Online Pharmacies! Just a click away...

The world is changing and e-stores are taking over the online world. It isn't a wonder, then, that the online pharmacy business in India is already taking off and is expected to reach great heights.

However, as all things new, there are very few regulations and laws dealing with the same, with the result that some of them have already faced problems with the authorities over spurious drugs being sold without prescriptions etc etc.

The point of this blog is to let out a few ideas and suggestions as to how this can work, especially in a place like India, where we are so used to service and convenience that we feel it is our birthright to have everything delivered to our homes!! Of course, there are working couples, old and infirm grandparents who can't make the walk to the chemist but at the end it's just a matter of convenience and let's be honest about this point and just agree!

The simplest solution is what is being followed by most portals online today. Partner with a pharmacy which has its licenses in place and use the online portal as just a point of contact with the consumer to collect their orders. I see nothing wrong with this concept as long as the onus is on the pharmacy to maintain the prescriptions it claims is mandatory to be supplied to confirm the order. This puts the responsibility solely on the dispensing pharmacy and leaves the online portal to be free of lawsuits, at least to a point where prescriptions and documentations are concerned.

The other solution which I think is the right way forward is to have stand alone e-pharmacies tie up with Doctors in the area to form a network so as to be able to obtain and confirm prescriptions by them. The model is simple, fool proof and would probably even benefit all involved. An example to highlight this would be if you lived in my area, you visit an online pharmacy which operates/delivers to our area, click on the medications you need as per my prescription and the pharmacy because it has a tie up with me along with others in the area and has some method to receive my prescription in electronic format, digitally signed, so they can legally dispense the medication. There also will have to be a confirmation check in place either via a coded SMS or simply a call to the clinic asking whether the patient did indeed receive this prescription. The best thing would be for the pharmacy to collect the physical copy of the prescription from the patient at the time of delivery. A simple flow chart that Boots online pharmacy uses is shown below.

While this is all good and hearty, the problems that can come up are many. There has to be a regulation on all fronts, from the authorities, to the Doctors using these pharmacies to self regulation by them. Silly things like expired drugs, substitute medications, improperly labelled medications, delayed delivery etc just will not work. An easy and no questions asked return policy is a must in such cases. It will build trust in the consumer and ensure repeat visits and orders online.

The e-pharmacies regulating themselves is an interesting point from another point of view as well. Most e-commerce sites will go to the ends of the earth to provide 100% secure payment gateways to ensure the safety of the consumer. Why not invest the same amount in legal requirements for dispensing drugs. I'm sure the IITian and IIMians can come up with a secure way to obtain electronic prescriptions and keep a check on expired drug stock and illegal medications. We do have a few online pharmacies already who are doing a good job. Off the top of the head, netmeds, mchemsit, merapharmacy and 1mg come to mind.

Despite all this, we will still have problems, because, you know, this is India. Nothing is done without Jugaad!! So, we will have some players, trying to make a quick buck by selling over the counter drugs at lightening deals and discounts. We will have those festival specials where they try and get rid of their soon to expire stock. We will have 'performance enhancing' medications being sold 'exclusively' under the aegis of naturopathy and all herbal preparations. We will have a few shipping stones in place of medications. Look, there are bad eggs everywhere. This doesn't mean we give up. Look at the US. A study conducted by NABP in September 2013 found 96.7% online pharmacies there were 'rogue' meaning they did not comply with US laws and regulations. 

There is one more unique problem in India. We are the land of 'pathies'. We have ayurveda, homeopathy, allopathy, naturopathy, herbopathy, patni ka pati and a whole lot more! Most of these do not have separate regulations and dispensing guidelines. While I have nothing against other pathies, it's only the pharmaceutical problems I am highlighting here.

We also have a host full of quacks! Every neighbourhood white coat man prescribes medications right from a bone setter to a superspecialist PhD. A very eloquent lawyer who wished to remain unnamed laid this argument in court during one of these cases against online pharmacies. "When the physical pharmacies hardly ever follow rules regarding prescriptions and dispensing, how are the online pharmacies expected to fall in line."

 

Like most law and order problems in India, there are enough laws but not enough enforcement. Hopefully, this new turn of events will make the people in power see reason and bring about a new law and guideline for online pharmacies. Even if they don't, I see a bright future for them. They are here to stay and will probably do better than the online groceries out there. What do you think?

Want to vent out at hospitals. This is better than violence!

The entire medical fraternity has their knickers in a bunch over the repeated violent attacks on resident Doctors. My previous post on Hiring Bouncers for Hospitals didn't go down well with a few of my colleagues.

What do we politically correct Indian's do when faced with controversial content. We pacify all groups! 

So, for all those who feel it just isn't their fault....here is a way to deal with your frustration with the Indian medical scenario. 

Make a difference.

I've started a small project which aims to rate hospitals based on actual user experience and offer a chance to review experiences in Hospitals for people who are interested in helping others make a better choice.

The next time you feel undone by a hospital, feel the need to ask for a suggestion book or a complaints register or simply want to congratulate the hospital for a job done well, log in to the web, click on the link below and spend 3 minutes of your time enlightening others.

Rate and Review Here

It's completely voluntary, will be acted upon, offers you a chance to vent against or support the hospital and it's doctors and staff and keeps the peace.

If you've been to a hospital, whether for yourself or with a relative, been admitted, operated upon or just went to visit someone in one of them, you would have an opinion about it. Share your experience and let others know what is good and what isn't. More importantly, let the hospitals know what they are doing wrong. You will be surprised at the difference you are able to make.

Here's hoping you fill the form out as many times as possible listing all your experiences at all the hospitals you've ever visited. Spread the word, share the link. I need a substantial number for my project to be complete and I can't do it without you, can I?

Bouncers in Hospitals and Drips in Discos!

A couple of resident Doctors were assaulted by some relatives of a patient at a public hospital recently. Again. The Doctors go on strike. Again. The hospital gives a knee jerk reaction. Again. The police register a case and do nothing about it. Again. We outrage on social media. Again. The government will issue a statement. Again. Life will move on. Again. Spirit of Mumbai. Again. 

The initial reactions were as follows:

• Assault happens between 4 am and 5 am. 
• Eagle Security Staff allegedly runs away
• Flash strike called as soon as the commotion dies down
  
  
  
• Hospital dean agrees to file and FIR
• Bouncers are hired for the protection of the Doctors
• Outrage starts on social media after newspaper reports (mostly because of the bouncers photos)
• I fail to see sense in these steps
• I write this post!

I'm not going to get into what should have been done and who was at fault. Simply because it doesn't matter. Violence is wrong and always will be.

The boy was unwell for three days. He had apparently been taken to some private hospital and this was their last ditch effort. They were apparently informed about the lack of an ICU bed. They apparently consented for admission into the general ward. They were allegedly warned about the high risk. Technically, everything was done, spoken and documented. It still happened. Are you surprised? I'm not!

I've been through an assault during my residency. Almost a decade ago. We, too, went on strike. We lodged a complaint. We carried out alternate OPD's for the patients (this is where we made make shift opd's outside the hospital premises to cater to the seriously ill patients). We were promised better protection, better conditions, better staff, the works!

Nothing has changed and frankly we didn't expect it to. 10 years on we have bouncers in the hospital.

How ridiculous is that? It's wrong on so many levels but mostly on the fundamental premise that it is only going to worsen the already deteriorating Doctor-Patient Relationship. How is a patient ever going to trust a Doctor who is going to hide behind bouncers to explain anything to him? What is to stop the guy beating the doctor outside the hospital premises? Where is the method to deal with the rage? Where is the training to avoid the rage in the first place?

The answer is communication. Not more Doctors, not more beds, not less patients, not more money/salary, not better infrastructure. All of these have a very minor role to play, of course! However, if the residents are not taught communication etiquette's we're not going anywhere for the next 10 years. Again! 

No matter what the condition of the hospital, the number of beds, the number of Doctors, the infrastructure, if a patient dies, there is bound to be a reaction. The art of controlling this reaction from the time of admission is what will avoid this in the future. Empathy, a kind ear, some small explanation, taking the relatives into confidence, documenting everything with signatures (not just obtained due to lack of options but after explanations), a good bedside manner, giving some time to a serious patient even though you're overworked (it's doable, we do it in private practice even though we're busy), offering some sort of grief counselling, breaking the news gently.....All of this will change the way the relative will react. I've done it. I know it works. I've been through everything these residents have.

Let me tell you a little known fact about civic and govt run hospitals. Most residents think no end of themselves while treating a patient. They have a bad attitude, most dismiss relatives thinking they won't understand anyway so why make the effort. They talk badly, show that they have no time, and are generally dismissive and uncaring. It's part of the situation but it needs to change.

That is the only way this will stop. Change is constant. Just look at some of the discos that have traded bouncers with hospitals for drips and skeletons.

Silicon Implants....Just not where you want them!

"Plastic Surgery is a Post Modern Veil" - Nawal El Saadawi

How true this statement is in today's times. It seems there is a procedure for everything. Right from that harmless facelift to the botox injections to surgery for dramatic weight loss and body contouring to silicon implants.

Not to sound sexist, but for a while now, these were the domain of the ladies.

Not anymore! There are post modern males stepping in who claim to be the new generation of cool while trying to hide their procedures and scars.

Our patient is one of these. One look at him and you instantly know he is a gym addict who has perhaps dedicated half his adult life to his goal of a perfect body.

He was clearly a bit off though. He admitted to have taken steroids while on his workouts. He also admitted to being a little crazy. What he admitted last was one that even surprised us.

He had silicon implants on his arms. Biceps and Triceps. Apparently this was to win some competition. He had them for about a year. Unfortunately for him, one of these migrated down to his forearm. Another one got infected. He also developed keloids (ugly scars over the surgery site).

He came to us to have the implants removed. This was the first time I have seen implants into the arms, in addition to, in a male.

Needless to say, we removed about 7 implants from both his arms, gave him a fairly decent scar after removing his keloids and offered him some counselling.



The icing on the cake was that this man, self admittedly crazy, took a discharge the same evening, decided he was a tough guy and didn't need anything, skipped his meds and went out for coffee the same night.




He returned the following morning for his follow up, wincing in pain, almost had a syncopial attack (fainting spell) while dressing because of the soreness, and promised to take his medications thereon.






This was his post operative scar!

Do you know of anyone with silicon implants in weird places?

Dealing with Death

Everyone dies. 

Sooner or later, everyone will. Everyone deals with it differently. Every death is a learning experience, an emotional one, but one that can make you so much stronger. Sometimes, you hear about deaths that don't concern you on a personal level and we pay no heed to these. Until the moment that you get informed that someone you know was involved. In the blink of an eye, it becomes an experience.

I wanted to say God works in mysterious ways, but perhaps it is more apt to say the creator works in mysterious ways. Right from a very young age we are exposed to death. 

While we are kids, if we are lucky, we get to see death take away our grandparents and great grandparents. If we are unlucky, parents leave, uncles and aunts, cousins. 

A little older and we see parents leaving, either ours or our friends'. Uncles and Aunts that we are fond of. Relatives from far off places (the ones you wouldn't be told about if you were younger). 

Once we're adults, we have more parents leaving, in laws, acquaintances, co-workers taken away too early. 

Once we're parents, the morbid fear of losing your children, the intense pain of hearing about other children and instantly checking on your own, the realization that our parents aren't going to be around forever, the understanding that if we are fortunate to still have our grandparents, it's only a matter of time. 

Once we're over a certain age (this is relative), it's acceptance and the wait for the inevitable either for our loved ones or ourselves.

 If we break up the ages when we deal with death, it would roughly come out as follows:

Below Teens : Too young to understand, too young to worry about it, listen to what's being told to you, accept it because you're too small to do anything else and somehow move on. The younger you are the easier it is to move on

Teenage Years: Old enough to understand, not wise enough to react well. Most teenagers will try to hide their emotions and try and be cool and show that they are taking it in their stride. In my opinion, this age group is the worst affected by death. They need to be spoken to but aren't ready to ask for help. They need to grieve but don't want to show emotions as it would portray them as weak.

20's to 30's: We're beginning to come to terms with the fact that death is a permanent fixture of life. (If no one has ever said this before, I'm staking claim to this as a wise man once said kind of line)

Young adults do unbelievably well in handling death. They have just the right amount of emotion showing through along with just enough wisdom to speak only when required and use non verbal communication most effectively (a nod of the head, a blink of the eyes)

40-60: The phase when you have seen enough death to not have to deal with the emotional component. You now become a facilitator in all that has to be done post death. You know its coming for you, you pray it staves off from the younger family members, you readjust your faith.

60+: You count away the people you know, with each one bringing you closer to your own time. There is no more fear, only the motivation to make the best of the rest of your time. If you are lucky, you have loving family around you helping you with everything you want to do and to achieve what you've wanted but missed out on because you were too busy before.

80+: You start to crave death while you still can. No one wants to go as a dependant. Everyone wants to go while they can still take care of themselves, while they are not a burden (or so they think). A dignified death is top priority. No trouble for the rest of the living. Peaceful death is a bonus.

What we are told about death while we are too young to understand, in my personal opinion, does not have any bearing on how we will deal with death later on. Once we are exposed to death, the education begins. With each death that we are a part of, we grow to understand how to behave, what to say, what not to say, when to smile, when to be blank, what to offer and how to offer it, how to support and how to accept support. Each death makes us wiser.

Every death that involves you personally would make the next one just a little bit easier to deal with. This is nature's way of preparing you for the inevitable death of your loved ones. A little pain at regular intervals dulls the final blow.

Over the years, I've lost many people I've cared about. 

My grandparents when I was very young. I didn't understand much then but reflecting on those times now, I guess I did. 

My friends' parents/grandparents. At first, I didn't know what to say, what to do. I would stand there and just be! With each passing, I learned. Now, I am able to offer a sentence or two in condolences. 

My uncles and friends. I could offer support to their families. I could be there for them to talk to.

My relatives and cousins. I could feel the pain that was not there with non relatives. It is different. You react differently to each death.You learn.

Death is inevitable. I know that now. I am still not ready for my parents to leave but I know I must be. There is no way to calculate how much time is left. There is, however, time to calculate how much we can enjoy each other. There is enough and more time to repair old hurts, to renew old friendships, to review life and make a bucket list, to tick things off for others.

Each generation should teach the next one about dealing with death. It would make the world a better place. I'm hoping somewhere in the future, my children read this post and understand why I never protect them from painful situations. If someone dies, they will be told they are dead. No fairy tale stories about heaven and better places and long sleeps. They will come to terms with it and be stronger for it in the future.

No pictures on this blog, no humour. Just feelings!

Swine Flu. Did Common Sense Fly Too?

We live in an era where anything sensational becomes viral. I sometimes, wonder, if people don’t sensationalize things more now because they want it to go viral. The prestige of knowing something before anyone else and being the first to update social media seems to have hit us hard. With the result that Swine Flu has taken over our natural conversations and lives. There is a fair level of paranoia going on out there. While I agree it is scary to most because of the lack of correct information, I also think it is prudent not to spread the wrong information gotten out of either social media or that ‘reliable source’ who swears it spreads via chicken!

Just to put everyone’s mind at ease, here are a few facts about the virus that we all should know in order to act rationally to care for our loved ones.

What is it?

It is a virus. Very similar to the common cold virus or flu virus. The difference is that this particular strain of virus has the propensity to cause severe infections in few people. However, most infections caused by this virus are still mild and almost exactly like the regular seasonal flu we all suffer from.

How does it spread?

Not via pork, not via chickens. Not even via mosquitoes. The virus did originate in workers who were in the pig industry but the virus has moved on and mutated itself to be able to spread directly among humans.

The main mode of spread is through droplet infection. This basically means that anyone in contact with someone who either coughs, sneezes or does not wash their hands before touching you are at risk. Just being in the same room is not going to get you infected!

How can we prevent it?

Regular hygiene! Covering your nose and mouth when you cough or sneeze, making sure you wash your hands regularly, not sharing handkerchiefs or napkins amongst children are all notable preventive measures. Mosquito repellents and creams have nothing to do with the spread.

If you somehow contract the flu, the safest thing to do is stay at home. This will prevent spread to others.

A paranoid fear of public spaces and closed rooms is unwarranted.

You may want to wear a mask -- but you need to be sure to dispose of the mask immediately after leaving the proximity of a suspected patient. If you wear the same mask repeatedly or touch it with your hands, you may be more likely to get yourself infected than if you hadn't worn any mask at all.

How Do I know I have it?

There is no way to know for sure without doing the specific blood tests. Anyone having common flu symptoms may be suffering from Swine Flu. The usual symptoms include fever, generalized bodyache, weakness, watering from the eyes, soreness in the throat. However, please be aware that you may not have any severe symptoms at all.

Is it worth skipping school or parties?

No, it’s really not. Unless someone attending is a known case of swine flu, the chances of spread from known people is highly unlikely. At the same time, just make sure you maintain hygiene and use separate napkins / tissues. Closed spaces are only a risk if a known source is there and that too if they are actively coughing or sneezing.

People can still shake hands with each other as long as they are not symptomatic. Again, the swine flu takes a respiratory root of transmission through coughing and sneezing and landing on a susceptible host.

Doctors recommend that after shaking hands, people should wash them or use hand sanitizer before they touch their mouths, noses or eyes.

Hand sanitizers have been shown to be very effective in killing the swine flu virus and should be used not only by people trying to prevent catching the virus, but also by people who have the virus to keep from spreading it to others

What are the treatment options?

There are two drugs available to treat swine flu but these will be effective only within 48 hours of contracting the infection. Antibiotics have no role in swine flu treatment.

Vaccination?

There is a vaccine for swine flu available but the protection it offers is only 65-70%. The older vaccine was available for adults only but the latest vaccine is available for both adults and children. Contact your doctor for more details.

Who should get vaccinated?

All children 6 months to 4 years (59 months) of age

All people 50 years of age and older

Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus)

People who have immunosuppression (including immunosuppression caused by medications or by HIV)

Women who are or will be pregnant during the influenza season

Children and adolescents (6 months to 18 years of age) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye's syndrome after influenza virus infection

Residents of nursing homes and other long-term-care facilities

Health-care professionals (doctors, nurses, health-care personnel treating patients)

Bottom Line:

The CDC says that a good way to prevent any flu disease is to avoid exposure to the virus; this is done by frequent hand washing, not touching your hands to your face (especially the nose and mouth), and avoiding any close proximity to or touching any person who may have flu symptoms. Since the virus can remain viable and infectious for about 48 hours on many surfaces, good hygiene and cleaning with soap and water or alcohol-based hand disinfectants are also recommended. Some physicians say face masks may help prevent getting airborne flu viruses (for example, from a cough or sneeze), but others think the better use for masks would be on those people who have symptoms and sneeze or cough.

The 6 feet rule works wonders. If you are six feet away from anyone who is sneezing or coughing, you would probably never contract the flu.

Rural Posting at Primary Health Centres (PHC). Why Doctors find alternatives?

Why is it so difficult to find Doctors who would work in rural areas? Maybe the problem lies with the fact that even after making it a mandatory posting for obtaining the degree, there is still no headway into solving this divide.

Let's start with the very basics. Most state governments would want their doctor's to work in the villages. Since the seniors are too smart to fall into this trap, they bring out a rule that says every Doctor who finished his/her internship must serve compulsory rural service.

This could in fact be a great rule to sort out the medical problems of the country. Unfortunately, like most great things here, the implementation is sorely missing.

The postings are given in a jiffy at most city hospitals that act as medical tertiary outposts for these centres which are commonly called PHC's or Primary Health Centres. Once you get posted there, you are supposed to go and report there for duty.

The trouble sort of begins here. You are told the address of the PHC and that is it!

No instructions on what to carry and what to expect. No clarification on where you will be staying. Nothing on who to meet, when to go, what to do once you get there.

Assuming you decide to take the plunge (now it's not an option remember), you reach the PHC only to find it locked up on most days.

                                    

If you are lucky and it is open, the medical in charge is almost never there.

The peon would most likely show you to your chair (there is no way in hell that you get a cabin because more often than not the entire PHC is the Cabin). 

                                                 

The person running the show is usually a qualified nurse who finds it in her heart to take you under her wing and explain things to you. If she doesn't, there is no way you are going to survive there.

The medical in charge usually finds out that a fresher has been posted and is out of his mind with glee since he now officially need not work anymore. He will come in within a day or two to sign your joining letter and disappear promptly.

The problems are just beginning. Remember, most Doctors trained in India are pretty much useless after their internship. They need to be mentored and taught the craft of intelligent practice since most of the PHC's aren't stocked for goats!

                                     

Gloves are a luxury, tablets are rarely if ever present. Injections seem to be the norm until you realise it's the same injection being given for a variety of problems. 

You basically learn nothing of medicine but become a master in the art of referrals and dealing with irate relatives who obviously do not realise that there is nothing you can really do at such centres due to a lack of material and quality.

                                        

There is no question of getting paid well, most of the time you do not get paid at all! The living conditions are deplorable to say the least and there is no security to speak of. Come to think of it, there is hardly any security at the major hospitals in the cities so expecting it here is ridiculous. (Remember all the instances of relatives beating up doctors)

                                         

If you somehow manage to finish your posting, getting the required signatures to prove you have done it is another post in itself.

Let's look at some positives.

If the govt can somehow improve living conditions, pay a decent wage and provide some sort of mentorship, most Doctors would be happy to work there. Discipline the seniors in charge of the PHC, the medical officers and the security and I see no reason for us to refuse. Until they do so, however, I don't see how young doctors can be expected to do their job. This invariably leads to corruption and bribery to complete the post and yes it happens even today.

Let's hope for the best!

P.S. (The pics are actual PHC's supposedly functioning)