Unsatified Patient

There are certain patients that irritate you. It may be because of their arrogant behavior, may be the negative comments for everything you do or may be because for some unknown reason you just dislike them. You hate it when they come. It is quiet understandable when they are really sick like running a high fever or when going through pain. Probably any of us will behave in a similar manner in these situations. When you are physically and mentally weak, even the smallest provocation is enough to bring any body’s worst character. But these are not the people i am not talking about. i am talking about people who basically have a negative way of looking at everything and trying to put down others. Take for example a patient i recently saw. This person presented to me with left side hemi-paresis (12h old) and at admission had a power of 3/5. A CT of the brain confirmed the presence of an infarct. With standard therapy (Of course aspirin, what else) he went back 72 hours later with a power of 4+/5. He comes back three days later and you can hardly make-out the weakness. He was quiet unsatisfied. He was unsatisfied that he has not come back to normal. i explained to him that this itself was quiet a remarkable improvement and neurological improvement gradually occur over a period of four weeks. He was not convinced and kept complaining back that he was the same as when he got admitted. There was no use in showing the documentation, that his power was indeed weaker at admission and had improved now. Luckily for his type of presentation, there is nothing sophisticated / expensive that could have been done that was missed-out but still we have an un-happy patient. These of course was just an example and we see quiet a few of these patients that are not satisfied even after proper explanations. (Lay people are not going to understand about a disease progression / improvement and if proper explanations are not given, definitely they are going to be un-satisfied). These people make me feel un-happy. One patient is enough to get you off your good mood for hours together. These patients put me in a soup. Whether to continue treating them or to refer them to some other hospital. We are supposed to treat even our enemy equally as we would treat our closest friends. Of course i will never ill-treat these patients in any way. That is wrong. But you loose interest in taking care of them. You just do what is necessary and nothing more. Previously i used to tolerate these hassles and continue treating them. I used to justify that we should not be emotionally disturbed by their behaviors. Of late, i tolerate it to certain limit and if they continue to bother i explain to them the reason for their referral and refer them off. I consider doctor-patient relationship is a long term affair. It is best if both the parties involved can sync. Otherwise it is going to be a trouble for both, especially so in treating chronic diseases. But the decision for me to start referring these patients was a late one. I always used to feel that i had to treat anyone who seeks me even if i do not like them. It always was an issue that took a lot of time to resolve for me. Now it is resolved for good. This i think is good for both myself and the  patients involved.  They may get some one who satisfy them and i will not be bothered.

PS: Of course i do not refer anybody when they are sick just because we do not get along. i treat them until they are well enough to be referred.

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Compromise

I always used to feel whether i am giving the best possible care to the patients i am treating. Take for example a common disease like diabetes. The patient needs so many tests like HbA1C, microalbumin, lipid profile, electrocardiogram periodically other than the regular blood sugar checks. If the patient can afford, then there is no question about the quality of treatment, he can have all these and we can see to that he/she is detected of any abnormality at a very early stage and proper precautionary medications / life style changes started. But what happens if the patient cannot afford as it frequently happens. Then cost rationing has to be done. Blood sugar is the least that can be done regularly. Though the standard of care requires HbA1C to be done, it seldom done because of the cost (Rs 250 compared to Rs 60 for fasting and post-prandial sugars) involved. So when a patient comes who cannot afford much, i always feel guilty that i may be missing out early evidence of renal compromise (Microalbuminuria), silent myocardial ischemia or the ubiquitous dyslipidemias. So what do i do in these situations? Explain to the patient the importance of doing these investigations either to find associated diseases or detect early potentially treatable complications of diabetes. i feel that the expense is well worth compared to the complications it can lead to and the compounding of expense to treat the complication, leave alone the added suffering. Some of the patients are willing to go through the tests once they hear these explanations. Most do not want the tests because they either think these are unnecessary (so digging their own grave) or really they cannot afford it (very few). In these patients, i have to go by the available information – clinical and investigative and hope for the best. When i initially started my practice, i used to feel quiet guilty that i am not helping them avoid preventable complications. I used to feel it is somehow a failure on my part. It took me a lot of time to realize that there are many things beyond our control – Out of which ignorance and low socio-economic status will top the list in India.

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What not to prescribe

This post is about the usage of drugs that is more and more being molded by the pharma industry. Not one day goes without the addition of a new brand and not a month without the addition of a new molecule. The question is should we go for the latest. This can be decided only after knowing for which disease we are talking about.
If it is the question of antibiotics, obviously an effective antibiotic with most narrow spectrum need be given. This is where our pharma friends come and ‘help’ us. They promote only drugs which are the latest and most powerful. They have visual aids which tell the indication of the drug. So you will see the visual aid showing Gatifloxacin and Gemifloxacins for URI. When a lie is told too many times, we may tend to believe it as the truth. Think about the general practioner who has finished his MBBS about 15-20 years before, he will tend to accept what is being repeated promoted as the truth. Unluckily for us there are no compulsory periodic licensing exams to keep ourselves up to date. So it is common to see the prescription pattern becoming dependent on the way the pharma wants it to go. Then we should not be surprised that Co-amoxi-clauv being used for common cold very commonly. Pathetic. Who to blame? – The pharma industry for misleading us or ourselves for not being up-to-date. I guess it is both. Finally who suffers? Of course the patient, who assumes that the doctor, knows best. In metros, when a patient goes to a big hospital and waits for an hour to meet the consultant paying big money for the appointment, they are not satisfied with a Paracetamol for the URI. The doctor writes a prescription worth at least his consultation so that the patient is satisfied. So a fission bomb is prescribed where TLC would do.
What I hate more is, doctors who are (supposedly) reputed, trend setters, using broad spectrum, powerful antibiotics which could have been taken care of a common, cheap molecule. Of course the patient gets relief nearly at the same time as the cheap, appropriate molecule would have worked compared to the all powerful, latest molecule. What it has paved way is, for community level drug resistance and rise in medical cost for the common man.
When the question of drug use is about a chronic non-infectious illness, it should be the drug which has the least side effect moderated to the patients affordability be prescribed. If you see the efficacy of various drugs in a class across the board, we will see that there are not many differences between individual drugs. So why bother about the hair-splitting differences between Losartan and Telmisartan. If the patient can afford, go for Telmisartan or any other later sartan. If he/she cannot afford go for Losartan. The same applies for other drugs like Glibenclamide Vs Glimepiride, Lisinopril Vs Ramipril…. That is the reason; all guidelines suggest the class of drug for a particular indication instead of a specific drug. While the difference in efficacy is small, the difference in cost is enormous. Ten tablets of Glibenclamide (Daonil 5mg by Aventis) costs Rs 6.60 while the same number of Glimepiride (Amaryl 2mg by Aventis) costs Rs 103. If a patient cannot afford much, we should not be writing Glimepiride just because no one is promoting Glibenclamide and because Glimepiride is the latest.
i want to conclude by saying, that we should use the drug for its indication and not for what the pharma person says. Importantly there is no alternative to keeping ourselves up to date.

Have the cake and eat it too

This is in reference to a nice, detailed post by Dr. Vijay. Basically deals with the current situation of a long medical course extended by one more year.

Any one now finishing 12th standard is faced with the dilemma – whether to become a doctor or any other professional like an engineer… Previously every one wanted to become a doctor. The reasons for that could be many – may be the pseudo-glamour created by movies / TV series (House MD, ER…), the respect the profession used to have or not the least – interest in the science and art of medicine. Now this has gradually reduced because of the length of the course, post course bleak income compared to the information technology which is the current flavor. A person who has finished MBBS after a tension filled 5½ year course will earn less than ten thousand rupees. Compare this to an information technology expert who starts earning more than twenty to thirty thousand rupees, that too one to two years earlier. The future prospects of his income going up with no extra-qualification are also high. Whereas the prospects of increasing the income with MBBS alone is very little unless the person is a genius like Doogie Howser. The other way was of increasing the income for most of us non-geniuses are to specialize into something which just cost three more years of the prime earning age (Provided that person is lucky enough to get the post-graduate seat immediately). Putting all this together, not much of the present students coming out of 12th standard are interested in medicine. If i had known all this when i finished 12th standard, probably a small town engineer will be blogging here.
Now sets in the complication. The already tedious, long path to add the prefix (Dr.) is going to be made tougher and longer by another year. This is because of the compulsory rural postings of one year that the government is planning to implement. Should every one be not happy because of the immediate job prospect? There lies the crux of the issue. The government wants to have the cake and eat it too. They want them to be appointed on a temporary basis. After that the person is out of the system. Basically the person entering MBBS is spending one more year before he can be independent to do anything.
i feel that is wrong. If the government feels, that there is a vacancy, fill it up on a permanent basis. Why keep them for a year and throw them after another batch comes to fill in these vacancies. Or make it optional so that people interested in a government job can apply and get a permanent post. Otherwise what the government is doing is to cheat one year of prime time out of people who are already graying when they are coming out of MBBS. If the trend is to be allowed, number of people wanting to become doctors is going to dwindle. Already there is a deficit of doctors in India compared to ‘developed nations’. This is going to become worse if the current trend is allowed. i hope the government finds an amicable solution.

Grand Rounds at Enrico’s

First of all profuse apologies for the bloggers (Not many. One or many does it matter?) who have been continuously checking my site for new posts. I feel guilty for not updating my blog. I can give any number of reasons from increased out-patient load, to exploring new horizons in blogging (Powncing), etc… All those are just excuses. I hope I will not let it happen in the future.
i visited a nice grand rounds at Enrico’s blog. It was enriching. First of all, it let me see a nice selection of different bloggers with differing views and differing presentation. Secondly, it let me see how blogging can be made useful to others. Last but not the least was how entertaining it was. Over all it was good.

Exploitation – The pitiable drug representatives

i feel, drug company representatives have the lousiest job. Allow me to explain. Most of the small drug companies, hire fresh graduates for a salary of Rs. 4000-5000. Most of the companies insist on the person getting a bike before he can be given an appointment order. After this the area manager, takes them on calls for a week or so before he starts going on his own. Bigger companies have a higher starting salary and they are sent for professional training for a month or so, where they are taught about the products they sell, go through personal development courses so that they are confident and over-all they return as better persons. Every year or two they have again refresher courses, so that they are kept fit.
Each representative is pressured by most companies to meet about 15 doctors a day and 2-3 medical shops. But on an average, usually they are able to meet 7-10 doctors only at the maximum. Not only local calls but they have to cover in and around 10-100km. That is where the work pressure starts increasing. At the end of the day, he has to lie that he made the fifteen calls or explain to his superior (Reporting every day is mandatory) why he was not able to keep-up. The next pressure is the targets, he has to reach – monthly as well as yearly – total revenue as well as targets for individual drugs. If he/she is not meeting the targets consistently, over say six months, they are fired. So the pressure is tremendous, he has to maintain his daily calls average and expect his products to sell also. A representative can promote his product but how can he guarantee that the doctor will take it up? In the town i am practicing, there are around 350 representatives (Believe me), representing hundreds of unknown, small companies and few large companies. With this kind of competition, how does each company expect all their products to sell like hot cookies? Some companies, do all kinds of weird sales gimmicks that increase the work load – pre-call and post-call analysis (Before they enter your chamber, they have to give their analysis of how much the doctor is already supporting, his potential and after the call, what he expects the doctor to take-up), keeping the cell phone on before meeting the doctor (So that his superiors can hear the whole conversation and assess whether his representation is of top notch), special campaigns – like saying good morning or good night to a few doctors everyday for a week or so, dressing up in costumes (Not exaggerating) and coming for certain drugs…These people work from morning (Certain doctors see only after prior appointments, a limited number of representatives, say 5 per day or so – So they team-up in front of his clinic before it opens and try to get the appointment for the day – as early as 5am) and late night (as late as 11pm – Because many doctors working in the government hospital practice only in the evening into late night).
What do these people get at the end of the day – vehicle accidents (Driving late in the night with lot of fatigue and pressure keeping them brooding about the next day), which in my place averages at five accidents a month (Minor scratches to worst –death), depression an divorces (Which wife will like a husband to enter the house at 12 in the night and leaving early in the morning?)
Is this the scenario for all the representatives? It is for more than 95% of them. A few companies have lesser work-pressure and higher respect to the individuals working.
Luckily these representatives are now forming their own association and putting forth their basic needs. But to this day what i have posted is the way of life for them. i pity them.

The gift trap

This post is about us doctors accepting gifts from drug manufacturers. These gifts range from different size and costs. From pens to microwave ovens to television to diamond pendants to Direct to home set top boxes to laptops to books to exotic vacations…They are very creative. They see to that once you accept it, you feel grateful at least at the sub-conscious level. Each time their representative comes, they ask how we are enjoying their gift, gently reminding us of their favor. Do you think that any of the doctors receiving it cannot afford it? Some people assert themselves saying, if you do not accept it, the representative is going to give it to somebody else and anyway there is no compulsion for us to write the product. Is it so? Once we accept the gift the least that happens is we loose our impartiality in judging what the patient needs. The worse that happens is, we write unnecessary drugs – from multi-vitamins that cost the earth (Otherwise why will there be so many different vitamin preps – especially so when there are very few indications to write it) to expensive, latest, most broad spectrum antibiotic to treat a simple upper respiratory infection (Prescribing Co-amoxi-clauv for common cold is not uncommon. Especially for some consultants, these kinds of antibiotics are the first line treatment for day-to-day fever. The patient is satisfied that he paid a lot of money and assumes that the drug should be great). These not only lead to increased pill burden but contribute to increasing resistance at the community level. It is a vicious cycle, you use powerful antibiotic to kill a common cold, the next time a bacteria strikes, it is usually resistant to that antibiotic. So a more powerful antibiotic is necessary.
Some pharmaceuticals appoint an exclusive person to take care of two or three big shot consultants. They take care of them in everything – including doing mundane things like paying utility bills to helping the consultant in preparing for talks to arranging their travel needs (Both for conferences and personal – of course all expense borne by the company as a service to the doctor). These are usually seen in metros for super-specialists like cardiologist, urologist… They are so nice that they home deliver things like the latest movies for the spouse in the house. You feel you are indebted to them. The least you can do is help their company products. You scratch my back, i scratch yours even better.
Some companies are smarter. They do not spend money in making quality drugs (i even doubt there is any real drug in it. If you see, where they are manufactured, it will be one of the small streets in metros where you know there cannot be any reputable, big manufacturing company) but they offer business deal to the doctor – certain percentage of the total sale (As high as 40% of the maximum retail price). After you make a deal, where is the question of ethics, quality…These doctors earn more from the prescription they write than from consulting fees.
One thing that should be thought of by us (doctors) is, can’t we afford that cheap pen or TV or our tickets to a conference? If we were to get sick and go to a consultant who we know supports a company and if he writes one of those brands, would we believe his judgment – do we really need that drug or is it just a habit, that he wrote to us that all-powerful antibiotic.
Do we need these gifts to trap ourselves into unethical practice?

Teachers that mattered

It is quiet some time since i posted. i thought i will post about some teachers that left a mark on me. My college days extended for a long 8½ years (5.5 in MBBS and 3 in MD). Quiet a few people left an impression on me.
These people can be broadly classified into two groups. The first group inspired me to be like them and the second group taught me – how i should not be.
The first group of teachers had a couple of things in common – vast practical logical knowledge of handling patients and their disease (very minimal book knowledge) and empathy to patients. These were the people who would go out of their way to help a patient. Whenever i come across a difficult diagnosis, i put myself in their shoes and think what they would have done and i usually get a solution.
The second group of people taught me how not to be. These teachers also had a couple of things in common – extensive book knowledge (They will be thorough with the latest and try to think of the most exotic disease even though there was a simple explanation for all the symptoms the patient would have given) and doing just opposite of what they preach. They try to project a holy self image and in reality they will be doing the most deceitful things without others knowledge (they thought no one will notice these).
Being jobless without many hobbies during my educational years i was close to both these groups thus i came to know their greatness and cunningness more clearly. i concluded, 1) knowledge is important, but more important is its application in day-to-day setting 2) being a good doctor did not take much effort – just think all patients were your blood relations and do what you would think you would do to your own son/daughter/brother/sister/parents – you will be good, knowledgeable doctor

old medicine new use

There is a good article cited by Gruntdoc. This is about the use of Minocycline in CVA.

It is surprising so many unrelated drugs are found to have so many other uses. Some have turned out to be quiet useful. Many just a hype. The example for previous one is Chloroquine in arthritis including the recent Chikungunya epidemic. i hope this minocycline is not just one of the later. Usually what happens is after some positive effect is found, many possible explanations (which are educated guesses) are given. Obviously only a large randomized, placebo controlled study with a large sample will be the answer.

This tPA business is also of questionable use, at least in Indian settings. The patient is supposed to report to a stroke unit and tPA can be given, if we can rule-out a hemorrhage. All these within three hours (For anterior circulation strokes – the commonest). Most of the time when a patient comes after a stroke he has already crossed the gloden window period. So tPA is useless. Secondly, most of the strokes occur in the early mornings. How do we know how long the stroke process has gone? A patient wakes-up and finds out he has weakness. May be it happened just five minutes before he woke-up or maybe just after he went to sleep, 6-7 hours before. Thirdly when a CT is normal, it can mean he is having an early stroke (Conventional CT can take -12 hours for obvious changes to occur) or he is having a Transient Ischemic Attack. So what happens – you lyse a patient with TIA and take credit for natural recovery and collect the fees in between? i just feel it is not suited to India where money, resources (Trained doctors & CT) are not that freely available.

For the non-medicos visiting my site, jargon buster for the above post.

Minocycline is an antibiotic of tetracycline group.

CVA – Cerebra-vascular accident – commonly called stroke – is due to blockage of arteries most of the time by a blood clot and some times by a bleed due to a rupture of a blood vessel. Thrombolysis is the process by which the clots are removed (Thrombus- blood clot, lysis- break-down). So obviously if accidentally a patient with bleed into brain is given a thrombo-lytic drug (like tPA – Tissue Plasminogen Activator), the bleed will worsen and can sometimes be fatal.

Usually a CT scan is done as the initial investigation to evaluate whether a stroke is due to clot or bleed. It will pick-up a bleed as soon as it occurs and a clot after a few hours (Up to 12hours).

TIA – is due to a small clot in the artery, which dissolves itself and so the patient recovers completely. It is a warning of instability in that area and these patients need to go on prophylactic drugs to prevent a full blown stroke in the near future.

Practice hours – part 2

i belong to one of the last two categories. Essentially an individual practice. Here the patient comes to see the specific doctor because of him and not because of the popularity of the hospital. (People go to Apollo, AIIMS… mostly for the hospital name and not the individual doctor’s popularity) Doctors in this type of practice essentially spend long hours in the clinic. Most of them start at around 9am in the morning and go for lunch at 2-230pm. Then re-start the practice at 5pm or so and then go on till 10-11pm. Few busy practioners i know, practice up to 1-2am. This goes on mostly seven days a week with very few of them having Sunday as holiday. Since this is a one to one practice, the doctor has difficulty in saying no to a patient, for he would have known him for years. The patient will be at a disadvantage if he sees somebody else, as the new doctor will not know all his past problems and idiosyncrasies. So the patient expects his doctor to see him, especially so when he is sick . So the compromise here is the doctor’s family life. How can he have a family life with working hours like this? He hardly gets to spend any quantity of time with the family. If the doctor has in-patient facility, his mind is constantly occupied by the admitted patients since at least one of these patients will have some complication that worries him. So the quality is also affected.

There comes the difficult decision – should he satisfy his patients and see them as much as possible and sacrifice his family time or should he restrict his time and spend more time with his family but refuse seeing his regular patients, who keep so much faith on him, during odd hours. i know lot of spouses of doctors with depression. Especially if the children have grown-up and gone to college and if the spouse happens to be a house-wife, there is very little to prevent her from going to depression.

This problem is not there in bigger set-up, where you know some-one who knows your way of treatment (the junior doctors in the hospital) will be tackling your patients. You have the added assurance of, if anything needs to be clarified, they can always call you up.

For most of the doctors, money is not the problem. Since if they have such a good practice, they earn more than enough. But it is the sense of guilt that keeps them from restricting their practice.

So where is the compromise? my personal feeling is this – the doctor, as well his family are definitely human beings with things that every one needs – spending time with spouse and children, spending time for oneself… So the first thing that needs to be satisfied is these basic needs to himself and his family. This is provided; he lives in a place where there are other medical facilities available, so that his patients can go in case of an emergency. If none is available as in villages, he is obliged to see patients at odd hours. The doctor should understand, that the world is going to continue spinning, whether he is there or not – so he should not feel guilty of not seeing patients and spending that time with his family.