
When we reach a level of seniority that, we’re confident, that our clients won’t leave us, we can warn such patients that you might not see them in future, unless they mend themselves. For many patients, this works wonders, since they don’t want to go elsewhere for medical advice.
Occasionally one of your regular patients, suddenly goes to some other Doctor, either on the advice of some friend or he couldn’t get your appointment when he wanted.
Dissatisfied with the other Doctor, the patient comes back to you, confesses his ‘mistake’ and asks for an apology.
Exercising good diplomacy, it’s best to say : ‘I’m happy you went to another Doctor, otherwise you would never appreciate the difference’.
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Generally it’s difficult and unethical to carry out double-blind clinical trials on patients coming to us for treatment, in an out- patient setup. Administering a controversial drug in one arm and a placebo in the other arm, may be potentially harmful to both and any such study on humans, without the clearance by the Ethical Committee of an institution is not legal.
Similarly doing an controversial operation, not considered standard, on a patient even with his ‘informed’ consent, but without the approval of the Ethical Committee, may invite trouble, if he suffers any damage out of it. Besides the liability of the compensation, it may attract criminal proceedings.
If you’re a participant in a multicentric study and the main author had already obtained the clearance from a properly constituted Ethical Committee, you are justified in carrying it, as a member of the team. It is advisable to consult the guidelines prescribed by the Indian Council for Medical Research (ICMR), available in their website, for further information, before we embark on clinical trials on humans.
A retrospective statistical study can be done from your database, without any permission or risk to patients, useful for epidemiological inputs, about a particular disease or a particular modality of treatment.
“I didn’t experience any of the side effects listed in the enclosed literature. Should I be concerned?.”
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97 Preventive healthcare
‘An ounce of prevention is better than tons of treament’. This is more relevant in the present scenario, with high cost of ‘quality’ medicare, beyond the reach of a common man. Neither the subject of Social & Preventive Medicine (SPM) is taught seriously in medical colleges nor an average practitioner has the time to focus his attention to preventive heathcare, in his day-to-day work.
Any Doctor who depends only on treatment by medicine or surgery, is considered incomplete. In the present global scenario, with shifting emphasis on natural remedies, we should also modify our strategies to suit the changing public moods and propagate alternate remedies through meditation, yogaasanas, pranayama, aerobic exercises, naturopathy etc.
We should impress upon our clients to always trust four important ‘Doctors’ for their positive health; Dr Diet, Dr Exercise, Dr Lifestyle and Dr Take-it-easy. ‘Meditation is better than medication’. It’s important to maintain optimal weight, carrying regular exercises (at least for 30-45 min, four times a week), avoiding unhealthy (fast) foods containing more fats, salt, rice and sugar, promote vegetarianism, oldtime habits like early to rise and early to bed, get good sleep and free bowel movement etc.
We should discourage people craving for ‘fast’ foods; they are probably so named because they lead us to heaven fast ! Proper and timely vaccinations are also important in all ages for various preventable diseases. The diabetologists tell us the ABCDE of glycemic control, to prevent complications, they are A1c (<7), BP (<130), Cholesterol (<200) & LDH (<100) and Dietary & other habits (tobacco, alcohol, weight) and Exercise.
Looking at the prescription given by a Doctor, one woman remarked ‘hope there are no side effects for these medicines’. The Doctor asked her ‘have you ever asked this question, while eating a pizza, burger or hotdog ?’ We talk about of pollution of air, water and noise, but how many think about thought pollution playing havac in ‘modern’ lives. The computer, mobile phone, internet, cable TV etc. have become essential in our daily lives, but we are paying heavy toll for the comforts they provide.
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Humor in medicine
‘Humor is the best medicine’ but it may not be very ‘remunerative’. During conversation with a patient (or with anybody for that matter), it’s highly desirable to have a sense of humor, but it should be delicate, decent, fitting to the context and shouldn’t be rude, vulgar or too time consuming, remembering ‘brevity is the soul of a wit’.
It also helps to convey a message through a ‘sugar-coated’ pill and diffuses any tension in the atmosphere. Often they remember our humorous ‘anecdotes’ much longer than other explanations offered, with high technical knowledge. Can humor alone cure illness ? No, it can be used as an adjunct to other things and may address the emotional component.
If we want to treat only by humor, patient also may crack a joke and leave without paying the fees, making your practice itself a ‘joke’. To an elderly patient who says he never visited a Doctor before in his lifetime, the Doctor remarks in a lighter vain, ‘what will be the fate of Doctors, if every one is like you’.
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‘Death with dignity is better than living with humiliation’.
It comes from a Greek expression, eu=good and thanatos=death (means ‘good death’).
Sometimes it’s used synonymous with ‘mercy killing’ or ‘assisted dying’.
Euthanasia is categorized in different ways, which includes voluntary, non-voluntary or involuntary.
Voluntary euthanasia is legal in some countries.
Non-voluntary euthanasia (patient’s consent unavailable) is illegal in many countries.
Involuntary euthanasia (without asking consent or against the patient’s will) is also illegal in all countries and is usually considered as a murder or homicide. We all remember the story of the legendary British nurse, Florence Nightingale, when she was young, she couldn’t see the suffering of a dog badly injured beyond salvage, decided to kill it, out of mercy.
Over the years, euthanasia had become the most active area of debate in bioethics. In some countries public controversy exists over the moral, ethical, and legal issues associated with euthanasia. Passive euthanasia (known as ‘pulling the plug’) is legal under some circumstances in many countries.
Active euthanasia, however, is legal or de facto legal in only a handful of countries (for example: Belgium, Canada and Switzerland), which limit it to specific circumstances and require the approval of counselors, Doctors and other specialists.
In some countries – such as Nigeria, Saudi Arabia and Pakistan – support for active euthanasia is almost non-existent. The advent of organ transplantation and redefining ‘brain death’ have created new dimention to this subject, more and more counties supporting the concept.
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In 2018, passive euthanasia is made legal in India by the Supreme Court, under strict guidelines, by means of the withdrawal of life support to patients in a permanent vegetative state, after harvesting the usable organs.
The ceritification of brain death for purposes of organ donation, requires endorsement of four Doctors, the attending physician, a Doctor representing the hospital, an independent physician who is not involved in the care of the patient and a senior neurologist or neurosurgeon.
“The Doctor is just wonderful!
He listens to all my irrelevent, boring stories.”
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Doctor may superannuate from service (either govt or private) at a particular age, but retirement from profession is mostly voluntary or rarely due to some disability, physical or mental. An elderly Doctor may also stop practicing, if his residence is relocated to another place, state or country.
Depending upon the mindset and health condition there are many options to keep yourself busy, such as reading, writing a book, play games, do some business, do social service, visit places or just spend time with friends, family, children and grandchildren.
What we should not do, is keep nagging your family members for petty things, making their lives miserable and regret for your retirement. Another important action is passing on your ‘franchise’ to Doctors in your next generation, son, son-in-law, daughter, daughter-in-law or grandchildren.
We certainly don’t want our goodwill, earned over several decades, go waste or unutilized. If their speciality is different, another room, adjacent to yours,
may be provided for them. If their
subject is the same as yours, you may stagger timings and gradually transfer your practice to them, to retire in a phased manner.
Of course, if there’s no Doctor in your family willing to take over, you may ‘sell’ your practice to another Doctor, who is interested to run it or you may convert the place into some commercial outfit.
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Twelve ‘Commandments’ for ‘healthy and litigation-free’ medical practice, compiled by me in 1990, are very crisp, easy to practice guidelines, to satisfy our patients and to maintain safe ‘social distance’ from the lawyers. They are self explanatory and most of them have already been covered in detail in various chapters :
i. Tidy appearance & warm reception
ii. Encourage free communication & clear all their doubts
iii. Explain therapeutic options & involve them in decision making, to the extent possible
iv. Outline the risks involved, obtain informed consent & never guarantee cure
v. Be punctual & available for emergencies (at least on phone)
vi. Maintain proper records & prompt correspondence
vii. Be considerate, non-commercial & avoid advertizing
viii. Join professional organization, read literature, attend CMEs, update yourself & practice evidence-based medicine (EBM)
ix. Respect co-practitioners & be willing to get a second opinion
x. Observe ethics, know the statutes & act judiciously
xi. Do some free service & involve in community service activities
xii. Don’t forget your family & children
“Alright, let’s Google those symptoms and see what we come up with.”
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‘Tele’ (Greek)=distance; ‘mederi” (Latin)=to heal. Although initially considered futuristic and experimental, telemedicine is today a reality and has come to stay. It has a variety of applications in patient care, education, research, administration and public health.
Worldwide, people living in rural and remote areas struggle to get quality medicare and often have no access to specialty healthcare, primarily because specialist physicians are concentrated mostly in urban areas.
Telemedicine has the potential to bridge this distance and facilitate healthcare in these remote areas. The necessity of Webinar meetings, CMEs, video calls and online consultations by senior Doctors has increased recently, thanks to the pandemic. Robotic surgery is yet another, sofisticated application of telemedicine or rather telesurgery.
Since the 1950s, healthcare providers have been offering remote services. Telemedicine first began on landline telephones. With the advancement of technology, it has grown to offer services in a variety of ways. This includes online portals managed by your personal physician, video software, that allows for remote consultations and apps managed by companies offering telemedicine services.
Telehealth is broader term, to include distribution of health- related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention and monitoring.
Infrastructure required :
i) You need sufficient bandwidth to transmit audio and video data (50-100Mbps or Megabites per second). In a rural set up, there may be difficulty connecting to or obtaining affordable and reliable broadband service.
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ii) Imaging (video) technology or peripherals are the backbone of telehealth. They allow rural health organizations to see and hear patients even when they are miles apart. Digital stethoscopes, for instance, can transmit heart and lung sounds to remote providers.
iii) Technical support staff can help installation and answer questions about telehealth programs. To help financial efficiency, technical support staff may be shared across the collaborating organizations.
In view of the cost and the required technical manpower backup, at present, this facility is available mostly in corporate set up.
Doctor : Due to new privacy regulations we can no longer use patient names in the waiting room…
Will the patient with the itchy vagina please follow me…
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103 Etiquette & ethics
Etiquette is defined as our attitude and behavior towards our professional colleagues, including paramedical persons. This subject is already discussed in detail earlier. Next to expertise, ethics is the most important virtue of a Doctor, which is appreciated by the profession and public and remembered long after we leave this world.
The list outlining the principles of medical ethics, virtually dictates the nobility and virtuous life style of a Doctor. Some of them might have been already discussed in detail in other chapters, but to recaptulate for comprehension :
Upholding the dignity decorum befitting the profession even in day-to-day public life, cordial, empathetic behavior with patients and colleagues, projecting a professional, noncommercial attitude.
Respecting privacy and modesty of patients, maintaining secrecy of matters revealed or discovered by you, including autopsy (exceptions : insurance company, court of law, health authorities, children and mentally challenged)
These are some activities by a Doctor, considered unethical : to employunqualifiedDoctors,nursesandotherparamedics
to receive commission or kickbacks from diagnostic centres as ‘interpretation’ fees
to have commercial interest in pharmaceutical companies or pharmacies
to have ‘unhealthy’ relationship, including adultery, with patients or the family members
to give illegible prescriptions, with a probability of pharmacy giving a wrong medicine
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to do offences involving moral turpitude, leading to conviction by a court of law
to issue false or misleading medical certificates to employer, court or insurance company
to withhold notifiable diseases or statistical data from health authorities
to perform abortion without proper medical indication or for purposes of female genocide
to refuse to provide emergency life saving treatment, without a valid reason
to put up unusually large name boards, with any material, to attract clients
to refuse to provide medical services on racial, religious or community grounds
to use Red Cross emblem, except by the Army Medical Services (GenevaConvention- Article7of1864&Article38of1949)
to practice secret or magic remedies, not in accordance with science or pharmacopeia
to conduct experiments potentially hazardous to patients, without their informed consent and the approval of the Ethical Committee of the Institution
to treat medicolegal cases without proper documentation or informing the police
Basically a Doctor, member of a noble profession and a respected citizen, should be law-abiding, familiar with statutory require- ments related to medical practice and act judiciously, not only while discharging his professional duties, but also in normal life.
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104 Japan’s secret for success
It’s exactly 76 years ago (in 1945), during the World War II, US bombed Hiroshima and Nagasaki (Japan), devastating the entire country. It’s amazing how the Japanese worked and resurrected their economy, to become leaders in various fields in the world market.
There’s a story : a Japanese and an American were walking in the forest and saw a tiger running towards them from a distance. The Japanese guy started tying his shoe lace, so that he could run fast.
The American asked him ‘are you foolish, can you outrun a tiger ?’ The Japanese replied ‘I don’t have to outrun the tiger, if I can outrun you, I’m safe’.
This is how they conquered the world market. The moral is, you don’t have to be the world’s best, if you show an edge over the next man, you win the race. This applies to all walks of life, including medical practice.
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What an agnostist calls as god, the scientist (or rationalist) calls it nature, which has tremendous healing (or mending) power and basic animal instinct of struggle for existence is always at play, to put the life back on the track.
We also have ‘karma’ theory that most of the happenings are predetermined and manifest under conducive circumstances. It says, like drugs, we all come with a prefixed ‘expiry date’ and there’s no escape from it.
It’s said in Bhagawadgita, ‘karmanye vaadhikaarasthe, maaphaleshu kadhaachanaa’, which means we only do the actions, but have no control on the outcome, the results are decided by the god (or nature). It’s also said, ‘Dharmo rakshathi rakshithah’, if you follow ‘dharma’ in all your actions, it shall come to your rescue, in times of need.
Researchers want us to understand modern medicine by separating body from mind – while mind is superior to body, as it constitutes the uniqueness of the human soul (the province of theology), body is inferior to mind as it’s a mere matter. Medicine simply considers the body as a machine.
While Dualism dominates clinical approaches to medical research and treatment, the legitimacy of the split between mind and body has been consistently challenged from a variety of perspectives, but experienced clinicians agree.
The therapeutic rationale of certain forms of treatment, such as hypnosis, faith healing, acupressure, music therapy, magneto- therapy etc. practiced by many, is yet to be fully understood, but certainly worth consideration.
It may be prudent for the young scientists to remember the three Murphy’s rules (Edward Murphy was an American Aeronautic Engineer, 1918-90) and the 4th one added by us :
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i) More complicated a procedure, more chances for it to go wrong.
ii) During the entire procedure, if there is anything that ‘can’ go wrong, it ‘will’ go wrong.
iii) If you think everything is going on well, you might have overlooked something important.
To these, we added another caution :
iv) Don’ttrustmothernaturetoomuch.Natureisgenerallygood and supportive, but we don’t know about patient’s ‘nature’.
Medicine remains a venerable and noble profession even in an environment of a rapidly changing social, technological, corporateandgovernmental influences.Unlikeinotherwalksof life, there is a constant demand on a Doctor’s time and one has to try and balance his professional, social and personal life.
It is the solemn duty of the present generation of Doctors to strive to uphold the quality and sanctity of medicine and pass it on to future generations. ‘Medicine may cure some, relieve often, but should comfort all’.
Finally one should realize that the patients appreciate the expediency, cost-effectivity and transparency of a Doctor, who is kind, honest and empathetic. Nurturing this kind of attitude towards our ‘clients’ is the core professional character, that makes it ‘noble’ and leaves no room for mistrust and litigations.
Child asked a wise man, “Tell me Sir, in which field could I make a great career?”
He said with a smile,
“Be a good human being. There is a lot of oppurtunity in this area
and very little competition.”
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Please note :
to avoid redundancy, wherever it’s mentioned ‘he’,
it is to be understood as ‘he or she’. The word ‘man’ is used to include both genders. Similarly the word ‘Doctor’ refers to consultants of various specialties,
as well asVgeneral practitioners.
I am grateful to
Prof Sudha Seshayyan, Vice Chancellor
the TN Dr MGR Medical University for the generous Foreword,
Prof B Krishna Rau, Senior Surgical Gastroenterologist for a very thoughtful Note of Appreciation,
Sri A S T Alaghuvel, Tymes Multiple Sevices
for designing & printing the book in an elegant manner,
M/s Systopic Pharmaceuticals Pvt Ltd., for shouldering the cost of publication & distributing copies of the book to the Doctors through their Field Staff
and Last but not the least, I bow my head to my Teachers for their noble contributions towards the success of my professional career.
- Prof C M K REDDY
Let’s close this book by invoking a Latin phrase, ‘primum non nocere’, which means,
‘above all, do no harm’, which is most appropriate to medicine.