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Monday, December 09, 2013

Response to Dr. Kiran's and Dr. Varun's Articles!

Hi Dr. Kiran,

This was a wonderfully written and thought out article.

However, it seems to me that it was thought of only in the context of Dr. Varun's post.

Let me offer you a background of where and what I have done before I continue.

I did my MBBS in a very small village town called Loni, Pravaranagar. I did my internship through there with the first 3 months at Shirdi wherein I contracted a disease that paralysed me for a year and I then continued my internship on a walker and crutches at Sir J.J. Hospital and its various posts. I did a one year stint at the PHC at Palghar.

I worked as a surgical resident at Rajawadi General Hospital (BMC run) for three years

There is so much truth in both your articles that it's easy to miss the bigger picture.

I have seen 'batting' and unfortunately or fortunately been at the receiving end of it as well. I've admitted patients who were clearly required to be admitted in the medical ward only because they wouldn't just to have them transferred to another unit the next day. 

We've had patients admitted in our ward who came to the casualty the night before but were not admitted because the other unit was exceptional at batting them away just to come another day

I've taken transfers to my ward till my fellow residents and interns begged me to stop saying our ward is always full.

There was just one answer to them all. The more you see the more you will learn and the more you will earn! For some strange reason, this chant seemed to calm them down everytime.

For the part about patients sitting out of the casualty I've seen that too. Maggots, Diabetic Foot, Gangrene...I've seen them all turned away by the CMO when I wasn't on duty only to be told to mind my unit's business on my non call days.

I've seen people come from across the country to meet and talk to my Unit Head just for 5 minutes because he was open to alternative medicine. I've seen that 67 year old Unit Head ready to come to the hospital from half way across town just to consult on a patient that we weren't sure about.

I've seen patient's relatives beating up my colleagues when the patient died. TWICE in my unit with different colleagues. Over a period of 3 years. With nothing done about it both times in spite of police complaints and strikes.

I've participated in parallel OPD's when the strike was on with almost all residents in attendance.

When you talk about corruption, I know people taking kick backs even now, after being established private practitioners, and I know people who flat out refused when we were doing our internship for free!

I have been made to stay up 56 hours caring for a patient as an Intern when my resident and registrar had to study for their exams. They were extremely good seniors and I did it because I wanted to not because I had to. But, there was a question in my mind, was this what I bargained for? Is this what I want to do?

Climbing up the ladder. In our day and age, working hard at PHC's and government posts to try and reach the level of the Superintendent is not only a far fetched dream, but is also much like the elections of today. There is no separating politics and climbing the organizational ladder. I say this from past experience wherein my Associate Professor stayed and A.P. for seven years because he was told the only way to get promoted to Professor was to leave his city and go work someplace else. 

The other issue is money and I hear many morale battles saying medicine is not about money. I would ask you to come back to this post about 8-10 years down to road when you are married and have kids and still have to depend on your family to cover expenses. People in the developed world take up positions in their respective government institutions because they are well provided for. 

Not matter how much this stings, it is about the money.
Would you not give up an opportunity at private practice if you are well compensated for your time at a government hospital.

Lastly lets agree that there are always two sides to a coin and there are enough good doctors to overshadow the bad but all Dr. Varun's post has done is highlight a side. At this stage of his life, it will look all bad. We tend to glorify the ugly because that's what gets people's attention and I suspect that's all he intended.

Only if someone highlights the issues will there even be a discussion for improvement. I'm glad that you have provided the flip side to show that there are indeed good things about the profession. But let's not kid ourselves. There's just too much to go and it will take immense efforts from all of us to improve this.

A simple thing that I have started in my private practice is to prescribe drugs with their generic names written alongside brand names. The choice is then on the patient!

Let's work together to change the system.

P.S. Why go abroad to get a degree in MPH. Stay on in India and change the system from here!

P.P.S. For those who haven't read the preceding articles, here are the links 

Tuesday, December 03, 2013

Those deadly Motorcycles!

Disclosures first up. I ride a motorcycle and have been doing so for the past 17 odd years. I always wear a helmet and recently bought one for my pillion rider as well.

A woman who works with MTDC came in to the Nursing Home today with a story that just plain scared us all.

She was going to work from the train station on her friends bike like she had been doing for the past many months.

Her dupatta got stuck in the rear wheel while the bike was in motion. She was lucky, very lucky. She had good presence of mind and immediately tucked her neck in and towards the wheel to minimize the pull and the rider stopped gradually.

She had severe abrasions over her neck, almost similar to what you get when you hang by a rope from the ceiling. The result could have been just as similar as well.

Ladies, there is a reason the sari guard is sold as an accessory. It prevents such things from happening. Also, if you are wearing things that can flow into the wheel, please bunch it up and put it in the front.

This lady was also not wearing a helmet. Something she didn't even realize till I asked her about it. Hopefully, she will get one now!

No wonder, bikers in the U.S. are called Organ Donors!

Here are the reported incidents from our very own newspapers

One of a woman nearly strangled (similar to our patient)

High Court of Kerala mulling a ban on sarees for pillion riders

Monday, October 07, 2013

Is it time for Subscription Based Healthcare?

I'm going to start with stating the obvious. This is the digital age, where pretty soon, everything is going to be controlled by either your cell phone or more recently your smartwatch.

The services industry is going gaga over providing the best service to you right where you are, mostly through the use of these digital devices.

All you have to do is subscribe to a service.

You can get food delivered to you at any point of the day / night. You can get updates on news, views, rants, campaigns, cricket matches, football scores or even the colour of the month! You could get a phone company servicing you either online, virtually, or even in person at your home on demand. Banks lure you into internet banking and send people over when you want to open an account. Basically, everything is at hand, where and when you need it. Almost everything. 

Healthcare is being left behind, and I intend to correct this. Why can't we have a subscription based healthcare delivery system. Sections of the industry are heading this way already. You can get your blood tests done at the comfort of your own home at any time. You can order in prescriptions if you know your chemist well enough. You can now even get emergency care at home with services like Topsline and others like healthspring.

What you can't get is an appointment when you want with your preferred doctor.

I propose a subscription based Doctor Patient relationship wherein you basically subscribe to a particular Doctor for his consultation services annually. You agree on a particular fee, and pay the Doctor in question, for which, he provides you free consultations and priority appointments for the said period.

This works at an advantage for both the patient and the doctor. 

The patient knows he has someone he can go to almost anytime for an opinion or just to clarify doubts, without waiting endlessly in a queue. He also has the comfort of emailing, whatsapping, messaging, videoconferencing etc etc with the Doctor without the Doctor feeling shortchanged for offering his opinion for free.
The Doctor, knows, he has a reliable patient who wouldn't go elsewhere (it's a fear all doctors have, trust me), the number of no-shows would decrease, and even if you are a no-show it causes no harm as nothing is lost in terms of time, patient space etc. The doctor is also assured of a continuous stream of information towards your health and can be in a better position to diagnose you!

The possibilities are limitless. The economics brilliantly simple and cost effective to both. The only factor going against this would be time and commitment. I really think this can work. I have a lot more thoughts about this, but I don't want someone stealing my idea just yet. What would you look for if you were to opt for such a service and how much do you think would be a fair annual subscription amount? Please do leave a comment and let me know your views.

Wednesday, September 25, 2013

Abdominal Drains are becoming a menace!

I've haven't been blogging for a while now but this is not due to lack of eventful happenings. I would blame it squarely on having no time to breathe let alone write!

Getting right into it, most of my regular readers would realize that the post on Abdominal Drain or Nasogastric Tube has got the most readership to date. It also has the most horrific pictures.

I guess I have a love-hate relationship with Abdominal Drains as this post will show.

Not too long ago, we had a patient who had a very bad stomach pain with severe constipation of recent onset. On the workup, he was diagnosed to be suffering from a low colon cancer. A straightforward decision for a resection and anastomosis was taken (cut and join for the lay people) and the patient underwent the surgery without issues and of course we put in an abdominal drain to prevent infection.

This is what happened!

It was fixed to the lateral wall of the abdomen. Where it was supposed to be fixed. Where it should have stayed. Where it generally always stays. But this is where I work you understand. It was done by someone else. But he came to us. The patient told us he was coming to remove the drain. As he was told by his doctor to do after 3 days. He had no clue. We had no clue at first. 

He was taken to the dressing room to remove the drain. Only there was no drain! There was nothing on the surface except the hole where the drain should have been. I asked him if the drain had been removed and he just wanted a dressing. He insisted that he was here to remove the drain. We got a feeling that something was wrong. We sent him for an Xray. This is it.

The drain had quietly and smoothly slipped inside the abdominal cavity. Inside. Without a mark or an ouch! Not even a sensation that the patient could feel. Just vanished into the body!

We knew this was going to be fun! We got him to a sonogram and tried to trace the drain but all we could see was the tip. We marked the area at the pelvis. We took a small incision and started digging. We emptied his bladder first, of course.

After some amount of fishing, this felt literally like looking for a needle in a haystack. Ultimately, we had to leave aside the instruments and move to our trusty fingers. They're the least traumatic you see. We hunted and hunted and finally felt the elusive tip. It took us about 10 minutes more to coax it out as it kept slipping back inside, but finally out it came.

That is how long it was. Luckily, it wasn't adhered to anything on the inside. The patient was discharged the same evening and made a complete recovery.

I don't think I'm going to use abdominal drains in the next few surgeries. Anyway, there is a lot of study as to the real utility in routine cases. What do you think?

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